May 14, 2013

Andrea's Athletic Pubalgia Surgery

[Update: Please read Andrea's Athletic Pubalgia Surgery #2. I highly recommend NOT seeing Dr. Brown as his surgery was unsuccessful and resulted in more complications.]

This could potentially be a long post, so I'm going to try and keep it as concise as possible, and summarize some of the information Andrea has been posting on her training log. I'll link to more detailed information when possible, and as always - if you have more questions, we are happy to answer whatever we can.

As most readers of this blog know, Andrea has been injured for a long time - she's basically been on the sidelines since the end of July 2012. Some of her updates on Wasatch and Beyond since that time:

September 2012 - Injury Pains
November 2012 - Still on the sidelines...
January 2013 - Injury Update

She was hurt (with no diagnosis) and unable to run from September through November, then made a bit of progress in December and January (even ran a 5K race), but then in February/March things fell apart again. If you read through those blog posts, you'll see that she was one of the most pro-active patients ever: she saw several MDs/PTs, went through multiple courses of physical therapy, tried no running, Alter-G running, backwards running, cross training, no exercise at all, etc etc etc. It was frustrating to say the least, especially with no diagnosis and no relief from the pain. Andrea did everything right for 9 months and nothing seemed to help. By April, the amount of walking needed to complete basic tasks (like going to the grocery store) were difficult and put her in a lot of pain. I felt awful for her and just wanted nothing more than for her to have some consistent relief.

Finally at the end of April she flew down to Nashville TN to see Dr. Thomas Byrd, who is one of the top hip surgeons in the world. He did a thorough evaluation, another MRI (#3!), and was able to rule out FAI and/or a labral tear as the source of her pain. This was good news, as those are difficult surgeries to recover from. I should note that about a month earlier, a local surgeon (Dr. Hickman, who I wouldn't let put a band-aid on me) told her that she definitely had FAI and needed surgery right away. Its SCARY how WRONG he was. Lesson is: don't settle for the first opinion, especially that of a junior surgeon. Dr. Byrd's feeling that FAI could be ruled out was also backed up by several expert radiologists that Andrea sent her imaging to.

A week after her appointment with Dr. Byrd, Andrea and I found ourselves in Fremont, CA for a consultation with Dr. William Brown, a "sports hernia" specialist. Dr. Brown diagnosed Andrea with this condition, and she decided to have surgery the following morning.

The injury turned out to be pretty substantial. Here's the quick rundown of specifically what was wrong and the surgical fix:
  • 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!" 

Andrea's daily log for May provides the day to day details of how all of this played out.

In one of her posts, Andrea explains a little more about this injury and process of diagnosis:

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.
We have been very impressed with Dr. Brown throughout this entire process. In the weeks leading up to her appointment, he talked to Andrea several times on the phones and answered all of her e-mails quickly. In the first 48 hours after we left the surgery center, he called at least 6 times to check in on her. His concern was real, and we would both highly recommend him in the unfortunate case you ever have to deal with an injury like this.

Andrea is almost a week out from surgery at this point. She will post more about the recovery process (not easy!) in another post.

Now, I'm going to post some images from the surgery. Don't keep reading if you are squeamish or don't like seeing this kind of stuff...

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 we 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)...

We don't have good photos of the adductor repair or the damaged nerves. Maybe that is a good thing!


  1. I've been reading your blog for awhile and just had to comment cause Friday I'm going in for my second hip surgery. I was diagnosed (also by Matt Poulsen, who I thought was awesome!) with FAI and labrel tear. I had surgery last September and my hip joint was a mess apparently and they did tons of work in there...but after 4 months of recovery all my symptoms came back so after more injections and MRI's I'm going back for a revision to see if they can find the problem. I haven't run in nearly 9 months (I'm not nearly as talented as you two:)) but I can empathize with Andrea. I just had to comment and say Hi cause this post hit a little close to home:)

    1. Aww Leisa, we feel for you. One of our close friends had FAI surgery two years ago, then some problems came back and she had to go through another surgery a year later. Its been a tough road for her, so we have a sense of what you are going through. However - she is doing SO MUCH better after her second surgery... like, the best she's been in years!... so keep your head up and don't give up.

      Matt Poulsen is a fantastic doctor. He is a good friend of ours and we'd trust him to help us with anything. Andrea saw so many specialists over the course of the past year, and Matt was the only one who kept telling us - don't rule out the sports hernia. He was right all along.

  2. Well I am glad that finally there was an answer. Here's to hoping for a good recovery.
    I am injured at the moment and I agree 100% with what you said about getting a second opinion.
    Doc 1 was one who is quick to send patient to the OR...I had a bad feeling right from the start when he assumed I had a torn meniscus before seeing my MRI. MRI was seen by 3 radiologists, all said the same: no tear. Doc 1 still says there is a tear and I need surgery. Went to see doc #2 who is one of the best knee surgeon in SoCal and his diagnosis made more sense with the pain I have.

    I hope Andrea will be back on the road and pain free soon.

  3. Hi! Can I please ask if you flew out to California for the operation on your own?

    Thanks, and best of wishes :).

  4. Hi! Can I please ask if you flew out to California for the operation on your own?

    Thanks, and best of wishes :).

    1. Mike - I flew out to CA w/ Andrea. It would have been very hard (impossible) for her to get around on her own in the days after surgery.