Drugs, Nutrition, and Bone Density
A Testimonial for Dr. Gross
"Clunking" or Snapping Hip Syndrome
New Hip + 13 days
These first were the toughest days. My hip was very stiff. Very hard to find a comfortable sleeping position except flat on back, but I can't sleep being on my back constantly. All the sliced/diced tissue made my hip underneath the 4" incision feel like a giant wad of old chewing gum. The first 3 days I was at the hospital, and the next 3 days I was at my friend Dave & Di's, where my good friends waited on me hand & foot. Good for the spirits! But no internet connection, and I'm an active stock trader trying to rebuild my plan for an early retirement from teaching and a return to full time research. So, when the stock market topped out in mid June I started losing money by not being on-line. And too, I wanted the comfort of a return to my familiar place and diet. So for the past week, I've been on my own at home. Each day begins with a self-injection of blood thinner. Today (day 13) is the last of them! Good riddance to that. I will open up the bandaging to expose the incision to air, tomorrow. The incision has looked good - or at least, as good as such a thing can look. No pain on the incision itself. Zero. Just a sense of stiff hard rubber there. No "foul discharge" and no fever (either would be signs of infection).
Here's my recommendations for others who live alone.
(1) Try to wait till after you're off the heavy drugs before flying home. My flight was a nightmare.
(2) Go to the market and fill your 'fridge and cupboards with food before you head off to surgery.
(3) Get a small table-on-wheels, like one of those bar things, for home. It's really awkward trying to bring meals from kitchen to bedroom when you're using both hands on crutches!
(4) Include plenty of fiber-rich fruit early on; even bring it with you to the hospital. Buy plenty of calcium/magnesium/vitamin D supplements.
(5). Do plenty of torsional stretches before surgery, so that you are comfortable lying on your stomach and twisting around and changing your wound dressing. I could do it, but just barely, and I'm reasonably flexible. You don't want to hire a live-in nurse for that. Your incision (if posterior approach, as most surgeons do, including Dr. Gross) will be at about the 8am position (12 o'clock being your belly button and 6 o'clock being your tailbone), and about centered on the widest part of your hip.
(6). Of course, get your raised toilet seat set up before you arrive home. If you have a strong good arm and leg, it's not strictly necessary, but surely safer and more convenient. Use a 64oz empty fruit juice bottle as an in-bed urinal to minimize trips to the bathroom.
(7). A "picker" is useful, but if you have a good leg, it's quite straightforward to bend at the good hip while keeping fairly straight with the operated hip as you pick something up. It depends on your fitness and comfort with this. Don't risk a fall, if you have any doubts, and get a picker (they will supply you with one at the hospital if desired). It's pretty useful for putting socks on your operated leg.
(8) Set up a wide table next to your bed before you leave for surgery. This table will rapidly fill with your med's, your used dishes, and with any/everything else as you learn to spend most of your new life in bed for a while.
It's "farmer's market" day, and I crutched my way from home, a half mile to the outdoor market where I filled my daypack with all possible fresh peaches, apricots, cilantro, kale, red onions, heirloom tomatoes, basil, nectarines... so gorgeous, after that hospital food! Hands feel mashed somewhat after returning home. A mile of crutching is at my outer limit in this regard. However, I note that this time I did not get any leg swelling afterwards. My first excursions, on Day 9 and Day 11 were similar in length, and I had hip muscle swelling, leading to a bit of sciatica afterwards (which dissipated by the next morning).
Progress is progressing! Pulled my steri-strips off at day 17 when they didn't fall of as expected. Scar looks "good". I've been pretty non-adventurous about stretching, but yet still the range of motion is increasing on its own. Can sleep on my un-operated side with no significant pain, especially with the pillow between the legs. The sciatica didn't come back. Leg swelling pretty much gone after day 18 or so. No leg pain or evidence of circulation problems. Main problem is just the restlessness of inactivity, and those damn crutches which hurt my hands. Crutching from Trader Joe's to home (1 mile round trip) with a ton of non-fat milk etc in my backpack really mashes the nerves in the palm of my hands. How did I crutch for 3 YEARS early on?! I don't know how I did that, now. Been taking 1 vicadin per day, but have this persistent ringing in my ears and wonder if it's drugs. So I stopped taking it on day 24. Pain levels OK, I think I'd already acclimated to the vicadin anyway.
Each day is a little less painful and a little less stiff. I was cleared for bath and pool therapy at the 28 day mark, and at 28 days I took the bus down to the gym and had my first workout. I joined my Ironman-bound friend at the pool for a 2400 yard swim. I used a bouy between my legs so my hip did not do any work except a bit of adduction to hold the bouy. Felt good! On day 30, I did 3600 yards in the pool. All upper body. I also continue to crutch around for shopping and now for the bus; about a mile every other day. No significant swelling in my hip, but it still feels stiff and I am not pushing for much ROM yet; I continue to worry about bone bonding with the prosthesis and with the reattached tendons, given my severe osteoporosis. I'll take it slow. But I do want to encourage good blood flow and (if its possible) blood vessel re-routing to my femoral head, and so these pool and hot tub sessions I believe are going to be helpful. I've been taking no drugs now for over a week, and don't miss them. Sleeping much better, now about as well as before surgery (which is still not good compared to before my hip went).
At the 6 week mark (day 42) I went to one crutch instead of two. Swimming about twice a week, 3000 yards or so. This past Saturday (day 44) I did my first race - the Lake del Valle Aqua Challenge 2-mile swim. Felt good, had a good swim (but no medals this year) and here's the story on that. At week 5, I had a slip on the walkway outside Spa Fitness and put my full weight on the operated leg. No fall or impact, but full weight. Don't feel any new pains so hopefully no damage. Trying to get a baseline of my morning urine pH. So far just two readings; 6.0 one morning and 7.0 another. Need more for some kind of pattern to emerge. My activity level is only going up very slowly. Still spend most of the day inactive. Going for a 2300 yd swim shortly, and will also do weights this time around, upper body only. Talked with Dr. Gross today on the phone. Here is a digest of the Dr. Gross information I got on my questions. Ringing in the ears has disappeared.
I'm still on one crutch. At week 8.5 I had my first return to teaching - a one-weekend field class to the Sierra. I figured it would be very hard for me to do everything I needed to do during this field class all on one crutch - and I in fact spent a fair amount of time "walking" without aid. No ill effects. However, my hip feels very turned out and I cannot walk without a severe limp, even though there is no pain causing the limp. I'm just very tweeked out. My left (operated) leg feels longer than the unoperated leg, but this is most likely that my hip/spine connection is tilted due to 10 years adjusting to a shorter left leg so I am not yet worried about it. When my bones are stronger, I'll get some proper chiropractic and see how straight I am. For the past 2 weeks I've been carefully monitoring my urine pH, which ideally should be 7.0 to insure no bone calcium losses are happening for pH buffering. The 2000mg of calcium which Dr. Gross told me to take turns out to be necessary to insure this, even though I already have a reasonably alkaline diet (fresh fruits and veges, no soda, alcohol, sugary stuff). It's necessary for me to take a final 500mg CaMg-Vitamin D tablet chewed up before sleep to insure a good morning pH. Since according to Gross my bone is continuing to bond with the metal here over 2 months after surgery, it is foolish for me to be putting stress on the hip. So, minimal walking, anything long (like a mile to/from downtown) I do on crutches but with reasonable weight bearing on the left leg. Around the apartment, I don't use crutches now. That's a week before I'm supposed to get off them, but I'm being very careful. Othewise, I continue to swim 2-3 times a week about 2,000 - 3,000 yards at a time. No particular pain in the bone, some soft tissue pain if I muscle around too much, but it goes away quickly. The "wad of bubble gum" feel to the hip surrounding area is less now, although the rotators are still painful to use at all, and I'm avoiding it till a bit later. Fracturing my fragile bone is the last thing I want to do during this period!
One thing I'm worried about is that I cannot bend my hip beyond 90 degrees, and it doesn't feel like tight muscles or scar tissue. Granted I've never before had surgery and may not be the best judge, but I can't help worrying that there is a mechanical limitation which won't go away as the tissues heal. I hope I'm wrong. If anyone else has first-hand experience from Dr. Gross surgeries I'd love to hear about it.
Today's the first "official" day I should be off crutches altogether. Did a stretch session in the gym before a light upper body workout and then 1400 yards in the pool. For the gym stretch, I used the big box and lay down, propping my left foot against it and bending my knee and hip as much as possible for a passive stretch of the glueus muscles. Then, to the Santa Cruz Track Club where I walked for 3/4 mile, focusing intently on not limping. Very tough! Just trying to walk properly required lots of conscious muscle involvement around the hip, and the muscles had to really work. Got better by the 3rd lap, after a session of instructed stetching from Art, the race walk coach. So far, so good. Progress!
I had my first appointment with an endocrinologist yesterday. Dr. Levine. He was not convinced my free testosterone was low, since the total testosterone was normal, and we're re-doing the test. There was nothing yet in my history or existing tests which shed light on my osteoporosis. He thought it suprising that even with my relative sedentary 10 years, that I would be so osteoporotic. He did feel it was possible that my lack of activity was the sole cause, given how dramatic is the bone loss in astronauts in prolonged weightlessness. However, he wanted to look for other causes. We're doing more tests, including parathyroid. His tentative suggestion is to try the new drug Forteo, which is a formulation of parathyroid hormone. This builds bone instead of merely inhibiting resorption as biphosphonates do. The effects are strong, but it is expensive and not always covered by insurance since it's around $10,000 / year (!). We'll see what my tests show. Here's a page on Forteo. Today I walked one mile at the Santa Cruz Track Club workout. Quite difficult, I'm relearning walking all over again. My hip feels like the nerves have been reconnected in a random way. Like the "wiring harness" has been disconnected, and reconnected with some random rotation. I can limp as per usual, but to concentrate and walk straight is just as hard this week as it was a week ago.
Week 17.0 (Oct 10, '07)
School's started. Still haven't gotten the blood work etc and return to Dr. Levine. But been focusing on urine pH levels and diet, and learning a lot. My hip is slowly feeling less stiff. Pain hasn't been much of an issue at all. However I did hyperextend my knee 3 weeks ago, but this is mostly healed now too. Walking "normally" is now much much easier than at week 11. Still must mentally focus on walking properly and not limp / "duck out" with my left foot. Did the swim's on the Big Kahuna half Ironman triathlon, and also the Sentinel triathlon here in town, and did well. Last weekend (Oct 5-7) I did 4 miles of mountainous downhill hiking at my Astro 27/Geo 27 field course at Pinnacles National Monument. Felt fine! According to Dr. Gross' schedule, my bone should now be 3 weeks past it's point of minimum strength. I'm walking more and more with only the slightest limp. walking up stairs without matching feet is still hard. Had an appointment with my chiro last week and he's impressed by the proprioceptive performance on balancing tests. He's happy with my progress. No running or even thought of running yet. I want my bone confirmed strong and at least 9 months of healing before even thinking of that. I am beginning to think about ordering the Soloflex WBV unit. My bone should be ready for this soon, I feel.
Week 18.5 (Oct 22, '07)
Hip stiffness continues to get better. Sunday I did my most ambitious exercise yet - an 7 mile bike followed immediately by a 7 mile hike into the Santa Cruz mountains on trails. Felt fine, just a bit of extra soreness that night, which quickly went away. I'm able to walk virtually normally now. The knee pain has also healed. To hike for miles and feel normal, what a great feeling! Can't wait for winter and snows and a chance to get back on my cross country skis.
Week 21 (Nov 7, '07)
Hip stiffness is now mostly gone, just a little bit left. Last Saturday I got on my Serrotta racing bike for the first time in 10 years. No problem doing an internal rotation to get in/out of the clips. Felt good! Sunday, a 26 mile ride to Sand Point. I walk most times I go downtown now. Also in the past 10 days, my first session of boogie boarding, up at Waddell Creek - an hour long. Stretching session; lying on my back, still can't bring my operated leg any closer than about 70 degrees (~10 degrees meaning I'd be touching my chest) angle. Also hard to get a standard piriformis stretch to actually stretch the piriformis. I'm still worried that there may be limitations to my hip articulation aside from scar tissue. But, I don't have anything to back up that worry except the way it feels.
Week 29 (Jan 2, '08)
Dec 30 I was at Yosemite, and for the first time in 11 years I tried cross country skiing. Just 1 mile, and a little up/down on the bunny slope as well. My muscle memory was sketchy and my 3-pin boots are more than sketchy - they disintegrated! So it was a short experiment and I need to get new boots. But it felt great. Then, Dr. Gross said I should be able to run by sometime "next year". Well, Jan 1 is next year and I felt ready to do just a bit. I ran for a half mile on the beach in my running shoes, keeping my stride very short to allow me to use my calfs to extra-cushion the impact. Felt great to run again. No hip or knee issues arose, just some unsteadiness in my ankles. Jan 1 was a glorious day, and I got on my Serrotta and did a challenging 40 mile ride up the coast to Swanton Loop. Pure joy, and no hip issues! Jan 6: I ran again, this time a full mile; first half with shoes, and second half mile barefoot, in the rain on the hard sand of the beach. Felt so delicious to run through the surf again for the first time in over a decade! No complaints from anywhere in my body, but it'll be a long way back to real running. I've re-joined the Santa Cruz Track Club, and have a Soloflex WBV platform on order now as well. I'm doing more significant stretching, hurdler stretches inside the hot tub at the gym to help support my body weight and give maximum flexibility via heat.
6 months (Jan 13 '08)
Got my Soloflex WBV platform and have used it for 20min each of the last 3 days, set at 0.4g, standing with most of my weight on my operated leg. Feels quite gentle, and no problem.
8 months (Mar 14 '08)
Since my last entry I continue to get more fit (slowly) and am doing harder exercises for my hip at the gym. Glut machine, standing donkey calf machine, leg press added to the routines with ab- and adductor machines. Cycling now up over 50 miles per training ride. Last weekend I decided to start regularly doing the Santa Cruz Sentinel Triathlon cycling course (23 miles), since I have several recorded competition times on that course (dating back 10-20 years ago) for which I can compare. Sobering! My times in the early '90's were 1hr 08min. Last weekend, 1hr 33min. Yow! But I felt good and had no hip issues. Just undertrained (and 10 years older). I'm motivated to cut that gap. Now one thing that continues to bother me is a "clunking" or "snapping hip syndrome" on the operated hip. I didn't think much about it early on, figuring it would go away on its own. Nope. It's only gotten a bit worse. So I clearly need to focus. Thanks to a lead in Surfacehippy, I found this link on "snapping hip syndrome" (and my own page on snapping hip is here), and will re-double my training and stretching exercises. I will say that my left hip is still nowhere near as flexible as my normal right hip. I can't pull my hip anywhere near my chest as I can with my right, much as I try and stretch it. Stretching elsewhere in my body feels like stretching normal tissue, but stretching my hip feels like trying to stretch a wad of old chewing gum stuck underneath a school desk. Doesn't hurt so much as it just doesn't want to budge very much.
I'm continuing with my 1000+ mg/day of Ca/Mg/Vit D supplements, going very easy on the cod liver oil to avoid getting too much vitamin A (bad for osteoporosis), lots of fruits and veges, especially calcium rich kale and green leafy's. I don't get on the Soloflex as much as I should. It's excruciatingly boring. Instead I am doing brisk long walks barefoot on the hard sand at the beach near my home several times per week. I try to run but my knees hurt and my first running in January, after a week of pure joy, I got an overuse injury of my ankle on the my good leg which lasted for well over a month. Got to be smart and measured about this, Nolt!
1 year (June 13, '08)
The gym work has paid off. I can now run again. Whereas when I first tried to run, in January, I felt like an "old man", now I feel like a "young man, who's never run before". OK, youngER man. Meaning, I feel the stress in my muscles, I feel slow, and my flexibility is not quite back to where it was, but not the pain in my joints as earlier. I'm enjoying walk/run's on the soft and hard sand at the beach several days a week. I just hop on my bike for the mile ride to the beach and it's a very nice break. My swimming is going well. I plan to enter an Ironman distance open water swim in a month. And, I plan to enter my first triathlon in 12 years - the Sandman Triathlon, a local race here.
My hip is much less stiff, hardly noticable except when I focus. Stretching is now more pleasant, more like I'm stretching tissues that welcome it, instead of the earlier feeling like I was trying to stretch old stuck-to-the-bottom-of-the-desk chewing gum that complained. I continue to take cod liver oil only very sparingly - just a sip once every day or two, in order to limit my Vitamin A intake (more than 2x RDA hurts bone density according to new data), continue to take my Ca/Mg/Vit D supplements from Trader Joe's, 1000-2000mg/day, in addition to the minerals I get from my pretty decent diet rich in veges and fruits. I continue to monitor my urine pH and use the alkalizing supplements Potassium and Ca/Mg/Vit D to help insure it stays neutral or slightly alkaline. I continue to stretch, often in the hot tub at the gym. The "clunking" I complained about has mostly gone away with the strengthening and stretching (usual runners stretches you can find in many places). I have not had a bone density scan. I'm really doing all I can to help my bone density, so if the density scan is not good, I'm not sure what I could do about it anyway (aside from drugs - and I'm not a fan of drugs).
14 months (Aug 3, '08)
My return to running continues to be slow. However, I passed a milestone today - my first triathlon since Ironman Canada '96. I did the Sandman Triathlon in Aptos (.75 mi swim, 15mi bike, 4.5 mile beach run). My swim was strong (not affected by my hip), my bike was OK, and my run was.... well, I did run the entire course w/o walking, and that's the biggest challenge I've put to my new hip, and it seems without any trouble. Photo's of my race day are here. Again, Dr. Gross says that there's a small chance of AVN under the cap developing between 1 and 2 years post-surgery, so I will continue to monitor closely the sensations in my hip. For today's race, I did feel soreness, but it was on the outside of the hip and consistent with soft-tissue being stressed. Any pain in the groin side and I'd have immediately stopped been concerned. The "clunking" I earlier complained of... seems to be entirely gone. Been a while since I can say I noticed it. Guess the stretching and weight room work did the trick.
14.5 months (Aug 24, '08)
Two days after my triathlon, my operated hip was sore when I'd put weight on it, much like pre-surgery. It worried me, and I even spent one day getting around on crutches just in case I'd actually hurt the bone in some way. But the symptoms got much improved over the next few days. Then, I used a gizmo my triathlon buddy Dave showed me, from tptherapy.com. You use your own weight to do deep massage on muscles around the upper leg and hip. It was quite painful, in a good way. I used this for about half an hour, while watching the Olympics Opening Ceremonies. Next morning, my hip felt great! I ran on the beach and did 42 miles on the bike and felt no pain. Went to my local running store and bought my own. Kind of expensive - $69 for the roller you see on the right on the page linked above. But, worth it in my opinion. Those rotators and insertion points around the hip after surgery are going to need lots of deep tissue work to minimize scar tissue tightness. Now, I'm upping my biking quite a bit and plan to do the Big Kahuna Triathlon in 2 weeks - a half-Ironman distance race. But I'll skip the run; I'm just doing the swim and bike. Can't run 13 miles yet.
16 months (Oct 10, '08)
My Big Kahuna Triathlon went just fine. 1.2mile swim and 56 mile bike, and didn't attempt the run. Since then, I've done only a little running, mostly because I've just been swamped with work. I did do a 2 mile run on the beach last week and felt great doing it, and felt fine afterwards, so I believe my hip continues to strengthen and accomodate to impact loading. I continue to have a couple of 500mg Ca/Mg/Vit D's from Trader Joe's, as well as yogurt and kale and other calcium-rich foods. Have not had a bone scan post-surgery yet.
17.2 months (Nov 23, '08)
Progess continues. No bone density scan (just too busy) or doctor visits to report. I never did go back to Levine. I got the strong feeling he was just another 1-trick doc - put me on very expensive drugs. Instead, I'm enjoying getting back to my active life. I've begun to run regularly now - no longer tentative and cautious, but running as if I don't have any reason to be fearful. I'm using my old favorite trail run - the Bridge Creek Loop - in Nicene Marks State Park as my benchmark. It's a 7 mile fairly technical trail run up through the mountains. For the past month, it's been my main weekly run. I'm very interested to find what running times I can post compared to my personal record time on that course - which is 1 hour flat - set when I was in my early 40's (now I'm 56). I'm doing surprisingly well! I can't tell my operated hip is any different, except the muscles are still not back to 100% of the unoperated side. Pre-surgery people might think you feel a hard metallic impacting on one side and the soft give of real cartilage on the good side - but this is not true. Virtually all of the shock absorption of running is taken up by the perfectly designed curves and resilience of the hip and leg bones, and the cartilage just gives a slippery (the slipperiest stuff known to man, actually) articulating surface. So; no - I don't feel any "harder" impact on my operated side than the non-operated side. The only issues are those of a runner just climbing the progress curve as skills and conditioning rapidly improve. Today's run, I felt good throughout, and good now, here in the coffee shop. I put together this quick'n'dirty Excel graph of my running progress. Click on it for a full size version. I will say, that the toughest muscles to bring back are the small rotator muscles cut through at surgery. They hurt a day after a tough run, whereas the larger muscles like the quads, glutes, illiotibial just feel sore.
I'll update this graph each time I run. The first run was on Oct 18, '08. Ran it again today (Dec 21) and a new post-surgery PR. I plan now to focus more attention on barefoot running on the sane, and change to more minimal shoes - my old racing flats - to allow a more natural and ultimately less stressful running form
19 Months (Jan 7, '09)
Did my first run on pavement since surgery. The Rio Resolution Run in Carmel exactly 1 year after my first tentative jogging on sand. I did 5 miles of the 6.2 mile run, in 55 minutes (and most of a mile warming up on pavement ahead of the race). My feet definitely hurt, especially my right foot (the unoperated side). Otherwise, all continues well. Having 15 year old running shoes probably didn't help.
19.5 Months (Jan 25, '09)
Felt good enough today to end up making a major step up in my distances. Ran my first half-marathon (training, not a formal race) - and it went very well! No hip issues at all. Took some Ca/Mg/VitD before, and after the run, and feel great.
20.5 Months (Feb 22, '09)
Took advantage of a free bone scan at the local health food store; using ultrasound on my ankles. Left ankle gave a T score of -2.5, right ankle -2.6. Since I've never had this kind of bone scan it's hard to interpret, except that's a very low score and shows very low bone density still, even after all the supplemental calcium, magnesium, Vitamin D, and return to walking and running. Will have to get a dexascan and see what the scores are, since I've now been very active for nearly a year and that should make a difference in bone density.
21.5 Months (Mar 24, '09)
Did my first triathlon of the season on March 7. My left hip hurt during the last half of the run but the pain went away after completion. Then, 3am the next morning I awoke with lots more pain. Went in for an Xray, which came out clean - no damage to the bone/prosthesis. Looks like it was tendonitis. Iced it the rest of the day and has been absolutely fine ever since, including during a half hour hill-repeats run yesterday. Its been 2 years since my last dexascan and I'm now eligible (after Apr 1) for insurance to pay for another scan.
22 Months (Apr 6, '09)
Feeling good. Did a 13 mile road+trail run on Sunday. Tired but no hip issues, except the left hip muscles are still weaker than the right, and I believe the extra pain I feel for a few days on that side is that my stronger right hip is simply outrunning and exhausting my left hip muscles, which are cramping (last months triathlon). Got my first post-surgery X-rays and dexascan. X-rays show still a solid bond between bone and metal. Dexascan results will be known in another week or so. Opportunity knocked, and I registered for the St.George Ironman Triathlon for May 1, 2010! I'm increasing my training and am glad to have a worthy goal now.
I rotated (in Photoshop) the image at left to level the bottom of the "sit bones" to define horizontal (and cropped the image along that line), then rotated the image again until the acetabular cup was straight across level, using Photoshop tools. The angle to accomplish this was 55.0 degrees. This, I believe, is my "cup angle". Anything above 55 degrees may make for unusual wear rates, according to a '10 article by Dr. Gross
2 years (May 31, '09)
Ran 13 miles road+trail run yesterday, identical to the one above. Hip pain has been getting more common after longer runs, especially yesterday's. I've changed my evaluation of the cause. It's illiopsoas tendinitis/bursitis. My psoas is definitely tight, and the other symptoms which go with this syndrome all fit. I've tried stretching the psoas, but there's a fine line between a good stretch and too much stretching, apparently. I thought I had it right, but yesterday's run sure proved that wrong. My swim and bike are doing fine, but my running is really stalled due to this problem. I'm recognizing now that I've had a weaker version of this problem even before surgery. It's possible that post surgery it's aggravated (was this tendon cut during surgery? I'm trying to find out).
2 yrs 1 month (July 5 '09)
Yes. Iliopsoas tendinitis/bursitis. Found out from Dr. Gross' office that this is not uncommon post-surgery. I've made stretching the psoas my prime directive, especially the left side. Especially in the hot tub at the gym. It's worked! I can now do 13 mile runs without pain. So I've been continuing running and cycling and weights and gradually upp'ing the mileage.
At left is my thigh size (circumference) before surgery (after 10 years of no activity for the left side; the right carrying all the effort), and now 2 years post-surgery. You can see the difference between legs has diminished, but there is still a difference and I can still feel that my operated leg is weaker. I'll update this graph as time goes on.
Still trying to get my detailed Dexascan results. However, the brief version says that I've raised my bone density in the lower spinal column and right hip by 3%. Encouraging, but not nearly as much as I think I deserve, what with the work and diet I've put in.
July 13 - Did a 13 mile run to Berry Falls from the ocean, and as an experiment tried it without my orthotics (which are heavy), since I've been doing frequent barefoot beach runs to train my feet to be stronger and support my arches. Now, my beach runs are a mile or maybe 2 at the most, so doing a 13 mile w/o orthotics was really not well-advised I suppose. But I figured - what's the worst that could happen? The result - not so bad. My right leg (stronger, unoperated side) feels just fine. My left was hurting for the last 4 miles or so. And still hurts today - 2 days later. Hurts along a line on the inner thigh hamstring area, and also the outer side. Feels like strained illiotibial band, probably from overwork correcting for the lack of orthotics. I'd say the experiment was a success, but I'll have to spend more days of recovery before any more running. The good news - no tendinitis/bursitis this time. Stretching the psoas is working!
2 yrs 3 months: (Sep 15, 2009)
My pains from that ill-fated Berry Falls run did not go away. Then, late July I got Swine Flu. Then, pneumonia, for which they gave me Avelox. I was too fevered to think about asking about the side effects. 2 days later my fever was gone and I did my homework. Alarmed to read that Avelox and all flouroquinolone antibiotics have a nasty side effect - toxic to the cells that make up tendons. I stopped taking Avelox right then and there. Fortunately, the literature also supports that one may not need to take the full 10 day regime, and only 3 days may be enough. In any event, my pneumonia did not come back. Took 6 weeks for my lungs to fully recover. Meanwhile, several days after taking Avelox my IT band issue felt different, now feeling like something was wrong inside my knee joint. Did the Avelox weaken my ACL or PCL? Doing hip abduction also made pain on the medial side of my knee, which seemed suggestive of damage inside the knee. I went to an orthopedist and after a thorough physical exam, they felt it was poor knee cap tracking due to weak VMO and surrounding musculature - no damage inside the knee. I'm still suspicous that the Avelox made for at least a short-term weakening of my weakest tendon point - left leg in the knee area. However, the good news is that that has resolved, thanks to IT band exercises (bought ankle weights and did VMO strenthening, and various stretches) and icing. Felt ready for my first "real" run in 2 months on Sunday 9/13 - my favorite, the Bridge Creek Loop 6.5 miles of hilly trails. Went slow (1:25) and felt tough. My IT band came through fine, but now its my old nemisis the iliopsoas tendinitis that got me. Iced well and seems OK now. These stretching exercises must be done EARLY and OFTEN and with INTENSITY, at least for me. No slacking is the take-away.
2 yrs 8 months: Feb 15, 2010
Sorry, I've not kept up these postings. But, no news is good news, right? I've worked in the gym to equalize my operated leg strength, doing single leg work on the press, abductors, adductors, calf (standing, donkey), step-ups, and others I can't think of right now. It's finally worked, and I no longer have the IT band or psoas tendinitis issues. Still, my running is coming along slowly considering that I've signed up for Ironman Triathlon - St. George, Utah. My new blog shows my training mileages in swim, bike, and run. No hip pain at all. My running mileage per week is still pretty low, about 10 miles. The marathon at St. George will definitely be tough. The swim and bike I feel confident. Been taking ~4-5 prunes, soaked in water, each day in my morning smoothie (banana, soy milk, frozen fruit, and soaked prunes). Several studies show prune's positive effect in improving osteoporotic bone density. See refs here and here. Has it helped my bone strength? Won't know for another year, when my lame-o insurance lets me get another dexascan. However, I have take two falls this winter. One on my Serrotta on the asphalt (but while standing still; couldn't unclip!) How embarrasing. Fell on my operated left hip trochanter. No damage except an ugly black'n'blue. Then on my mountain bike a month later, did a 360 over the bars and down a slope after hitting a rock on single track downhill ("fuel break" in the Pogonip). No hip damage; just lots of raspberry scratches, bruises, and poison oak.
3 yrs 2 months: Aug 2, 2010
Hip still feels fine, although I'm having a devil of a time returning to pain-free running. Imbalance between left and right side is not easy to fix quickly. I'm also getting more "clunking" again, and have started putting together a page to chronicle solving hip "clunking", as other hip patients are having this issue as well, and not able to get much info from their doctors or elsewhere. My St. George Ironman was disappointing not because of my hip, but 50 hrs straight of sleeplessness worrying about the race beforehand! And, a virus too. 2 weeks ago I did my first completed long triathlon since surgery; the Vineman Ironman 70.3. I'd done 2 passes of the Markleville Death Ride the week before and not recovered really, and while I had a great swim, my bike wasn't strong, and my run was pathetic. See the stories here and here. I'm still eating ~4 prunes per day, getting 1500-2000g Ca with magnesium each day, and 1-2 2000IU vitamin D capsules as well. Also started taking DHEA as my testosterone levels were barely in the normal range and I have trouble building and recovering quickly despite my good diet and training. But as for my metal hip, it's still fine. No pain in the joint itself, just the soft tissues it seems. My new blog chronicles my training mileages, so if you returning athletes wonder what can be done by a 57 yr old after 10 years of relative inactivity after a new hip, you might be encouraged.
3 yrs 6 months: Dec 29, 2010
With triathlon season long over, I've focused intently on running, with just occasional biking and swimming. Doing 13-23 miles per week, mostly in short runs mostly on pavement of 2-4 miles: home to the beach, along the sand to the San Lorenzo River, back to downtown along the levee, and then to home. I've gotten great advice from my DC Tom Smith, exercises to strengthen my glutes and hone my balance. Love running to the beach and spending 45 minutes doing one-legged stands in the wet sand in the surf, as it give me a nice burn in the glutes and other muscles around the hip. Doing touch-downs on stairs, lunges, reverse lunges, and wobble cushion balance exercises. My left hip is now as strong as my right. I've still got a problem with my left psoas and hip flexors giving pain if I run more than 6 miles, but at least I recover from that pain now in just a couple days instead of a couple weeks like a year ago. Also, for reasons unclear, the "clunking" issue has gotten quite a bit better and is not something I notice any longer. I'm fit, and leaner, and wonder whether it is at least partly due to swearing off soy in early October. The female hormone mimics in soy can mess with guys, I've read, if they have the quantities of soy milk (my only real addiction, so it was tough to go cold turkey). Not sure who to believe in the battle over soy and men; feel we're all caught in the cross fire between the dairy industry's studies and the soy industrie's studies. Maybe both are biased science... Recent races include the Silicon Valley Half Marathon, Turkey Trot 10K, and the North Face Challenge Half Marathon (2200 ft of steep climbing and steep downhills with very little level ground - very tough!). X-ray taken in November showed the bone/metal interface was still perfect. Looking forward to the Rio Resolution 10K Run on 1/1/11, and a month later joining a local running club heading to Death Valley for a couple days of rugged trail running! How fun!
3 yr 8 months: Feb 20, 2011
My running continues to improve. Did the Rio Resolution 6.3 mile run in Carmel, coming in just a tad over an hour. Much improved from 2 years ago. Got some good exercises from my excellent chiropractor (and runner) Tom Smith, and learned some things at Bikram Yoga in Aptos. I enjoy running to the beach and doing one-legged balance/strengthing poses in the soft sand as the waves lap against my ankles. In late January I did a running / kayaking 3 day weekend at Pt. Reyes. I surprised myself with 20 miles of running - trails, hills, single track, paved roads, sand, wet and dry... and felt great! I thought I was ready for the marathon running at Death Valley with the Tullamore Dew Running Club.... till I got a chest infection which hung on for 3 weeks - till antibiotics knocked it out. Today was my first day back (although midway I felt OK enough to do a 9 mile run (last 4 miles were painful on my left hip flexor) and 38 mile bike, before heading back down into my diseased state). Today, I XC ski'd in the local Santa Cruz Mountains (maybe once every 5 years do we get enough snow to do that!), and also did 6 miles of running. In general, I can say that given proper stretching and training, my left hip is now as strong as my right. Given periods of inactivity and insufficient stretching/ strengthening, I will again have pain in my left hip flexor and psoas. But at least those pains go away in a day, instead of weeks like in '08 or '09. I continue to have ~4-5 prunes per day, 2000mg of Ca/1000mg Mg, 2000 IU vitamin D, and folic acid, 50mg B complex, 500mg vitamin C. I'll be insurance-enabled to get another dexa-scan in April, and I'll be very interested to see how my diet and running has improved my bone density.
3yr 11 months: May 24, 2011
I've now gotten back my standing pelvis X-ray taken May 10. From this, we can measure the cup angle. Dr. Gross finds that the cup angle should be less than 55 degrees to make sure that the loading on the cup is not "edge loading", which creates excess wear metal particles. His article on this is here. While I measured this angle on my supine X-ray of 2009 (see above), Lee Webb says it must be measured while weight-bearing. Supine, the angle I measured was 55.0 degrees when lining up the bottom of the sit bones on the '09 Xray. Here, while I tried hard to line myself up straight on and stand straight for the Xray, I don't look square here. If gravity is truly straight down in this photo, my cup angle is 58 degrees as I stand here.But if I rotate the image so that my bottom "sit bones" line up horizontally, that requires rotating the image 2.5 degrees CW. I get the same 2.5 degree CW tilt if instead I use the point where the femoral neck transitions to the femur and there's an overlap shadow. Then remeasuring the cup angle gives 55.5 degrees.
I had my blood drawn for metal ion testing. 5 vials were drawn on May 17, and one vial (phlebotomist said for the chromium) on May 20. I did a 2 mile run which put me at the Quest lab on May 17, and a 4 mile run getting me to Quest on May 20, in case that might have anything relevant for wear debris which results.
I've still got no symptoms of anything wrong with my metal hip. Did an 8 mile run on the Hoffman Loop on Sunday and felt great at the end. Been doing about 12 miles/week lately as my broken toe heals quickly. I hardly notice it now. I broke the little toe on the right foot on Apr 21, 5 weeks ago. Ran the Wildflower Triathlon just 10 days later, which was painful, but doc said I wouldn't hurt anything. My first fracture ever! Not bad for a 58 year old. I was running barefoot from kitchen to bedroom and snagged it on a steel weight bench. Man, that hurt.
This is my Apr '09 X-ray, shown for convenience right next to my new X-ray, right. The point to notice is that the operated femur is clearly has much lower bone density than the un-operated side. Two years later, at right, the two sides are much more similar in bone density. The femoral bone on the operated side has clearly gotten much denser.
Standing May 10, 2011. Clearly I look tilted. Am I really tilted, or is the camera tilted? Click for full resolution. Assuming this picture is not tilted relative to gravity gives a cup angle of 58 degrees.
Now let's assume the X-ray film wasn't mounted perfectly with gravity and could be off a couple of degrees. Seems entirely possible given my impression in the X-ray room. First rotating 2.5 deg clockwise to get the bottom of the sit bones horizontal, also makes horizontal the femur/femoral neck transition shadow against the medial femur edge at the bottom. Looking at the whole picture, the spine now also looks vertical. This looks more gravitationally aligned to my eye. On the resurfaced hip, I draw a line connecting where cup and cap meet on each side. This gives a cup angle of 55.5 degrees.
4.000 Years! June 13, 2011
I've successfully made it for 4 years. All is well. I'm running about 10 miles/week on pavement, and some trail running as well.Yesterday did the Tour de Cure (80 mile + 7,000 ft of climbing) Benefit ride; Palo Alto, over the Santa Cruz Mountains, down to the ocean, up the coast, and back over the mountains to Santa Cruz. No nagging injuries.
Dr. Gross' office has done a first measurement on my hip X-ray and finds the same angle: 55.6 degrees. The first of my blood levels of metal ions has been received. Cobalt level is at 1.7, which is within the normal range (0 to1.8) for a person w/o a metal hip, and well within the normal range for a metal-on-metal hip patient, which is up to 10. Considering all the running (~10 mi/week) and other activities, this a good sign. I should look to see if there's any work been done on how high a level a healthy person can handle and excrete. No word yet on the chromium and titanium levels. Update June 21: A more careful measurement at Dr. Gross' office gives a cup angle of 54.6 degrees. So, both the cup angle and the cobalt levels look like I'm in little danger of excess wear. Run, Rick, Run - and don't worry about it!
Got my dexa scan bone density results back as well. These were disappointing. T score on my lower spine is -1.9, when it was -1.7 in 2009, so I lost a bit of density there. My right hip has had no change; T=-2.3. Deep into the osteopenia realm. They cannot do a reading on the left (operated) hip due to the metal. However, my impression, and that of friends who've looked, is that the left hip bone density is much higher; closer to that of the right side vs in '09, as described above. That's good, but why no improvement elsewhere? I've done EVERYTHING to improve my bone density (short of drugs, which I frown on as you know by now). High impact activity, vit D, Ca/Mg, prunes (albeit only an average of ~2 prunes/day, I admit I'm a bit forgetful on these), and an alkalizing diet... So I'm re-opening the acidosis question. Re-doubling efforts to test my urine pH at every opportunity and log the foods eaten before. I do see that my urine pH is usually acidic, no matter how good my diet. The only things that alkalize it are potatoes, baking soda, and potassium citrate. Normal fruits and vegetables don't make much difference it seems. But protein definitely acidifies, and it's possible that high exercise does as well (will have to study this). I'll also look for more systemic testing which can be done for me (e.g. parathyroid issues?) to see why I'm not building more bone. Since my left leg is now much closer to my right side in density, it's possible that my body is being smart about putting ALL of it's bone building energy into the place most needed. The sheer magnitude of the density loss may mean that 2 years isn't enough to normalize. I'll keep at it.
4yrs 4months Oct 23, 2011
Hip still fine, although my running still hasn't returned to where it should be. Ran the Carmel "Run In the Forest" 10K race a couple weeks ago, which began with a mile of steep downhill to the beach on 17 Mile Drive, and my hip hurt a lot for the rest of the race, and the rest of the week. Illiotibial band syndrome has taken the place of the hip flexor troubles. However, I've also had some long runs over the past few months, including a 14 mile trail run through the hills of Nicene Marks, with good recovery. Need to keep reminding myself to spend more time with the roller and ice, and stretching and strengthening. No bone problems at least. The hip joint itself continues to be symptom free, despite the running. My exercise blog tells all... I'll be running the Four Bridges Half Marathon this coming Saturday, and plan to do the North Face Half Marathon in early December. I continue to have ~4-5 prunes per day, no soy, only occassional yogurt, mostly my protein is from whey powder, and lean chicken, and Twin Labs "Mass Fuel". I do seem to recover more quickly from hard runs when I get lots of protein immediately after stopping. 2nd annual routine colon cancer screening came back today, negative.
4 yrs 5.5 months - Dec 5, 2011
3 half marathons since my last entry; The Four Bridges Half Marathon in Folsom, CA on Oct 30, my own hill training run up West Ridge in Nicene Marks State Park on Nov 13 (15 miles), and the very tough North Face Challenge Half Marathon on Dec 4. To do 3 half's in 5 weeks, and feel good about it, for me, is real progress! The Four Bridges and North Face races, I improved last year's time by 15 minutes in each race. Still, however, my limiting issue was pain in the left hip flexor or psoas bursitis location. Some progress here, in that the pain didn't start until mile 7 or so, and was a bit less severe than in my earlier races, I believe. More on that below. And also, important to note - after the North Face race, I immediately put a pack of ice on my left hip flexor after I crossed the finish line, and left it there until it was all melted. The result - no pain, and no need for ibuprofen - and the soreness (which in the past would last for days or even weeks), didn't appear. At all! Ice is magic!
4 yrs 6 months - Dec 27, 2011
Hip is quite fine. I've probably forgotten to take my prunes as often as I remember to take them, truth be told. And so what! - my running continues to improve, with no bone pain. My friend Dave Delucchi sent along to me an interesting article No Glutes - No Results: The Plague of the Mediocre Athlete. While my excellent chiropractor, Tom Smith, had been telling me a similar story for almost two years, my rehab of my glutes (recall my surgery went through my left glute area) had been mixed. Truth was, I simply could not viscerally imagine in my mind my glutes firing and contributing to my running. The theory sounded reasonable, and I did do exercises, but as I ran, I could only imagine pulling my leg forward and then using my quads to push it back. It's a deeply ingrained pattern. But after reading this article and trying again, this time I simply imagine my glutes firing the appropriate moment of each stride. Not forcing them to fire, just gently imagining them firing, while picturing. And I have finally gotten the hang of it. Now I'm pulling myself forward by using my glutes to pull my leg backwards. The result is that my stride has lengthened by 9% (as measured on my standard 1-mile course and my old-fashioned pedometer which measures steps) while not feeling like it has lengthened. In other words, in the past when I would think about going faster and lengthening my stride, I'd end up over-striding, which is more stressful and ultimately slows you down. Now I'm simply gliding farther forward with each stride, rather than reaching further with my hip flexor with each step. I'm clearly going faster as well. Not bad, as I'll be 60 in less than a year.
4 yrs 7 months - Jan 29, 2011
I had my best run since surgery at the Rio Resolution 10K Race, a very hilly run through Carmel, on Jan 1, 2012. For the first time, I was able to run as hard as my cardio-vascular conditioning would take me, with no limitation due to my nagging runner's hip pain. No IT band syndrome either. I took 9 minutes off the previous year's 10K time, which of course is huge. Felt great afterwards as well, with no late issues coming on except muscle soreness to be expected from all the asphalt pounding. Since then, I've run done a 12 mile or a 13 mile run each weekend, and runs of 2-4 miles mid-week. I have had some left hip pain come back in the last 2-3 miles of these runs, but felt fine enough to do mid week runs of 2-4 miles within a few days. 12 or 13 miles is a lot for me. I've run more half-marathon runs or races in the last 6 months than perhaps in my all pre-hip surgery (and certainly post-surgery) years put together. Have to admit, after my last 12 mile run 8 days ago, I haven't felt like running since then. But I figured I'd just need to loosen up and again I'd be fine. Why do I figure this? Because I finally learned how to engage firing of my glutes while running, and I thought this was going to liberate me from the anterior hip pain that has nagged me ever since surgery when I run.
I wasn't sure if I'd feel up to it, but I signed on for the Mission 10 Miler at San Juan Bautista yesterday and felt my left hip start to hurt within the first mile. By 2 miles it was significant, and by mile 2.5 it was clear I'd have to stop very soon; which I did, at the mile 2.8 aid station. I rested there for about 20 minutes and then jogged back in, feeling a fair amount of hip pain. Major bummer! Why? What the heck is going on here? I should be strong enough now that any hip pain would wait till at least mile 8 or so before kicking in. So I'm on the web now, trying for more insight. If 12 o'clock is facing straight forward, the pain is at the 12 o'clock position on the hip. Not inside the groin, not outside near the IT band, but straight on top if I'm lying down. It's noticably swollen and hot to the touch if I don't ice it (yesterday, I did ice it with blue ice right away). If I keep running after it starts hurting, the pain won't go away and slowly slowly gets worse. It comes on slow and goes away even slower. If I don't ice it immediately, it'll then hurt for hours or even days. When I pulled up at mile 2.8 yesterday, I really could not go any farther. But 20 minutes later, after standing around on it but not running, I was able to run back to town, although painfully. The pain is least if I use my right leg and right glute to do most of the work of running, and just pull my left leg forward as little as possible; to about the neutral position. A definite limp. If I stand on my left leg alone, it does not increase the pain. I can tonight even stand on my right leg and then forcefully slam my left heel into the hardwood floor and thus sending a shock up my leg through my hip and into my hip girdle, and not feel any particular pain. That's reassuring - it says to me it's not got anything to do with the bone or bone/metal interface. So what is it? My DC thought it was probably psoas bursitis. On this diagram, the psoas bursa, however, looks to be a few inches below the hip socket. My pain seems to be right at the hip socket but "above" it (if lying down). I don't see a bursa at this location. OK, wait. On this page, it describes the pain pattern for iliopsoas bursitis/tendinitis, and it fits me very well. Not iliopsoas syndrome; I don't have those symptoms. Immediate treatment is here. Here are images: how to stretch the iliopsoas and, more confirmation, I just tried the "best one" - and it was far too painful to even get a start on. Ice, wait, try later...
5.00 years - June 13, 2012
My hip/bone interface remains strong. I continue to work to strengthen my glutes and my psoas tendinitis has slowly gotten less of a problem. I do run more and more miles before that tendinitis/bursitis kicks in. Just today, I did a 12 mile run up West Ridge, after doing a 50 mile (+3800 ft of climbing) ride on Satuday, and felt only a bit of mild psoas pain in the last mile, and affected me hardly at all the rest of today. It's summer, and I'm getting back to a nice beach regime - run to the beach, do balance and glute exercises, and do an ocean water swim. I do glute exercises by doing 1-legged arches lying on my back, at the beach sets of 100 on each leg, maybe 2x100 if I'm feeling strong. One thing that is very helpful, but I do too rarely, is the roller work. I just don't like getting down on a dirty floor and contorting myself to get those painful muscles deep massaged. I need a (free!) masseuse to have me passively lie on a table and tenderize away. If only! My training blog has my races. I'll have some new stuff soon, as I'll be doing the June Lake Triathlon in the Sierra in 4 weeks.
I haven't mentioned the "clunking hip" syndrome for a long time. That's because I've forgotten about it! I haven't experienced that for years now. Indeed strengthening and stretching the muscles of the hip seem to make it go away, whatever the cause may be. My left side, indeed, is now more stable and has better mechanics than my right side. Even though my left leg continues to be a bit smaller in mass than my right, it is my right that is now producing as many or more of the little "niggles" pains that come and go as a normal part of athletics. Doing my glute exercises I experience that my left side has more endurance than my right. Interesting.
5.1 years - July 13, 2012
Last weekend was the June Lake Triathlon - Olympic distances (1.5k swim, 40k bike, 10k run). I'd done a 12 mile hilly run 1 week earlier, and a 60 mile 4800ft of climbing) ride on Tuesday before. My left hip area pain has gradually gotten less on average as I continue to work on glute strengthening. Still, 12 miles is the outer limit of what I can do, and the last mile or two I did feel some pain in my left side illiotibial band and psoas. I didn't get it iced right away, and the pains pretty much stayed the rest of the week. So when I got to the triathlon, the run was tough. It was a very tough 10K anyway - at 8,000 ft, and very steep trails mostly, with some hilly road running as well. Lots of IT band pain for the last half of the run, and I haven't felt like running at all in the 5 days since. The first two days after the race, especially Monday and Tuesday, my left hip area pain extended to referred pain down to my knee. A few ibuprofen finally got the upper hand on it, and the past two days have been OK. Even did a half mile jog this afternoon, but as a run it was quite pathetic. I'd done a fair amount of roller and foam roller therapy on my legs the nights before the race, but that didn't seem to help much. Sigh. 3 steps forward, 2 back. Anyway, no serious trouble, nothing like bone or joint pain. Even my mild right knee pain I've felt for the previous month, has subsided and hasn't bothered my running or biking.
5.1 years - July 28, 2012
Recovered fine from June Lake, did the Skyland 5K and made a brick of it (45 mile ride, 3000 ft of climbing) on the following weekend July 14. I recovered from that OK, and so when the opportunity to run the entire length of Nicene Marks State Park came along the following weekend (July 22), I was intrigued and went for it. That's 16.5 miles, most of it fairly hilly, and much of it downhill. Unlike the 12 mile Death Valley adventure, the surface here was harder (about half trail, and half hardpacked fire road). I'd rate it the most severe test yet for my hip. I felt my left side illiotibial band about 5 miles into it, but it never got very severe. Possibly because I took acouple of ibuprofen just before the start? My left psoas and IT band did ache some for most of the week, but not badly. Overall, I'm encouraged. And it was certainly a fun experience. Did just some swimming and 30 miles of riding during the following week. No running. Tomorrow's the Sandman Triathlon. Been using the roller on my left leg. We shall see. But I can reassure any readers - my hip joint itself remains healthy and solid.
5.3 years - Sept 28, 2012
Some long runs and rides in the past two months; 60 mile rides several times through the SC Mtns, and the Pier-to-Peak Half Marathon 3 weeks ago. Then, the Santa Cruz Triathlon (Olympic distance) this past Sunday. I've not really recovered fully from the July 16 mile run, and the other ~13 mile runs through Nicene this summer. And it showed. Pier-to-Peak I never expected to finish, but did. And the SC Tri run was just plain ugly. 1:12:29 on the run and my left hip hurt a lot right from the start. I haven't run much this month, and did a 10 mile hike and 6 miles of running during the two days prior to the race. This may have been more than I should have. After more self-exam, I've decided that my soreness is focused not on the illiotibial band, but instead on my tensor fascia lata (TFL). This is now the limiting factor in my running, and sore psoas only comes in weakly, later, if I'm still running on the inflamed TFL. I think there is more than one tendenitis and muscle injury involved. Massage and diagnosis techniques for hip area soft tissue is here. The good news is, I still have no symptoms of any problem with hip bone/metal interface.
5.5 years - Dec 23, 2012
I'll hit 600 miles of running this year of 2012; new post-surgery high. Also highs for cycling miles, cycling elevation gain, and swimming. Still get pains along TFL, psoas tendinitis. Now that it's winter break, I plan to do more concerted time stretching, glute strengthening, and micro-massage of these spots to see if I can get some faster healing happening. A radiology tech who's in the SCTC told me that tendinitis can become permanent unless deep drastic breakup is undertaken. That seems to be my case. Unfortunately, since the psoas is so inaccessible, I'm not sure how I can do much in the way of massage. Using the foam roller on the inner side of left leg as close to the top as possible, does get some good stretching happening, but so far I see no improvement in when psoas pain sets in. I did an 8 mile run a week ago (West Ridge trail), and the last 3 were pretty painful. I tried a 2 mile run (to Adventure Sports) a few days ago and had to walk most of the last 1 mile. More stretching, and then yesterday I did a 4 mile run (easy, to Kathy's, some hills) and made it to the end, but psoas and TFL pains were setting in again towards the end. Looks unlikely I'll have a great run at the Rio Resolution Run 10K in Carmel on New Years, as I did a year ago. We shall see...
I continue to get 1500-2000 mg of Ca, and 1/2 that of magnesium. Also recently (November) upped my daily dosage of vitamin D from 2000 IU to 4,000 IU after reading a paper that that is a typical level needed to optimize resistance to certain types of diabetes, colon cancer. More on that study here.
5.6 years - Jan 23, 2013
Still no symptoms of any bone/metal issue. I continue to push the envelope on the soft tissue around my operated hip, however. I was doing well till I did a 9 mile run up to UCSC six days ago which had me limping for 2-3 days thereafter. Could bike OK, but the hip hurt. Even today, 1 mile was all I could do; just feels "beat up" still. Didn't take any ibuprofen this time, just iced it. I've happened upon some SurfaceHippy articles on groin psoas pain stories which I want to link, and ponder. I interpret "groin pain" as pain you'd point to by placing your finger at the very top of your leg on the medial side. My own psoas tendon issue (I think it's psoas), is felt on the forward side, right next to the hip flexor. If not right at "12 o'clock", then at 12:30pm or 1 o'clock - not at the medial side 3 o'clock.
I'm putting together a page of new links and images to help me resolve this ongoing issue.
5.7 years - Feb 14, 2013
Got comprehensive metabolic panel done; all were normal, except glucose which was 59 mg/dl = 3.44 mmol/l, normal range 70-100 mg/dl. Danger levels seem to be below 2.5 mmol/l, so I'm just a tad low, not seriously low. I've had 4 glucose levels done in the past 10 years. First was low (57), second two were normal, and this last one was a bit low (59). Seems not to be a big issue, but I'll continue to look at what it may mean that I'm tending a bit low. Cobalt ion levels in my blood were 1.3 mcg/liter; vs normal range of less than 1.9 mcg/liter.
Also got my HMO doctor to agree to new hip X-rays. I wanted to test the idea that perhaps my acetabular metal cup extended beyond the edge of the acetabular bone and this might be causing psoas tendon irritation. And too, to see if there was any change in the quality of the bone and bone/metal interface. I continue to have, on running any more than a few miles, a sore, slightly swollen diffuse pain at the anterior side of the femoral head, just an inch or less beneath the skin surface. And a second pain area about where that #1 calcification is (see far right image). This feels like TFL muscle pain. Ice or ibuprofen knocks the pains out within hours or less, and it doesn't return until I run again. A year ago, at the '12 North Face Half Marathon - a very tough hilly half marathon, my hip hurt a LOT during the last half of the race, but I got an ice bag on the anterior side immediately and by the time the ice bag had melted and I removed it an hour later, I felt fine and had no problem after that. This doesn't sound like bone/metal loosening type pain, which I would think would hurt continuously. Bone turnover is very slow.
Radiology report said good fixation, and "punctate calcification lateral of femoral head, unchanged since '11". However, Dr. C notes the gap at the edge of the cup on the extreme right, and the lower opacity along the boundary just inward of this, at the maximum weight bearing area.
Compare to '09 identical view
Same view, from May 2011, for comparison. Dr. C says no significant change in the worrying pattern at the top of the cup, since '11. I note that this film above was taken while I was standing and weight bearing - the goal being to be able to measure a functional cup angle. The new film at left I was laying on the X-ray table. That might make a difference in how the area projects, as indeed it does to my eye. So perfect comparison isn't possible. I'd need another weight-bearing X-ray to compare to '11. Instead, he compared to my '09 film and still saw no real change.
Frog lateral view.
Same, without added text
I'm uncertain about the meaning of the calcifications, despite some web searching. Do they spontaneously resorb in some cases? Could it (or they) be the source of my hip pain during running? From the different views, it should be possible to triangulate the location and say something more definite about what they mean and what I can do about them (or it, if it's just one calcification).Some links I found possibly useful
Calcified Tissues Links
LocalHealth - Calcification
eHow - says that dystrophic calcification occurs after muscle trauma. Metastatic calcification occurs from a mineral imbalance and most often the deposits are in muscle and connective tissue. Dystrophic is by far the most common.
This source - Dr. Sircus (alternative medicine, so unknown validity. Mostly w/o links to journal papers in support) - says that too low a Mg/Ca ratio can result in calcification in other organs. Also says increased protein intake needs increased Mg intake. Is my high protein (not THAT high, really) from eggs, chicken, and MetRX, possibly causing an imbalance?? In yogurt and milk, Ca/Mg ratio is about 10. Ideal is 2, or even lower. If true, then cut back on yogurt! My supplemental Ca/Mg for quite a while now, is 1000mg Ca / 400mg Mg, with 50mg zinc which I am told competes with Ca and so may make less Ca intake. Barb says her reading suggests need more Mg, and she takes MgCl supplements, 500mg. I should order these.
5.7 years: Mar 3, 2013
I have an appointment with an orthopedic surgeon to confer about the calcification(s), this week. Running anything more than a couple of miles continues to create pain near the TFL and also right at the ball/psoas area, near as my feelings can determine. I am suspicious that the opacity seen on the special final Xray view above, just next to the metal, is calcifications in the psoas muscle/tendon as it crosses over the femoral ball. I hope I'm wrong and that it's normal and always looks this way on Xrays. We shall see. I did a 60 mile bike ride yesterday, going harder than usual to test any weak points. Nothing concerning came up, despite the fact my hip still feels sore somewhat from my Thursday 9 mile run up to UC Santa Cruz and back, which was quite painful in the last 3 miles.
I found a great video interview with Dr. Gross, done just 2 months ago. Quick summary; 2000 cementless hip resurfacings (I was one of the first). Amstutz paper recently shows no difference in survivorship between active and sedantary patients. But for very high impact vs high impact, there's a small difference in that very high impact patients have more failures (loosenings, he found) - these are all cemented. Gross' patients do much better. Over 99% survivorship for men in Gross' cementless patients at 5 years (I'm one of 'em). Zero loosenings. He says 5 yrs is about the time you'd expect to begin to see failures in cemented. A 2009 interview has these nuggets: women on average do worse than men in postsurgery fracture and other failure rates. Cup angle very difficult to measure on X-rays, need 3-D (although he said nothing about this on measuring my '11 X-rays and saying the cup angle was 54 deg). Interesting, that cobalt and chromium are normal in the body, so I would infer that the body has mechanisms for controlling the levels, and so only when the load is consistently high and higher than the body can correct for, do you see trouble. Good that my Co levels are normal even for non-metal hip patients.
5.7 years: March 8, 2013
I saw Dr. Christoffersen on March 7 to consult, thinking the calcification(s) may be the source of my running pains. He said no. Could the psoas be rubbing against metal lip instead of bone? Yes, although he thought the placement of the cup looked good, he couldn't rule out this hypothesis. These X-ray view angles would not tell this. He said the psoas crosses the femoral ball more medial and inside than my orientations would show. Instead, his focus was almost entirely on the cup/metal interface on the X-rays. I've added notes to the X-ray panels above. He said that the way to tell if the bone was "hot" (high bone metabolism, indicating active repair was underway) was to do a bone scan. He could order this, but thought I should ask Dr. Gross about these X-rays and my symptoms and ask if he's seen this in other of his patients. I've sent a long email on this, last night. I told Dr. Christoffersen I was one of the first to get the cementless Re-Cap/Magnum design and that so far Gross has had excellent results in these first 6 years since the start of these implants. Dr. C says that the normal metal ion levels aren't indicative - it is quite common to see loosenings with normal ion levels, and good fixation with elevated ion levels. The labs are also not very accurate. Overall, he puts no importance on the blood metal ion levels at this point.
To organize my thoughts on the cause of the my hip pains, I've put together a dedicated page on the theories and evidence.
5.8 years: Mar 22, 2013
My bone scan is next week. Yesterday I ran for the first time in 10 days. Ran a mile on pavement to the beach, that felt just fine, and so I then ran barefoot on hard sand for a mile on the beach. That felt OK too. I did some glute work; 3x100 bridges on each side, and then ran back home. The last 200 yds I started to feel pain around the psoas crossover point again, and so walked the last couple of blocks. No lingering after effects. Done a lot of cycling as well. Over 100 miles last week, and will do 100 miles this week too. Back to regularly checking my urine pH as well, so far typically 6.4 or so unless I have a potato, then it's over 7. If it turns out there's some thinning or loosening bone, I'll want to be triple sure that I keep my pH over 7 at all times. Better get to like potatoes. Bananas do nothing, and even the potassium citrate I am now putting into my smoothies, doesn't seem to be near as powerful as a single small potato is at alkalizing.
5.8 years: Apr 6, 2013
Bone scan done and read by the radiologist. While there's some non-descript diffuse "heat" on the left acetabulum vs the right, there is no change from '09 and the radiologist feels that cup "loosening is unlikely". -- Bone scan taken Mar 28, '13, has this radiology report . After this report, I conducted an experiment: I did another UCSC run to the IGPP Friday seminar. If my pain was bone pain, the long layoff from running would make my bone more healed, and I'd expect to be able to run longer before any pain set in. On the other hand, if it was muscle/tendon, then the layoff would weaken these and my characteristic pain would set in sooner. Outcome: I got about 2, maybe 2.3 miles, into Pogonip, before my pain started, and it got worse the rest of the way, and homeward as well, although downhill wasn't quite so bad (which again indicated muscle/tendon, not bone). The case for this issue being muscle/tendon seems now to be pretty strong, although I obtained the digital scan images and will mail them to Dr. Gross this week and he'll give me his opinion. I'm waiting for Christoffersen to give an opinion as well, but so far nothing.
So I've added columns on my training log for doing "bridges" and roller work. I'll look for any correlation between this work and running pain. I had another thought today, after my 60 mile ride (hey, my 60 mile ride wasn't that hard even after the 9 mile run yesterday - not bad!), I thought of the Flemming & Flemming PT prescription ~15 years ago for those neck exercises, which seemed to me they were strengthening exactly the wrong muscles... yet they indeed worked. I thought of Smitty's prescription for strengthening glues to solve my pain, even though if my psoas and hip flexors were tight and weak, I'd expect stretch and strengthen them would be the actual solution. Yet early experience was that glute work indeed helped. My psoas does not appear to be too tight. If I instead stretch the opposite, my hamstrings and glutes; maybe this may be important. I tested and they're tighter now than they were a couple years ago. I have neglected them lately, admittedly.
What about hip flexor strength? Today, after the 9 mile run yesterday and today's 60 mile bike ride w/ 4700 ft of climbing, my hip flexors are a little sore, and I cannot do even one single leg raise (which seems pathetic, in fact. This may indeed be important).
Apr 19, 2013
Tried to do a 6 mile run from Harvey West Park to UCSC for the IGPP seminar. After 1 mile of uphill running my left hip was hurting too much to continue, and I walked most of the remains. I ran/limped/walked an hour later back down to the car. I seem to have fewer and fewer miles in me before the hip pain slows me to a limp. A single, or double, Ibuprofen once again knocks out the pain and it does not come back. I do not and have not done any continuations of ibuprofen to deal with these episodes. Just a single tablet or maybe two. Once the run's over and the ibuprofen has had a chance to work, the issue is over; I can walk and bike ride pain-free. My suspicions are veering away from bone/prothesis trouble and instead to irritation of the psoas and/or hip flexors over the metal edge of the cup, if the cup were perhaps just slightly protruding. If those are continually being irritated by this, scar tissue may be more and more easily inflammed with further running. Uphill running brings on the pains and downhill is less painful. I feel no "impact" pain which is what I'd expect if the bone/metal interface were inflammed and coming loose.
Bone scan and X-ray radiology reports sent off to Dr. Gross and he will comment soon. Link to my AnteriorHipPain theories and evidence page
Aug 30, 2013 (6.2 years)
I'm on track for running 600 miles this year. With some extra effort, I can keep my goal of bettering last year's total. I'm WAY ahead on my biking and somewhat on my swimming as well. Mostly been doing lots of 2-3 mile runs. On long runs and psoas rubbing comes in. Conversation on the phone with Dr. Gross in Spring added much more certainty that my diagnosis is correct - rubbing of psoas tendon over the metal lip of the acetabular component. Cannot image this because of the metal, but the symptoms match what he's seen in a few early patients and is why he made smaller cup angles a priority. At 55 degrees, my cup angle is on the ragged edge of being too steep and might cause irritation. Stretching conscientiously seems to help, and stretching of hamstrings and psoas before each run may help as well. I have not done a 9+ mile run since Fall Creek in late July. 6.7 mile June Lake triathlon run was very painful on psoas after mile 1.5. I'm planning on a long trail run this Labor Day weekend just beginning. We shall see... Gross says that if strengthening/ stretching fails, I might consider a resection of the psoas tendon with reattachment. This surgery has some success in curing this problem as it shortens the tendon and allows the muscle part to be what rides over the edge; softer and better at healing. Meanwhile, located a good review article on glucosamine sulfate and its good effectiveness in cartilage osteoarthritis (Belguim study. I would not trust any study in the U.S. influenced by the drug companies).
Mar 21, 2014 (6.8 years)
Finished '13 with 642 miles of running, and over 3900 miles of cycling - both post-surgery high marks. On average, I continue to improve my outer limit of running before my left hip psoas gets inflammed and slows me down. This year 2014 I had a bit of a painful New Year's day Rio Resolution 10K race, but since then I've felt and run very well, and may even do 1000 miles this year if all goes well. I'm on pace for 900 miles currently. Best of all, I had a very fast (for me) Hellyer Half Marathon in San Jose, the goal being to beat 2:25 so I could qualify for the Pikes Peak Half Marathon in August. Did a 2:18, 15 minutes faster than my previous best half marathon (post-surgery) at Lake Natoma a couple of years ago. I'm able to do 15, 17, 18 mile runs and not feel my left hip crippled by the end, which is really gratifying. I stretch, do barefoot beach running a mile at a time, but mostly I am just running more and finding my left hip is stronger and more resiliant. I confess after the Hellyer Half my left hip hurt a lot, for several days, and I wasn't even tempted to run again for over a week. But since then, I've run 2-9 miles every day. I'm bouncing back from whatever left side psoas and IT band pain does happen, in just a day or two instead of a week like had been happening in earlier years.
June 12, 2014 (7.00 years)
7 year anniversary tomorrow morning. I'm doing great! My running has really improved, I'm able to do 3 miles a day almost every day, and a long run on the weekend. My left psoas only hurts if I run hard for long miles. Example was the Hellyer Half, but I bounce back very fast. No leg or running or hip symptoms requiring any doctor visits. My goal this year is not just to beat last year's running mileage total, but to join the "1000 mile" club and pick up a trophy from the Santa Cruz Track Club - which would be my first 1000 mile year. I'm on pace for a little over 1000 miles as of today. Big events coming up: a training run/power hike in the Sierra's in prep for Pikes Peak. I run typically 10-14 miles on Saturday or Sunday, on trails in Nicene Marks or Fall Creek or Big Basin usually. My typical daily run is to the beach (1 mile), then doff the shoes and run barefoot for another 1-2 miles depending on how I feel, then shower off the feet and put the shoes back on and run home for a total of 3.5- 4 miles. I did have a period of pain on my right knee due to running too long on the hard sand which is canted slightly. It's great impact work and teaching good foot placement/sensitivity, but I tried upping my weekly barefoot mileage too fast as late Spring arrived, and I felt pain in the knee when twisting. Not so much during running with shoes on, but at home in daily activities. That's now gone away.
June 23, 2015 (8.00 years)
8 year anniversary a week ago. I'm still doing well. Finished last year with 1025 miles of running, and last summer especially I was at my fittest; doing the Pikes Peak Half Marathon, and long high altitude trail runs at Wheeler Peak and in Yosemite high country, and the Big Kahuna half Ironman. This year I'm on pace for 1000 miles or a bit under. However, I still have left hip psoas pain if I run hard, or run on pavement. Easy runs, even long ones, on trails I can do usually without much trouble. This year in general I'm having more pain. Finished Morgan Hill Half this March, but it was very painful. And Stanford 10K was as well. I've been slacking on the calcium/magnesium/Vitamin D, but there's no indication that thin bone is involved. I'd also been slacking on the stretching and this summer I'm putting more time into this, and strengthening. Ferrell and I are doing 8 triathlons this summer (!), 3rd is this weekend, and I've paid for most of them already. Got to solve this.
Dec 20, 2016 (9.5 yrs)
Metal/bone interface is still great, by all indications. I've got in 1000+ miles once again for 2016. However, it's been more painful - my psoas issue has been getting worse. Pain only on lifting the leg, not at all on weight-bearing. Pain on the last pushoff moment when the psoas is most stretched, yet no pain when I stand on one leg, grab my ankle and tighten glutes to stretch the left psoas and hip flexors; it feels like a good stretch and in fact is even more limber than my healthy right side when doing the same. So what's the issue? I don't know. I'm going to get an X-ray tomorrow to see if perhaps there's calcifications growing in the hip flexors or psoas which were perhaps incited by the surgery initially, or contact rubbing over the metal cup? That would show up on Xray. Strictly soft tissue would not, but I can't get an MRI with the metal in there, so only perhaps a sonogram, which I'll ask about tomorrow as well. Could it be just plain weakness and the muscles are cramping and saying "Uncle!" with my running? Hard to believe, frankly. I can only run a mile or so lately before it kicks in an brings me to a limp-walk. Then I need ice to settle it down, and then I'm fine - until I try and run again. Now, I DID successfully run an entire half marathon in Redwood City Oct 29, but that was the last time I had a good long run. Every attempt since then has resulted in the symptom I describe above, and which has dogged me more and more often over the past years. What have I tried that I think at times has helped? Stretching the inner thigh by folding left ankle over right knee when sitting or laying down, seems sometimes to help. Hip adductor/abductor work at the gym, seems to help I thought (but not lately). I did the Mt. Baldy "Run to the Top" on Labor Day with Rick Ferrell. It's 4,000 ft of straight uphill and almost no level running. I had no hip issue at all and put in a solid time of 2:17 (Ferrell was 1:42) for the 8.4 miles to the summit. And, that was immediately after a 2-day Yosemite backpack with the Delucchi's, to Sunrise Camp. Lots of elevation gain/loss with a 35-40lb pack. That, in turn, was shortly after ending my sessions with Tom Smith on re-hab'ing my hip issue with his assumption that it was just an old pain pattern that kicks in and is probably not intimately related to real damage in there. He worked on better running form; glute work, etc.
*Here's the SurfaceHippy page on this issue, which is common with HipResurf's.
*Incidence of Groin Pain in Metal/Metal HRresuf .
*Jasani et al. "Pain Related to Psoas in THR"
* Illiopsoas release in hip replacement inflammation (Heaton and Dorr 2002)
* Arthroscopic Psoas Release for Illiopsoas impingement following THA (van Reit et al 2016)
* Illiopsoas Syndrome - stretching and strengthening exercises
* Long et a. 2012 "Common Sonographic Findings in the Painful Hip post arthroplasty" - excellent! Makes a strong case that psoas and other soft tissue trouble should get sonograms.
Radiologist report finds no bone or prosthesis issues. All looks normal. But, didn't notice 'punctate calcification' of the '11 Xrays and no comment on my symptoms. It didn't look like he considered the symptoms which had me order the Xray to begin with. Questions still to answer:
* Can deep/hard massage or Rolfing of psoas break up scar tissue?
* Can stretching alone relieve symptom?
* Psoas and Illiac massage - excellent visuals YouTube 8min
* Dr. Berg Psoas test of tightness. (1:40) Subject here could do 45degrees at least. I'm a little tighter on metal side, 27 deg, but still only maybe 30deg on right side. Tight?! Stretch: put roller under hip laying down and let it stretch for at least 2 min. Also side-bed stretch.
* Psoas adhesion breakup; kettlebell on top of tennis ball on top of psoas hip lying on your back.
* List of YouTubes "Testing Psoas Muscle"
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