Nine Months To Arrive At The Final 1st Opinion. May 2012 - Feb 2013

If the years running up to Donna, my new physiotherapist believing I have FAI were complicated, then the next 18 months were just as much so!. My advice when you are going through the GP referral process is that you keep a note of everything, just jot down in your diary or create a document on your computer. Record appointments (and cancelled ones) and a brief description of what was said. It makes it far easier to keep track of everything rather than relying on memory or leafing through the pile of paperwork you will inevitably collect! I recorded mine on my computer, which now makes explaining the shenanigans a little less taxing on my brain!

So here goes, I warn you, its a long story!

16^TH May 2012 -  went to see new physiotherapist Donna, she suspects FAI in left my hip and would like it MRI’d

1^st June 2012 Referral letter from Donna to GP

               “....she describes a constant lumbar pain, radiating into the left hip with a burning pain into the buttock and lateral thigh. She also complains of left hip pain.....she has a flat lumbar lordosis and poor muscular control around her pelvis. Her left ilium is slightly higher and rotated at the sacro iliac joint. Forward flexion is painful, limited and she compensates with side flexion to the right. She has a small degree if neural tension on slump and L4/5 S1 is painful on palpation. However, her hip pain is reproduced with impingement tests and brings on her buttock & thigh pain....I have referred her for clinical Pilates to deal with muscle deficiencies around her pelvis and I have started a gentle manual therapy programme to restore more natural movement in the spine. however I am concerned her left hip pain has never been investigated. In light of the strongly positive impingement signs and reduced movement, I think an MRI would be sensible”

8^th June 2012 - Appointment with GP. I giver her the referral from the letter from the physio and ask for a private referral to someone at the private hospital. She recommends Mr W.

9^th July 2012 - Private Appointment with Mr W,  following letter goes as follows

               “ ...At present lateral left hip and groin symptoms have become more troublesome. She can only walk for 30 minutes and will the experience more persisting low back and left hip pain. She has an occasional clunk in the groin on hip movement which appears to be related to the psoas muscle on provocation today....she walks with a slightly stooped forward gait. The leg lengths are equal and Trendelenburg test in normal in each hip. There is some discomfort on full flexion, restricted to 110° with positive anterior hip impingement test. The Psoas provocation test was positive, producing a clunk. Gilmore groin test did not produce any pain in either groin but did produce low back pain. Faber test produced pain in the low back and left sacroiliac are but not the hip. There was localised tenderness over the left sacro iliac joint, with no significant pain in the gluteal tendons or trochantic bursa area. There was no palpable inguinal hernia.....some of the pain in the lateral left hip and groin area could be related to impingement at the left hip. I have recommended further x-rays of her pelvis and left hip, to be followed by MRI arthrogram”

This was a private consultation that I  paid for, I was then referred on to Mr W's NHS clinic. This required an almost duplicate consultation as above, but at Mr W's NHS clinic, carried out by the his registrar Mr P. This appointment did not happen until the 12^th October. 2012, 4 months after I initially saw Mr W.  
In the mean time I had an x-ray of my pelvis at our local hospital. Between seeing Mr W in June and Mr P in October  I began to get the same symptoms in my right hip. I struggled through with Donna trying her best to keep my back happy. We managed to get me into the gym and I was trying to use the static bike, wave machine and leg press equipment alongside Pilates with a colleague of hers to try and strengthen my back. But all these exercise only worsened my hip pain on both sides and we had to drop back to just very simple floor exercises. I had a little routine of clam shells, pelvic rolling/rotating from side to side, leg lift and “sit ups” that I could do at home, along with walking the dogs for work.

 12^th October 2012 – Finally  I have my first NHS appointment with Mr W's understudy, Mr P. He had my Xrays that were taken during the summer. He  says the X rays look good but seemed surprised when he examined me and FAI tests were positive in both hips. His following letter read:

               “...on examination of the lumbar spine, there is only mild pain on facet joint compression active lumbar flexion is good. Examination of the hips revealed equal leg length. There was pain bilaterally on the anterior impingement test on flexion, adduction and rotation and there was also some clicking felt particularly on the right side...she reports the pain was felt in the groin rather than in the back. Range of external rotation in flexion bilaterally was 40° However there was less internal rotation of approximately 10° to 15° bilaterally....x-rays of her pelvis and left hip show no signs of degenerative arthritis. She does not appear to have a retroverted acetabulum on either side as evidenced by lack of cross over signs. There was a suggestion of small bilateral cam deformities...I have ordered bilateral MRI arthrograms. I have explained to her that should these scans show any labral pathology, then we may discuss the possibility of surgery. However, she also understands that the scans may be negative.”

27^th November 2012 Hip Arthrogram on both hips. I found this very painful, though many people find it is not, my hips were injected with dye. As I had both hips done, I had to be pushed in the wheel chair and to the MRI machine. I was allowed home straight after, My hips joints had a weird “full” feeling which wore off after a few hours and I had no nasty side effects. I don’t know what sort of local anaesthetic was used, but I had no pain relief from it chronic-pain wise.

It took until the 19^th January 2013 to get any results back regarding the MRA, and a variety of difficult phone calls to Mr W's secretary, one of which was on the 12^th December and I was told a letter with the results was in the post!

29^th December. Letter dated 24^th December arrives with appointment see Mr W or  one of his team on 2^nd Feb 2013.

19^th Jan 2013 letter dated 11^th January 2013 arrives from Mr W

               “I am writing to let you know the result of you MRA performed on the right hip on 20/11/12. This showed a minor split or tear in the labrum and a small bony lump on the femoral head that may be causing some impingement. The appearances were better in the left hip with no significant labral tear and minimal femoral bump....however the appearances are not sever and may not be the cause of your symptoms. I am mindful that your suffer with low back pain. Nonetheless, if you are keen to explore surgical treatment for your hip problems, we should consider arthroscropic surgery for the right hip and possible removal of the the bony lump and torn labrum at operation....if you wish to proceed with surgery, let me know and I will put you directly on the operating list at Southmead”

There it was in black and white. A diagnosis. I went through a range of emotions very quickly. First I was very upset at the thought I had something physically wrong and that I needed an operation. Then I was relieved that there was something wrong and I could have an operation to fix it. Then I was upset that he was saying the findings were actually quiet mild and might not be causing my pain, but that he was willing to do surgery. I didn’t want wasted surgery. And yet just by making a telephone call I could put myself on the list for scope surgery, and probably have it done in about 6 weeks time. I didn’t know what to do. At first I thought. Yes. I will have the surgery....but I cant have it yet, because work is getting busy for the summer, I could have it in the autumn. Could I last that long in pain? I asked a few questions on Face Book and the consensus was that by waiting I could make it worse. So I very nearly booked that surgery. And then, I don’t know why, I didn’t. I decided to wait for the follow up appointment that had come though for 2^nd February, to discuss further.

2^nd Feb 2013 Appointment with Mr Ward. We had to wait to 2.5 hours after our appointment time and so I was very sore by the time I got into see him. He was obviously having a very stressful morning clinic. I think we were in there with him for about 6minutes all together (after waiting a further 10 minutes in his room for him to appear). His computer was not on and so he had no MRI images to show me. The opinion from him was that I had only slight FAI symptoms and that it was unlikely my pain was due to the hips. He said he could still do a scope, but it would be unlikely to help as  he was certain my hip pain must be coming from my low back/facet joints. My husband asked him if a hip steroid injection might help, as the ones I had had in my back previous had not worked. He said there was no point in doing that, that it wouldn't make a difference to my pain. He suggested I do some Pilates to improve my core and get my GP to refer me to a spinal specialist and explore that route, if that was unsuccessful then return to him. Also said that I should stop horse riding, as it was not a wise thing to do with the issues I have in my lower back. This flattened me. My horse Charlie Brown is my life. I started to cry, not something I wanted to do in front of this patronizing man. He held my  hand and tried to comfort me (in a patronizing way). He made me feel like a child! I wanted to punch him! 

I left that clinic in floods of tears and have never felt so down, depressed or lost in my life. I had come full circle, from having undiagnosed back and hip, to a diagnosis of FAI, to a hip surgeon that was telling me my pain was probably all coming from my back,  and that I should go back to improving my core. I had been trying to improve my core for the last 10 years but can't because my back and hips wont let me. And I could not believe that after everything he had said, he thought may actually want to have a scope surgery from him one day. Although I did not know what to do next, I was certain that that man would never come near my hips with a surgical instrument.

Here is some of the content of his following letter:

               “Examination shows the right hip flexes to 120° with increasing discomfort beyond 100°, with similar findings in the left hip. In the right hip, there is restriction of internal rotation to 25°, with increased external rotation of 55° when the hip is extended, with positive anterior impingement test when the hip is flexed and internally rotated. The Psoas provocation tests were negative...MRI of the right hip has shown a possible small anterior labral tear in association with the recognised cam lesion or bump on the femoral head neck junction. The joint is otherwise well preserved, There is no sign of a labral tear in the left hip despite her symptoms....I offered arthroscopic surgery of the right hip, but stressed that most of her symptoms were related to the cam lesion on possible impingement. She describes further pain in both hips being possibly worse in the left at the moment. Clinically the symptoms to not really match with a primary impingement problem and I am concerned that her symptoms are probably driven in a large part by her chronic back pain, with increased sensitivity to pain in both hips and legs.....there is a chance we could make her worse with surgery, a chance we could make her better, and fairly high chance that we  won’t make much difference to her level of symptoms. It would be far better for her to spend time concentrating in improving core stability and condition of her back. She really wants to return to horse riding and I have tried to persuade her that it is not a realistic expectation given the extent of her back symptoms and problems.....I wait to hear if she would like to take up the offer of surgery after appropriate further rehabilitation.”

Interestingly he never mentioned seeing a referral to a spinal specialist in this letter.