Andrea: Athletic pubalgia Post-Surgery Weeks 3-6

See related posts: Surgery and Weeks 0-2

The rehab rollercoaster continues...

I feel like I am on a never-ending cycle: pain ("I'm never going to get better") - some relief / not too bad ("I'm getting better!") - aggravated / pain ("this is never going to end")... repeat X a million times.

The good news here is that the pain doesn't get quite as bad each subsequent cycle, the bad news is that I can't seem to truly improve in my overall progress level...and I am a mental basket case. 

Summary of Weeks 3-6 post-op:

The beginning of this block of time was not great. Quite frequently I had sharp pains in my left abdomen and pubic bone. The left SI joint felt out of place and I was constantly trying to pop it back into place. On the right abdomen, the seroma still had a ton of fluid and hurt a lot like the pain prior to surgery. I had small, tight bands of tissue on the right side that became more pronounced/painful with activity.

The steri-strips came off right at 3 weeks. It probably wasn't until a week later that I noticed that the end of the left incision had not completely closed. It would occasionally have a white discharge or bleed with redness around the area. I waited a few more days and then Dr. Meyers put me on an course of antibiotics to make sure this reaction didn't become a full blown infection. 

I started doing some mild stretching and massaging of the incisions and muscles. This progressed to more aggressive by the end of six weeks. I have been going to PT Danny 2-3x a week and that time is almost entirely devoted to soft tissue work on the adductors and incisions (...and talking me down from the ledge). We added many new exercises to my therapy as well.

By the end of week 6, the right seroma had decreased in size so there was only a little fluid left, although it still swelled during exercise. The left "reaction" went away and I finished off the antibiotics.

My typical day:

Morning - heat, massage, and stretch
Afternoon - walk, bike ride, and/or weights
Evening - PT exercises, heat, and ice

New exercises since last post (still doing most of the others from weeks 0-2):

-Bent knee fall outs
-Single leg raises
-Modified planks -> planks
-Ball squats -> Modified squats -> squats
-Modified lunges -> lunges
-One leg bridges
-Adductor squeezes (Note: it was difficult to do adductor exercises on the left side because it would increase pain at the pubic bone significantly, so I had to do some modifications and only do them when it didn't increase pain.)
-Stretching of hip flexors, abdominals, and adductors

I tried running a couple times in the last 4 weeks just to see what it feels like, but I can tell that my body isn't ready for that yet. The elliptical causes too much irritation, so I'm sticking with mostly walking and biking for now. And playing with my favorite puppy!

Thank you Amiee for letting me borrow Roo for happiness :)

Andrea: Athletic Pubalgia Surgery Post-Op Rehab Weeks 0-2

I am now two weeks out from surgery. I spent the first six days in Philadelphia, working with a physical therapist (Nicole) at Vincera Rehab and checking in with Dr. Meyers. My dad was nice enough to take a few days off from work and keep me company, as I would have gone crazy from boredom without him.

I traveled back to Salt Lake City after six days, and the traveling day was hard on me. Over eight hours of sitting in an airplane is not easy after abdominal surgery! I had increased swelling and pain the following day, but it returned to previous levels after another day.

Throughout the second week, my pain level remained about the same, if not slightly increased. I have been consistent with my physical therapy exercises and walking prescribed by Nicole. I started seeing PT Danny at Canyon Sports Therapy in Salt Lake City, and he has been great so far - he even contacted Nicole to discuss my surgery and the appropriate rehab program for me.

At 11 days post-op I noticed an accumulation of fluid in the lower right abdominal area. Dr. Meyers told me it was called a seroma and was related to the extensiveness of the tissue dissection on that side. Jake and I call it my "pooch" - let's just say it does not make my stomach look attractive!

Other things to note: I went back to work after 7 days but limited my time there to only a few hours and worked from home the rest of the second week post-op. I also lost 3 lbs since surgery (good-bye muscle) and needed 10 hours of sleep at night plus a 2 hour nap during the day!

Here are the PT exercises that I have been doing -

250m walking
4x25m side steps
4x25m backward walking
2x10 bird dog – arms only, lead with thumb - then progress to both arms and legs
3x10 posture shoulder exercise (arms at right angle and rotate out) with 3s hold
3x10 clams with 5s hold
1x30 transverse abdominis isometric contraction with 5s hold
2x10 bent knee adductor squeeze with 5s hold
2x10 bent knee abduction against resistance with 5s hold
3x10 bridges with 5s hold - then progress with both a band around knees and ball b/w knees
1x5 extended leg lift and resisted adduction with 3s hold
1x30 back flexion and extension
3x10 side leg lift at 120 degrees (targeting glute medius) with 3s hold
250m walking
2x25m side steps
2x25m backward walking
Heat and ice several times a day
Massage starting at 10 days.

Icing after a round of morning PT exercises

I feel like I've gotten better and worse at the same time. The exercises are becoming easier for me, but I'm also having more pain than I anticipated after how well the first week went. I'm also an emotional rollercoaster - super optimistic one minute and then convinced that I'm never going to be pain-free the next. Jake really enjoys dealing with the mood swings on a daily basis! :)

Andrea: Athletic Pubalgia Surgery #2

She's back - this is Andrea's first post on Wasatch and Beyond in 2014! 

Dr. William C. Meyers

Last week I went to see Dr. William C. Meyers of Vincera Institute, the expert in the field of core muscle injuries (aka sports hernia, athletic pubalgia, etc). This has been a long time coming as it has been 16 months since I had an unsuccessful surgery with Dr. Brown in May of 2013. I tried many, many types of rehabilitation over the past year to recover from the chronic pain that intensified after the first procedure, but finally came to the realization that there was nothing more that I could do.



What I really liked about the Vincera Institute is that it comes as a whole package - the imaging, doctor's office, surgery center, and rehabilitation are all in the same place and are focused on the same patient. Unfortunately, the monetary cost is quite hefty due to the "experimental" distinction of this surgery by most insurance companies. One thing I have learned in the past two years is that my health and well-being are worth a LOT!

After MRI imaging, Dr. Meyers discussed my injury with me and did a thorough evaluation. He then brought in the radiologist to discuss my pain and ensure that all pain areas were examined on the MRI. He confirmed the critical areas that need repair by having 5 diagnostic/steroid injections done in my hip and groin. Based on all of these findings, Dr. Meyers recommended that surgery was my best option and scheduled it for the following day.

This is a very complicated area!!

Here is a summary of the surgery:

1) Left adductor compartment release
2) Left surgical reattachment of the rectus abdominis muscle to the pubis
2) Both sides psoas tendon release
3) Right adductor longus reattachment
4) Right re-repair and release of abdominal tissue

I have three incisions from the procedure. As he re-repaired the right side, there was a lot of excess blood/fluid so Dr. Meyers put me on a drain to wear for 4 days (gross). Because of the extensive nature of my surgery, he also recommended that I stay in Philadelphia for a week so that I could see him a few more times and also start rehabilitation immediately.

I honestly can't believe how different the recovery has been already from this surgery. I took pain medication as instructed but have really not felt much worse than before surgery. Definitely nothing compared to the pain from the first surgery (which makes me believe that something went very wrong there). I was able to walk a mile without difficulty the day after surgery and able to sit/stand/lay down mostly on my own. I  had a bit of nausea/sickness but food and drink helped - apparently you burn a lot of calories after surgery!

I will be posting updates on my recovery and rehabilitation. I am optimistic that this is the beginning of the end of this injury. There is still a small part of me that is afraid that this surgery won't work just like the last one, but I know that a positive attitude is critical to recovery. I will do everything I can to be pain-free again.

In good spirits :)

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!