Surgical Decision Making

As many of you know, six months ago I had arthroscopic surgery to repair a labral tear in my hip.  It was a LONG recovery – I mean, it’s been a full six months and I’m still not quiiiiiite where I want to be.  Granted, “where I want to be” is running half marathons every month and sporting six-pack abs, but you know. Progress.  On the whole, I’m super pleased with the outcome on my left hip.  I lift 4x per week, do an hour of pretty intense cardio 3-4x per week, and spend 1.5-2 hours per day walking my puppy (yes…he does need that much exercise, or he’s just too pesty while I’m trying to study!).  I’m slowly getting back to squatting and deadlifting, slowly adding weight to the bar, and trying little runs here and there. Running has been the biggest sticking point for me, and I still have soreness when I do too much or sleep awkwardly on my hip, but overall, I’m in a very good place and I truly enjoy putting in the blood sweat and tears that will get me back 100%!

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That said, my first surgery – on the right hip in 2013 – did not go as well, and in the almost four years since, I’ve never been completely pain free in that hip.  We did imaging back in September, which showed some capsular insufficiency (apparently my capsule was not sewn back up during the operation and did not scar down correctly like it was supposed to), some FAI, and some *possible* labral insufficiency.  So we scheduled a surgery for Dec 8, the day after my last final exam of the semester.

BUT….it’s not happening.  After digging through my training logs from the past two years, troubleshooting with my PTs, and talking with my surgeon, I’ve decided to postpone that surgery.  It wasn’t an easy decision, because as you’ll see there’s a LOT that goes into it, but as soon as I walked out of the doctor’s office after having given him my decision, I felt a huge weight lift off my shoulders. It’s interesting to me to look back on that decision and be able to validate it from both a personal standpoint and the standpoint of a doctor of physical therapy in training.  In this post, I’ll take you through my reasoning – both clinical and personal – of why surgery is not the best choice for me, right now.

PERSONAL FACTORS: 

-I’m not a professional athlete.  This isn’t a situation of “I need to get this fixed now so I can get back out there and not lose my sponsorship and be able to put bread on the table for my family”. Can I do my favorite thing (running)? Not really.  Can I do a ton of other things I love?  Yes.  Can I do my job and do it well?  Uh…ask my professors about the “do it well” part LOL.

-Two weeks before Christmas is probably the worst possible time to have surgery.  My boyfriend can’t take off work.  My mom can’t fly down to help.  I would have to navigate a 10+ hour drive from Durham to Philadelphia while on crutches, carting along not just my dog but also my CPM?…yeah…no. Not to mention the inability to participate in all of my favorite holiday traditions. Yes, I have a life outside of sports and that matters too 🙂

Conversely, I have 2.5 weeks off from school in February, followed by a very relaxed spring and summer semester to recover.  Here, my boyfriend would have enough vacation days to help out, and my mom could fly down to help for a bit as well.  Even with waiting 2.5 months, I would still be able to go off on my clinical rotations fully recovered at  6 months post op – about where I am now!

-Honestly….I JUST DON’T WANT TO RIGHT NOW.  This is a painful surgery, and it takes forever to recover.  And then after you recover, you have to get back in shape! It’s frustrating, it’s demoralizing at times, and I JUST finished going through that while also navigating the most frustrating, most demoralizing school semester of my entire life.  Judge me all you want , tell me I’m not “committed to my sport”, but I would love to have a couple months where I’m free and feel good before going through all that again. And as you’ll see below, waiting a little bit is actually the right thing to do clinically.

CLINICAL REASONS: 

-I’m not actually in pain.  

All clinical examinations specific for intra-articular pathology are negative/not painful.  FADER, FABER, etc etc.  Nothin.

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Yeah.  The structural damage is there, so says the MRI, but the hip generally does not bother me.  After having two labral tears, I like to think I know exactly what it feels like, and this feels nothing like that.  Before my recent surgery on the left, that hip hurt so badly I couldn’t sit.   Currently, on my right hip, it gets mildly sore at the end of my workouts, sometimes. Most of what I feel is muscular.

-Morphology does not = Pathology all the time.  Labral tears need to be repaired, I have no doubts about that.  FAI on the other hand……?!?!?!  Clearly I have some, clearly it’s not causing me that much pain.  So does all FAI cause pain and loss of ability to function the way you want? Not necessarily.  Morphology – the shape of the femoral head, in this case – doesn’t necessarily = pathology, or pain.  This is a big debate in the PT and medical worlds – check out this JOSPT viewpoint written by my MSK professor and PT hip expert Mike Reiman on the subject (Hi Dr. Reiman, hope you are proud of me for this bullet point).  But, in general, FAI alone (without clear labral pathology, IMO), is not a reason to operate.  The patient has to be symptomatic, and should probably try conservative rehab first! Which leads me to my next point….

Future pain is NOT a good reason to operate. My thought leading up to this surgery was “but it might start hurting again once I increase my workouts and try to run”….a pretty normal fear for a girl who hasn’t been able to run for about five years due to hip pain! But, my PT education is paying off – y’all, the fear of pain that MIGHT happen is NOT a reason to do a major operation.  What if I get super strong in the gym, increase my running, and, lo and behold, STILL don’t have pain two months later?  What if?  I need to at least give myself that chance before shelling out $1000+ and going through 24+ weeks of rehab.

Weak hips make poor recoveries!  The one problem i HAVE been struggling with is that my right leg is a lot weaker than my left.  Hence my above thought about agressive strength training! I especially have difficulty activating my glutes, which means that during running, squatting, and deadlifting, my gastroc, soleus, and hamstring tend to kick in more than they should.  My right quad gets sore during cycling.  If I press on with my workout despite these muscles burning, THEN I start to feel some joint pain.  So….the answer here is probably not “operate on the joint” just yet but rather get that leg STRONG again!  It MIGHT allow me to return to training without joint pain.  But if it doesn’t then at least I’ll be going into surgery stronger than I am now – which is necessary if I want to have a solid recovery like I did with the left hip.

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SO….what’s the plan?

Currently, I’m planning on spending the next two months getting strong and mobile AF.  I’m going to have a surgery scheduled for mid-February – the next convenient time for me, for school, and for my family – and will make a decision closer to that date.  If anything, I’ll be stronger and fitter going into the operation than I am now, and that will lead to a better outcome. But, best-case scenario, I might be able to avoid going under the knife (the scope?  the surgery magic wand?).  Either way, I spend all day preaching about the power of strength and mobility to my classmates, my patients, my mom, etc – I should probably give it a chance for myself.

Here are some of the resources I plan to use to kick my legs into beast mode:

-Dr. John Rusin’s Functional Hypertrophy Training

-Chris Johnson (obviously) and all of his videos as zerenPT.com

-My good friend and strength and conditioning specialist Erika Sperl at FiveToolFitness

MobilityWOD (….obviously)

The Run Experience (Mobility and running form)

Though it didn’t come easily, I have a ton of experience that led to this decision – not only have I already had TWO of these surgeries (which means I know exactly what I’d be about to get into), but I’m a future clinician, so my decision is evidence-based as well.  Overall, I’m happy with my choice, and can’t wait to spend this holiday season killing it in the gym!

Special shoutouts:

-My surgeon, Dr. Richard Mather, for doing a kickass surgery and for actually being a nice person to talk to while making these decisions (shoutout to the resident too!)

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-My physical therapists, Mijo Cotic and Brian Diaz at ActivEdge Fitness and Sports Performance, for treating me like a friend and spending a lot of time troubleshooting with me.  Y’all are the reason I can do everything I’m doing!

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-Dr. Reiman for being cool and indirectly helping with my clinical decision making, both through his FAI research and our MSK class!

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