Going With The Flow

Update - I went to Dr. Byrd in TN on Monday. After another MRI, evaluation, PT, and hip injection, we have almost completely ruled out a hip joint problem. Athletic pubalgia (aka sports hernia) or other abdominal tear is likely. Next step is an appointment with Dr. Brown in CA next Tuesday with tentative surgery scheduled on Wednesday. Not sure how I feel about this....

13 miles at 6:02 avg pace... felt relaxed and controlled, except for the massive tear in my external oblique.

Half of that sentence is true :-)

Saw Dr. Brown in California today. I have a pretty significant tear in the aponeurosis of my external oblique (at the pubic bone attachment) and potentially the internal oblique and adductor in that region as well. He will know for sure once he operates tomorrow. He is also concerned that there might be some damage to my iloinguinal nerve, and that might be contributing to the persistent pain. He showed Jake how to palpate the damaged area and there is a "hole" that you easily feel (when you know what you are looking for).

So... Surgery first thing tomorrow morning. It's a quick procedure, shouldn't take more than an hour. I decided to get local anesthesia and hope I don't have panic attack! Needles, blood, and surgery freak me out.

I hope tomorrow is the beginning of a new chapter. I'll update once I'm coherent again :-)

Surgery day.

I was very nervous before surgery this morning.

Everything went about as smooth as it could have, though. They gave me twilight anesthesia and that knocked me out good. I woke up just after the procedure was finished. After it was over I hugged all the nurses and immediately asked for a milkshake - I was so hungry because I had been fasting, something I am not used to!

Then they let Jake come back and see me, and we waited a little bit for Dr. Brown to join us and explain exactly what he found/fixed, and show us the pictures.

Here's the quick rundown:

-external oblique aponeurosis tear, about 2 inches long, was sutured back together.

-internal oblique underneath that spot was damaged and about to tear, thicker portions of the muscle were sutured together across the compromised area. It had also separated from the conjoint tendon, and needed to be sutured back to that.

-2 branches off the iloinguinal nerve were frayed; these were cut off.

-adductor longus was partially torn off the pubic bone and was attached to the adductor brevis in order to relieve some pressure from the pubic bone.

He said it was the WORST injury of this type he has ever seen in a female. He said something along the lines of "i dont know what in the world you did to cause this!" This is a much more common injury for men (although still quite rare)... go figure it would happen to me.

Post-surgery... I can't say it is going great. Apparently you use your abdominal muscles for everything, so any movement at all puts me in A LOT of pain. I'm not feeling too good right now. I owe Jake a lot for being my nurse and dealing with my constant whining. It can only get better from here, right?

I will post some more info about what he did (and pictures of the tear) when I get home on a real computer... Not to mention being able to sit up and move more than an inch. I'm such a baby when it comes to pain.

Thanks everyone for the support and for thinking of me :-)

Post-Surgery Day 1 (day of surgery, yesterday) ended up being pretty rough. I really couldn't move without significant pain. I tried to stand up (with lots of help from Jake) and both times I was on the verge of passing out. Most of the pain was at the site of the incision and my back was also cramping quite a bit. I finally called the doctor at night, and he doubled the dose of pain medication. It took a while to kick in, but I finally felt a little relief.

Post Surgery Day 2 was overall better except for the traveling home. I could stand up for a while and finally loosen up a bit. We went to the park and laid on the grass to soak in some sunshine. I was stupid enough to think I would be fine traveling today. The traveling went okay at first (with a wheelchair of course). By the time we got off the plane, got on the shuttle then to the car, I was not doing well. I started to shake and panic from the pain which only made things worse. It took us two hours from the time we got home to calm the pain and be able to go to sleep. Poor Jake had to deal with me...

This was waiting by the door when we got home :-)

Post Surgery Day 3

Got some sleep (in about 2 hour increments). The incision area(s) are still painful and sore. I am able to move a little better today and my range of motion has improved some as well. But it is still hard to walk and I get shooting pains when I walk. Overall I think I am making progress, although I wish I was improving faster!

Dr. Brown called to check in for the 6th time in the past 48 hours. I am very impressed with him and his concern for me. He told me not to stretch at all for a while, and try to slowly taper off the pain medicine without putting myself in too much pain.

Here are some pictures from the surgery. If you are squeamish, don't scroll down any further...

The injury I had is what is considered a "sports hernia" although it really isn't a "hernia" at all (somehow it got that name a name a long time ago because it occurs in roughly the same area as a regular hernia and happens to athletes). A better term to describe it is Athletic Pubalgia. Diagnosis is very difficult, because it basically occurs through process of elimination of all other groin/hip injuries. It is also rare (very rare in females), and a lot of doctors don't even know about it (for example, I had one surgeon in Utah tell me such an injury didn't even exist!). Matt Poulsen actually suggested this could be the problem all the way back in September, but he also knew it would take some trial and error to accurately reach this conclusion. He was right all along. Typically, people with this injury are encouraged to try several courses of physical therapy (along with ruling out FAI, labral tears, etc). I did all of those things and as you will see by the size of the tear, there was no way this was ever going to heal with PT or conservative treatment alone. The amount of surgeons who work with higher-level athletes and repair this injury can be counted on one hand. Dr. Brown was the closest to SLC and had excellent reviews; I'm very glad I chose him as my surgeon.

This is the location of the injury, for reference:

This first photo is of the primary tear of the external oblique aponeurosis. The tear is 2-3 inches long and separated by a full thumb's width. The arrows show where the tissue should be attached. That entire area between the arrows is torn.

The second photo is another layer down, now looking at the internal oblique. This area wasn't torn, but the area outlined by the yellow box was very thin and barely being held together. It was at risk of tearing at any point. The internal oblique was also torn from the conjoint tendon (but I don't have a photo of that).

The third photo is showing how Dr. Brown is pulling thicker/stronger portions of the internal oblique together over the thin/compromised area.

The fourth photo is Dr. Brown pulling the external oblique together (essentially attaching the ends separated by the yellow arrows in photo #1 back together).

I don't have good photos of the adductor repair or the damaged nerves. Maybe that is a good thing, I don't know if I need to see that as well. This is enough. 

Post surgery Day 4. Moving a little better again today - I can walk 50 ft instead of the 25 ft yesterday :) Incision area is still pretty swollen but less numb. Sitting up and side motions cause pain, lifting right leg is okay now, and the cramping has lessened.

Goal for the first 7 days is merely to recover...go on short walks as tolerable but mainly just rest. Slowly taper off pain medication. Glad the weather is nice to lay out in the sunshine!

Post Surgery Day 5.

Big improvements today. Less back and butt cramping. I was able to double the distance I walked from yesterday and be more mobile overall. I even took an adventure to the grocery store, although I had to drive around in the scooter chair.

I might just be being paranoid, but I am feeling some discomfort on the contralateral side from the surgery, and I'm worried that side is going to end up injured too. Hopefully its just a symptom from the overall discomfort of the past few days and nothing major to be concerned about.

Post surgery day 6. More progress - three walks of 0.2 miles and stood up for an hour straight. Exciting stuff!

So here's my theory on the injury. It all started when I strained my iliopsoas muscle. Once that muscle weakened, it created an unequal distribution of forces in the groin region compared to normal. This resulted in unusual strain of the internal and external obliques near the groin. Eventually, the aponeurosis tore. I had so much instability in my hip with the tear and the weak iliopsoas that the other muscles surrounding the hip (gluteus medius, TFL, IT band) became protective and overworked, causing pain in those regions as well.

Because the injury was so long, a really important aspect of my rehabilitation is going to be retraining the muscles to perform the right functions again and redevelop stability in my core.

I am open to other theories and ideas for getting back stronger!

Day 7 post surgery. Made it an entire two hours at work today before completely crashing. I was able to walk .35 miles this morning and will try again this afternoon. Mostly discomfort at this point instead of cramping and pain.

A week since surgery. I did "a lot" today...probably too much. Walked for 3/4 of a mile then went in to work for 3 hours. It was Fitness Day and they held a 5k so it was pretty much mandatory that I at least go and cheer everyone on since I convinced a lot of them to run it. Probably walked another miles during this time. I finally made it home and hit pathetic mode for the remainder of the day.

Getting off narcotics + doing too much yesterday made me regress quite a bit...mostly spent the day laying in the bed or on the couch. I was able to walk for .75 miles this morning and started some very light stretching. My psoas muscle and gluteus are so tight but I still have a few more days before I can really massage and stretch like I want. I also went for a couple short walks in the afternoon, just to keep my muscles from complete atrophy. I am now searching for puppies.

Felt the same as yesterday. I did a slightly longer walk this morning then a lot more laying around. Feeling achy in both the groin and the adductor. I also noticed quite a bit of swelling right around the ASIS that hurts to the touch. I did try stairs in the afternoon (down and back up the track stadium) and felt a lot of weakness with lifting my right leg, doable though. I'm off the narcotics now and decided to take regular ibuprofen until all the swelling is gone.

It may seem like too much info post surgery, but I do want to make sure I document well for my own purposes later on and in case someone else wants to know what the recovery from athletic pubalgia surgery is like.

Good progress today, definitely my best day yet. I did the same amount of walking but was up on my feet and moving around a lot more. Whenever the pain started, I was able to lay down and get it back under control within 30 minutes. The sneezing gods were against me today, though...I probably sneezed 10 times and it still does not feel good to do that!

Hit the magic 1 mile mark for walking today, as well as a couple shorter walks throughout the day. I am now able to start light stretching/massage and a couple exercises (partial squats, posterior pelvic tilt, and calf raises). 

This week is dedicated to more and more walking (and backwards walking!), then at 3 weeks I can begin light biking/elliptical/hill walking. Most of the rehabilitation protocols I have read indicate a 6 week time frame before running. That puts me at June 19th - just in time to race in the Sugarhouse Relays! :)

I made it (well, mostly) through my first full day of work. I got nervous after a couple hours because my abdomen started getting uncomfortable but it never hit a breaking point. This is very good news! Walked for .75 miles this morning. I'm starting to feel a tiny bit of optimism creeping in for the first time in months...

Felt the effects of yesterday. I managed to work until 3pm before going home and laying in bed for a few hours. The lower abdomen/groin starts to feel crampy and I get shooting pains to my back -  that's when it becomes too much. I went back out for a fun girls dinner, laughed too much, and started hurting quite a bit again. That part was worth it though :) I need to take it easier...it's just that life's getting in the way. 

Started off the day not feeling great, so I went on a very short walk then to work. Felt better as the day went on - just a little achy. Ice is pretty much my savior right now.

I'm starting to get worried about this glute and hamstring pain again...it feels about the same as prior to surgery. I really hope it'll get better as the abdominals are healing. If it's not associated with the athletic pubalgia, then I have no idea what's wrong. I have to keep telling myself - it's only been 2 weeks since the surgery, and I can't expect all my problems the last 9 months to just disappear. 

Went to a physical therapist for a consultation regarding my injury. She specializes in pelvic disorders and does a lot of manual therapy in her practice so I'm thinking about trying her out.

I felt pretty rough this morning but it got better as the day went on. I went a few short walks today instead of one longer one. Also, I got a massage cushion today to try to loosen up my very tight back.

Day 16 post surgery and I feel very similar to my pre surgery injury most of the time. Now is the real test...will I keep improving? I hope so! Heading to Portland this weekend for a wedding...my dancing skills may be compromised, but I'll be dancing next to Jake so I don't think anyone will notice.

Flew to Oregon and drove the scenic way through the Columbia River Gorge. We stopped at all the vistas and waterfalls along the way - this area is absolutely beautiful. We got lucky with a sunny day too. I probably walked 2-3 miles over the course of the day with only mild discomfort.

Hung out around the water in Hood River at parks and the pool. Several short 10 minute walks throughout the day. Tried dancing at the wedding but it was a failure and had to leave early. Beautiful area with amazing views of Mt. Hood.

Pouring rain in OR. Jake got lavender poisoning and I was feeling pretty rough from the last couple days so we layed low until our flight back to SLC. I realized that the pool seems to help my injury so I'm glad the pool opened up this weekend for me to relax. Almost hit a breaking point by the end of the day - flying is still pretty rough on me.

Feeling pretty achy and sore from the weekend. Lots of activity! Here are some shots from our adventures in Hood River - 

Felt pretty good today...walked for 1.3 miles and did some very light exercises. I went to a PT yesterday and started psoas release, connective tissue rehydration, and gluteus medius monster walk. I also started scar mobilization which is really uncomfortable. I'm feeling grumpy, impatient, and worried. Thank goodness a puppy is coming in a few days.

Short walk this morning with Jake. My deep glutes are worrying me more than the incision area - I really think they are overstimulated from the months of compensation. I need to find ways to inhibit those muscles. 

PM - Jake got tons of prototype Saucony shoes today and I couldn't resist but to try them out. I was able to shuffle run for about 15 seconds in three different pairs of shoes! Then PT and lots of ice.

Interesting article about the relationship of altitude and obesity. I thought these illustrations were pretty cool - 

Short walk with Jake. Will walk a mile this afternoon and PT. 

I am now at Phase II of Rehab (weeks 4-6). I get to start doing things! Here's the plan (as tolerated with only mild pain) -

GOAL: Improve soft tissue flexibility. Re�introduce core strengthening and mild to moderate cardiovascular re�training.

ï‚· Begin with flexibility training of all lower extremitymuscle groups, i.e. hamstrings, adductors, gluteals, calves, hip flexors, quadriceps, etc.
o Low load, long duration to softtissue in orderto have plastic changesin tissue

ï‚· Core strengthening/Core Stability exercises, i.e. Pelvic tilts, Planks, Dead bugs, etc.

ï‚· Isolated muscle progressive resistive exercises
o Straight leg raise for hip flexors
o “Clamshells�/Sidelying hip abduction and bridging for gluteals
o Sidelying hip internal rotation “Cowboys�2 for hip internal rotators and adductors
o Wall squats/sits for hamstrings and quadriceps
o Heel raises for calves

ï‚· Straight plane motion of weight bearing, body weight progressive exercises
o Forward lunges(not deep lunges)
o Single leg pendulum dead lifts
o Moutain climbers (use of plinth or table to start)

ï‚· Proprioception training
o Single leg balance activities including cone taps, hurdles, hip sliders, etc.
o Unstable/dynamic surface added to progress difficulty, i.e.foam pad, pillow,tilt board

ï‚· Cardiovascular retraining
o Elliptical use to pain free tolerance, monitor distance and time
o Seated/Recumbent bike
o Treadmill walking
o Swimming