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The insidious onset of hip pain

The hip pain started in my mid 20’s (around year 2005), although in retrospect, there may have been subtle signs during my childhood. My hips would intermittently be aching and I would experience tightness. With time, the pain would become more frequent. At that time I was a critical care nurse, and believed that my symptoms were due to the physical demands of my job. Initially, I would feel better after exercise and stretching. However, eventually I had to start seeing a chiropractor and a massage therapist on a routine basis. This, in addition to popping ibuprofen, sufficed for a few years.

In 2007, I then started to notice that my LEFT HIP was worse in comparison to the right hip. I had to lie on a heating pad to go to sleep. It would be aching/throbbing/burning in the buttock region and would radiate down the outside of my thigh. I saw my PCP, who performed a steroid injection in my left greater trochanter bursa (the first of many), and I really did not feel improvement. He referred me to physical therapy (PT). I was a shining star in PT and could do all the prescribed activities and stretches. I was always complimented on my flexibility. You should have seen my Pigeon Pose! However, despite all the therapy, I required prescriptions for NSAID (non-steroidal anti-inflammatory) and muscle relaxant. See my next blog post called “All The Drugs.”

In 2015, at age 34, I had my second child. Surprisingly, my pain had subsided during the first pregnancy, (2012) but immediately returned after delivery. This second pregnancy was hard and I saw the chiropractor twice weekly. I tried to avoid taking much medication. I was also now a critical care nurse practitioner, which eliminated much of the intense labor I had previously experienced as a bedside nurse.

In 2016 I was back down to my pre-pregnancy weight of 115lbs. The pain persisted, and I underwent an Autoimmune workup, which was negative other than my psoriasis (mild).

In 2017, my left hip pain was really becoming unbearable. Still tight and aching posterior and down the lateral side. Still burning in the buttock region. No sciatica shooting down my leg yet. I do also have intermittent pain in the right hip, both hands, and sometimes neck….but nothing like the left hip. So, I finally obtained my first MRI of the hips, which only reported sacroiliitis. I saw my first orthopedic surgeon, who had no explanation for my pain and recommended Airrosti.

In 2018, I decided to run 2 half marathons. I trained for 3 months and did well. I fell in love with running. Of note, I could only run 12 minute miles, and ran on my toes. The fresh air and listening to music took me far away from my pain. My hip pain fades away with physical activity, but returns with standing in place, sitting, or lying down. I had to take a break from running due to worsening left hip pain. I felt like something was structurally wrong. I would just do a little 2 mile jog from time to time. I had to start seeing a pain management doctor. He did steroid injections of my left hip in several places (greater trochanter bursa, SI joint, piriformis, etc), but no relief of my symptoms. He tried other prescription NSAID’s and opioids on me, but to no avail. I then had a 2nd MRI of the hips + lower back + hands. This was part of a Psoriatic arthritis workup by a Rheumatologist, since everything was “fine” on my prior imaging. My back and hands were essentially OK, but now there was “focal fissuring deep to the anterosuperior labrum on LEFT hip.” Interesting! So, what does this mean? Apparently NOTHING, according to another ortho surgeon that I consulted. He watched me do all the perfect range of motion, including touching the floor with my palms from a standing position. He had no further recommendations for me…Ugh!

By 2019, Depression had set in. This stinks! Will I become disabled by the time I reach 40 years old!?! The pain was now reaching around to the front of the hip. I had a 3rd MRI, which now showed a LEFT hip labral tear. I was then sent to a 3rd orthopedic surgeon who recommended surgery for a left hip femoroacetabular impingement resulting in this newly developed labral tear. WOW! He repaired the tear and shaved down the bone in hopes to fix my impingement. Maybe this will cure my pain! Unfortunately that was not the case, despite my surgeon even performing steroid injections during my recovery phase. Therefore, I found a new PCP who recommended a special anti-inflammatory diet with me. I was willing to try anything. I stuck to the diet 100% and took my daily oral supplements, but the hip pain persisted.

In 2020, My surgeon referred me to an expert hip specialist in Dallas, Tx. My first appointment with this surgeon was very promising. I was diagnosed with a recurrent labral tear and a congenital ischiofemoral hip impingement (basically not enough space between my pelvis and thigh bone, causing my muscle and nerves to get trapped). I underwent extensive imaging and preoperative psychiatric evaluation. I was deemed a good candidate and underwent surgery in July 2020 (during the Covid-19 pandemic)! It was a long and painful recovery. I was prescribed physical therapy to do on my own at home. After 6 months, I could successfully sleep while lying on my left hip (he had removed the bursa), which I had not done for many years. I no longer had sciatica shooting down to my foot (which had developed following my first surgery). However, I still had debilitating pain deep in my joint and posterior buttock.

It is now 2021, and I have seen my 6th orthopedic surgeon. Of note, all ortho surgeons are highly specialized. I was referred to this trauma ortho surgeon for another congenital defect. I have limited range of motion in the left hip due to a retrotorsion of the femoral head (basically my thighbone twists backwards, instead of frontwards as it should) . He literally wants to break my left leg in half, rotate it, and stick a rod through my femur. He says it will hurt… a lot. He cannot promise it will solve my pain, and that this is only one way to find out. I have decided to defer another surgery for now. I am back in physical therapy, chiropractic therapy, and massage therapy. I am seeing a new pain doctor who has performed bilateral SI joint injections, and this has helped some. I am on multi-modal analgesics (see “all the drugs” post under Resources page). I have decided to build a pool in the backyard so I can do my own aquatic rehab.

I have pain every day and have realized that it is not going away any time soon. I am finding other ways (besides just surgery and drugs) to cope with chronic hip pain. I have faith in the great physician, Jesus Christ. I now realize that God has plans for me…and I know that my pain and suffering are part of His plans. I want to help others in my situation or similar. I will make another post soon about my spiritual journey. God is good all the time. All the time, God is GOOD!

ALL THE DRUGS:

We always start with over-the-counter (OTC) medications, right? I never gave Acetaminophen (Tylenol) much of a chance (until later) as my initial focus was on the anti-inflammatory effects of Ibuprofen (ex: Motrin), which is a non-steroidal anti inflammatory (NSAID). I probably only took Ibuprofen a of couple times a week starting out in my early 20’s, but eventually progressed to 2-3 times daily. So, my primary care provider (PCP) was wise and placed me on Meloxicam (Mobic), a long acting NSAID, to avoid side effects (renal failure) of Ibuprofen. At that time I started my physical therapy (2007). I was born in 1981, so this made me about 26 years old. Mind you, I was already undergoing Chiropractic And Massage therapy. I had ongoing tightness in my hips, especially if I went a day or two without stretching. Therefore, Cyclobenzaprine (Flexeril), a muscle relaxant, was added to my drug regimen.

I was able to sustain with this for many years! I just had to take the Meloxicam and Cyclobenzaprine daily, along with stretching, nightly heat pack, and using a foam roller. However, after having a second child (2015)…things got rough. The LEFT hip pain and tightness was more frequent despite all the above treatment modalities. I knew something was really wrong, but I was told by 2 orthopedic surgeons that the MRI was negative. My PCP at the time wanted me to switch the Cyclobenzaprine to OTC Magnesium. She seemed to have a stigma against prescribed muscle relaxant, if my MRI was negative. For those that don’t know, magnesium at certain doses produces relaxation of the muscles. I gave it a month, but my symptoms worsened. I was having leg twitches at night. Not jerks, but like small twitches under the skin. Weird! I went back to using Cyclobenzaprine and things got better.

As far as my NSAID use, I went back to Ibuprofen, as I found it more effective in immediate relief of my pain. So, I was switched to Tivorbex (Indomethacin), a short acting prescribed NSAID. It worked well and it could be taken up to 2-3 times daily. At one point, it just did not seem as effective in managing my pain. I am actually tempted to give this drug another try in the future if needed. Of note, Naproxen (Aleve) does not do a darn thing for me. A couple of times during my journey, I have tried Celecoxib (Celebrex), which is even more powerful prescribed long acting NSAID, but my hair would fall out. I honestly started wig shopping until I figured out that it was just from taking this drug!! Apparently that can be a side effect of any NSAID.

So I eventually went the autoimmune route with my pain, since imaging did not initially show any structural problems. I saw a Rheumatologist who thought maybe Psoriatic arthritis could be the source of my pain, given my history of Psoriasis. We tried many immunosuppressants, including Otezla, Taltz, Xeljanz, and Methotrexate. My Psoriasis completely cleared up while on some of these medications, but NOT THE HIP PAIN.

Another drug class that can be helpful in chronic pain is antidepressant. My Rheumatologist prescribed Duloxetine (Cymbalta), which is a Serotonin/Norepinephrine Reuptake Inhibitor (SNRI). This drug was added on as an adjunct to the NSAID therapy, since I was not getting an inadequate response with NSAID therapy alone. I did notice a positive improvement in my mood, but I don’t recall a big change in my pain. I attempted this medication twice in my course of treatment, but unfortunately I was part of the 13% that would develops headaches as a side effect. I have honestly not tried any other antidepressants, but I know people that have done well with this drug class for anxiety, pain, depression, etc.

Don’t forget Hormone Therapy! In keeping a pain diary, it became evident that 10-14 days leading up to menstruation my chronic pains (both hips and hands) would significantly worsen. Therefore, my gynecologist has placed me on specific hormone therapy (birth control) to better regulate my hormones. This has helped to “regulate” my pain levels and prevent further ovarian cyst ruptures. This has definitely helped.

Well, POO! So, on to the OPIODS. These should be used as a last resort due to its highly addictive properties, increased death rates, risk of overdose, and narcotic bowel. You can also build up a tolerance, requiring higher and higher doses. Tramadol (Ultram) works well for my breakthrough pain. I have used Hydrocodone (Norco; Vicodin) in the past after one of my surgeries, but now it makes me itch so bad and I cannot tolerate it. Tylenol #3 (Acetaminophen-Codeine) has worked well for me too, but I am now taking extra strength Tylenol (Acetaminophen) and do not want to go over the limit and cause my liver to fail. My most recent hip surgery was in 2020, and my surgeon had me take OTC Tylenol (1000mg) three times daily as he wanted to avoid all opioids. Unfortunately, this led to rebound headaches (HA’s) when trying to wean off the drug 6 months later. So just remember, that even when weaning down OTC pain medications after several months of taking them, you can develop these severe headaches. It was rough, but I got through it. I would sometimes take Excedrine or Fioricet when it got really bad, but you really have to pay attention because these medications have Tylenol and NSAID. Don’t overdose on these medications as it can hurt your liver, kidneys, stomach etc. It probably took about 6-8 weeks for the HA’s to resolve.

I almost forgot to give a shout out to topical analgesics! I was prescribed a topical compound after my first hip surgery that was very effective. It included medications like Gabapentin (GABA analog), Ketoprofen (NSAID), Lidocaine (analgesic), Cyclobenzaprine (muscle relaxant), and Capsaicin (analgesic). I have also used topical Diclofenac (NSAID). There are some natural hemp creams that have served me just as well. These have included active ingredients such as Menthol, Turmeric, MSM, Arnica, and Emu Oil.

Multimodal analgesics is the way to go for chronic (and acute) pain! I do see a pain management doctor. It is now 2021 and I take extra strength Tylenol 1-2 times daily, Ibuprofen 400 mg 1-2 times daily, and a Tramadol about every 2-3 days for breakthrough pain. I also take Gabapentin (Neurontin) daily for my psoriasis and sciatica. Cyclobenzaprine for muscle spasms and tightness. Lo Loestrin Fe for hormone regulation. I also use some of the above topical analgesics, especially while waiting for oral medications to take effect. I am never pain free, but have found a way to live with my chronic pain. Of course, all of these medications are in conjunction with my providers recommendations, current physical therapy, chiropractic therapy, massage therapy, joint injections, meditation/prayer, and journaling.

Please know that everyone’s body reacts differently with OTC and prescribed medications. Always speak with your provider when starting a new medication. Make sure that they know ALL the medications that you are taking. Keep an updated list of your medications. I advise keeping a daily pain diary, just as I have for many years. I just type it into my apple note pad, but there are many free or paid for applications or notebooks out there. This will help you to know what works and does not work for you. It will help prevent you from overdosing. It will help you identify side effects that you may be having. Also, know that a medication may not work for you during one season of your life, but may actually work at other time in your life. I experienced this with some of the above medications. Hang in there and be willing to change things up. Be forgiving and patient with your body.

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