Unusual symptom presentation

[SteveT]

Hi All,

I've been lurking here for a long while, occasionally chiming in on something I know a little about, and trying to figure out how to proceed with my hip issues. I've diagnosed with OA in both hips but my symptom presentation is different from most of the stories I've read here.

Have people had significant pain, on and off, even while their ROM remained intact and their x-rays didn't yet show that much damage.  That's my situation, at least part of the time.  I've still got good ROM, particularly in my right, clear signs of OA on x-ray but not enough that Dr. Su was at all impressed (right side is particularly early).  But in the last month, after a few years of generally mild, intermittent pain, I've had things turn worse.  Both hips sore, the right, surprisingly, worse (I had trouble walking a few blocks).  They responded to a week of celebrex but don't feel like they've gone back to the state they were in a month ago.

I'm scheduled to see Dr. Su again next week and look at new x-rays to see if there's been any change but I have to admit I'm confused.  With my intact ROM and still early OA I wonder what's going on.  And I'm quite confused about when to have surgery.  I feel like a hopeless whiner compared to everyone here who pretty much ground down their femurs before having surgery.  Would love to hear others' perspectives.

Steve

[KirkM]

Hi Steve -
Glad to see you putting this out there so maybe someone has experience that can provide some clues to this seemingly contradictory situation. 

Sorry I couldn't be much help when we spoke last week.  I am wondering if the pain could be coming from somewhere else (either in the same area or referred from your back or legs) and you are assuming it is the hip?  I don't recall if you said you had other possible issues explored for the pain.  Or maybe it could be a compensation issue or gait issue that is causing pain or straining that isn't actually the pain coming from bone-on-bone contact (muscular vs. skeletal).

Just throwing stuff out there since I have no clue but am very curious to find out the explanation to this pretty unique circumstance. 

I wish you the best in this investigation and look forward to someone having a possible answer.

Kirk

[Denver_wrench]

My own experience, which may not apply here, was that my labrum had probably torn and then ossified, which created a lot of groin pain. I don't know if that's a chicken and egg thing with the OA, but most soft tissue injuries would show up on an MRI rather than Xray.

[halfdone]

Hi Steve
A few non-expert opinions based on my experience of two OA hips, now both resurfaced (2006 and 2011) which may or not be relevant to you.
Everyone seems to have a different pain threshold – the only one you should care about is yours.  When your quality of life is significantly impaired, it’s time to get serious with your surgeon.
Everyone seems to experience different combinations of pain, loss of ROM etc. (Perhaps that’s because we are all a little different mechanically and all have slightly different bone on bone dynamics.)  I had OK ROM but quite a lot of pain.  And the pain was never consistent, nor did it progress consistently.
It may be possible to manage the pain and remain very active through appropriate pre-hab exercise and judicious use of pain killers. I was originally diagnosed with OA in the late 90s and managed to defer the surgery until 2006 – I stopped running but kept cycling and swimming, which I'm sure helped my hip.  However, I would not have deferred as long if: 1. HR was already a well established alternative to THR in early 2000s; 2. I had confidence then of what I know now – ie that HR hips can perform well in my sports (though I have not returned to running); 3. I realized how much my pain was compromising my QOL and my family’s QOL.
X-rays are good diagnosis tools but not perfect.  The surgeon only truly knows the position when they “go in”.  Although for my second HR the X-rays showed a much less progressed OA than my first at the time of surgery and I was in much less pain than before the first (I didn't want to suffer as much again!), the surgeon said after the surgery words to the effect of “oh yes, you needed the new hip”.
Deciding when to go is a balance of considerations, yes - to be worked out with your surgeon, but also very much up to you.  Good luck with finding a good time for YOU to go ahead.  

[SteveT]

Hi Kirk!  Good to hear from you.  How's the recovery progressing?

@Denver and HD, thank you both for sharing your experience.  I did have an MRI 2 years ago when the first surgeon (a total nitwit btw) diagnosed my FAI and wanted to do the procedure for that.  It showed some labral degeneration but no tear; from what you guys are saying, it's possible that that is contributing to the pain in my left hip.  As for my right ... just weird.  I mean I could probably just about put my foot behind my head (I used to be able to do this at an age when it might have seemed charming (14), but probably couldn't manage it now, but you get the idea). So ROM is not a problem, yet I'm feeling it some with each step as I walk up stairs. Except sometimes.

I'm hope I'll know more after my meeting with Su next week.  Meanwhile, I feel like I'm in this weird limbo place of having some pain some times, more pain occasionally, knowing that the surgeries are somewhere off in my future but truthfully, not feeling so bad that I could pull the trigger on major surgery.  So I'm left wondering how long I can manage this with occasional NSAIDs or wishing it would get worse so I'd know just what to do.  That last part sounds a little deranged but it's true.

Steve (aka clueless in Brooklyn)

[KirkM]

Recovery is going very well, thanks.

This thing about the pain being there sometimes and then sometimes not is strange, maybe a clue of some sort?  This almost makes me feel grateful that my hip was just wiped out and grinding bone on bone like a mortal and pestle, as sick as that sounds.  It was no question that my cartilage had left the building and resurfacing was imminent.

Just be careful with the use of NSAID's, since I have read that they can contribute to bone softening.  Ask your doctor or Dr. Su (I am NOT a doctor and don't even play one on TV*), but it may be better to use Tylenol or some other non-NSAID pain reliever when you need it.

Keeping my eyes and ears open for any possible info about this and hoping for a timely resolution!

Kirk

* Old people will get this reference, the "youngsters" out there probably won't.

[Denver_wrench]

I would also warn against too many NSAIDS; in my case ibuprofen pretty much eliminated the mucus lining on my stomach and opened me up to a nasty H. Pylori infection, which nearly derailed the surgery.

[Tin Soldier]

Not sure which one you're using, but ibuprofen increased my blood pressure and I think that's fairly common.  May not be a big deal temporarilly or if you're not prehypertensive. 

My right hip looked worse on x-ray (less spacing), but my left hip was in more pain.  That pain was most likley associated with a labral tear (very common in OA).  The pain associated with a labral tear can come on quite fast and be very significant.  I had 4 surgeons (2 very experienced HR surgeons, and 1 very experienced arthroscopic hip surgeon, 1 local ortho) all confirmed right off the bat with ROM test and x-ray that both hips were shot.  However, I was still walking faster than most my coworkers and appeared to them to not be in too much pain.  I had reduced the more physical exercise to pretty nothing, though.

The pain would come and go and if I would have just sat in an easy chair all the time, I probably wouldn't have thought much about the problem or even known that I had OA.  All I'm getting at is that we are all different as halfdone pointed out. 

What about MRI's or CT scans, maybe that would help identity the problem.   

[Anniee]

Steve, I feel like I was pretty much where you are now a few of years ago.  Intermittent pain, nothing serious showing up on X-rays, no noticeable reduction in ROM, and not much change for several years.  Then (pretty suddenly, it seemed), I started having a lot of pain in my right thigh, which I thought was muscle strain, only it never went away.  It didn't really stop me from doing anything, but the pain was constant at that point.  I lived with that for about 6 months before I went to the orthopedist, who was a sports medicine doctor, not a hip guy.  He saw nothing on X-rays, prescribed PT for 6 weeks which did nothing, except make it obvious that my ROM was not good, then sent me for an MRI and referred me to a hip specialist in the same practice.  OA showed up on the MRI.  The hip guy said he could give me a hip replacement when the pain got bad enough.  I did not want that, so I waited about another 9 months before I found out about Dr. Gross and went to see him.  He told me that the X-rays showed I was bone on bone in both hips, only I had hardly any pain on the left side.  I had my right hip resurfaced last April, and it's doing great, but now my left one has started hurting!

As others have said, we are all different, and we all have a different threshold for what we can tolerate.  I'll be very interested to hear the results of your visit with Dr. Su next week.

[Luann]

Hi Steve,
 My ROM (in my right hip at age 45) was much reduced, dx was OA. However, all the radiographs showed were "bone spurs" galore! My cartilage was almost completely intake (VERY small amount of narrowing abserved mid-socket). I was very concerned with this. I had a lot of pain, like you, and could walk only short distances (at least, without it looking, and feeling, very ugly!).
 When considering sx, my thought was, what a shame to have to remove all my cartilage (which, of course, is what they have to do in any replacement to fit the "socket" part of the prosthesis) when it isn't even damaged!
 Eventually, though, enough pain and missing out on activities got the best of my worries. I went through with the operation 13 months ago. I just was not willing to live like that anymore. Being scared of living like an invalid out-weighed being scared to do sx too soon.
 Does this help you at all? I have, so far at least, not been a least bit sorry. As a matter of fact, I think I should have done it at least 6 months to a year earlier than I did. I still wonder what kind of damage I did to my kidneys with all the NSAIDS I took!
 When you are more worried about NOT getting sx that having it, you will know you are ready.  Good luck, Lu

[SteveT]

Well, I went to see Dr. Su.  I ended up seeing one of his PA's, a reasonable guy named DeVries.  They looked at my films, heard about my sx, checked ROM (basically almost no limitation yet) and basically told me that it was just too early to be considering surgery.  Sort of a relief really and sensible too.  I'm not in much pain most days.  Occasionally have flare ups but these still seem controllable with a couple of days of celebrex.  If that starts picking up, then I'll have to move on to next steps, but for now, their strong feeling was to manage it for now and check in with them if/when it starts getting harder to live with.  So that' the plan for now. Thanks everyone for weighing in on this.

STeve

[KirkM]

Thanks for the update Steve.  Just keep and eye on it and be careful with the NSAID's.  Things can change rapidly so you might consider regular 6 month x-rays or some other check to keep tabs on it.

Mine, again, was the opposite of yours.  I had completely tolerable pain without any painkillers at all and could do most anything but my ROM was really bad.

I think you are one of the few here to actually be on top of the whole resurfacing thing BEFORE it is absolutely needed.  Most of us showed up to this party fashionably late!

[ScubaDuck]

@Kirk, you nailed it.  I had no idea it was OA for years.  Slowly lost strength and range of motion.  Didn't use ibuprofen (called it vitamin I) until the last two years.

Good luck, Steve.  At least you know what you have and what your options are well ahead of time.

I am four days post surgery and think I did it at the right time for me.  Recovery is better than even my most optimistic hopes.

Dan

[SteveT]

Thanks again everyone for chiming in.  One last note: at my appointment, this PA Devries was going over my films, pointing out the perfectly adequate space in my hips (while noting the obvious signs of cysts in the acetabulum - a preview of troubles to come), then, for comparison, brought up the hips of someone whose time was NOW.  The difference was enormous.  This person was bone on bone all the way around , both hips.  There is no way that I'll be waiting that long.  Just looking at it hurt.  And I get the impression that many people here were far closer to that than my current situation.

So I'll be checking in here occasionally for new hip news or perhaps to chat and expect that some time in the coming years (1? 2? who knows?) I'll be posting one of those countdown announcements.  Best of luck to all.

Steve