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Bursitis, ITB tendonitis after total hip replacement

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I am female, 51 years of age. I had a lateral, right THR, without cement, 8-5-2012. I have always had anterior thigh pain since the surgery. A couple of months ago, I started to get the groin pain again and lateral hip pain. My surgeon did xrays, implant looks good, told me to take ibuprofen for two weeks and call if not better. The pain didn’t get better, called the surgeon, they referred me to Physical therapy for 5 weeks. The therapist thinks I have bursitis and IT band tendonitis related to scar tissue at the incision site. I have had 7 sessions with PT consisting of ultrasound, hot packs, massage, electrical stim, stationary bike riding, and leg presses on the weight machine. Nothing is helping. I now have pain in my right knee when walking. I feel like my surgeon is blowing me off. Do I continue with the PT, ( I am half-way done), or insist on something else? I am so tired and frustrated of being in pain. There are days I wish I never had the THR. I didn’t have PT post-op, surgeon said I could do it on my own at home, because I was young.
Thanks in advance for any suggestions
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First Helper User Profile Gaelic
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Users who thank far40us for this post: Flahippy 

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replied January 7th, 2013
Especially eHealthy
far40us,

You did not mention if the therapist is doing any stretching exercises for the ITB. You may need to really stretch the ITB and its muscle, the tensor fascia lata. The Ober test is done to determine if the ITB is tight. If it is tight, it will need stretching. The modalities are nice for soreness, but they will do nothing for the tightness.


If you think that the physical therapy is not helping you at all, then speak with your orthopedic surgeon. He can do some testing to see if there is an infection in the joint or if there is loosening of the components. He can examine the knee, to see if there is anything going on in it. He can examine the motion of the hip, to see if you have iliopsoas tendonitis or bursitis in the front of the hip (groin). This can sometimes be treated with steroid injections.

Unfortunately, if nothing is found, are you ready to handle the fact that you may just have to learn to deal with the discomforts. With the lateral approach, there is some scarring of the tensor fascia lata. It sometimes responds to stretching.

Also, you only four months out from the procedure. It may be that you will not reach your final recovery for several months yet. It is not uncommon for patients to take as much as a year to 18 months to fully recover from a total joint. It depends upon what condition you were in before the surgery. If you had been using a cane or crutches before the surgery, and not doing a lot of physical activity, you are going to have to get back into a decent physical condition.

It may be that your tissues are not used to the level of physical activity that you are now putting them into. They are getting sore, like when an athlete is getting back into condition after being off for a while.


But, again, sometimes, it is just not possible to tell why a patient is having problems.

However, it is worth a try to speak with your surgeon about it once again. You might also have the physical therapist write up a narrative summary, stating that the physical therapy is at an end, that it is no longer helping.


Good luck. Hope you find out what is causing your pain.
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replied January 8th, 2013
So sorry, I had the THR in 2011, not 2012. Yes, my therapist is also doing stretching. I have an appointment with my surgeon in a couple days. No, I am not ready to live with this pain. I am a nurse in a long term care facility and need to be on my feet most of the 8 hours. I can manage to live with the thigh pain, but not the lateral hip pain. When I called for the appointment, I was told they don't do cortisone injections after a THR. I will keep you updated, thanks for your information and help.
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replied January 9th, 2013
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far40us,

It is understandable that a total joint surgeon would not do intra-articular injections with a steroid agent, but it is not uncommon for them to do steroid injections for bursitis around the greater trochanter, or even anteriorly, for iliopsoas tendonitis/bursitis.

Maybe the person on the phone thought that you were speaking of an intra-articular injection, which of course would probably not even address your lateral hip pain at all.


Lateral approaches are notorious for causing lateral hip discomfort. But, of course, the approach is better in terms of it lower dislocation rate. So, there are the "pros and cons" of each approach.

When the tensor fascia lata and the gluteus medius are divided, there can be quite a bit of scar formation. Also, sometimes how the surgeon actually gets to the hip joint can cause post-op problems. If the greater trochanter is removed and then replaced, the internal fixation used to hold the trochanter in place can sometimes cause lateral hip irritation.


You have a difficult problem. You also have a very strenuous job, in that most total joint patients do not have a full time job, especially one which requires them to be on their feet most of the day and do a lot of heavy lifting (patient transfers). So, you are stressing the joint a lot more than most prostheses were designed to handle.


But, the surgeon should be able to find some way to treat the tensor fascia lata/ITB problem in some way. The usually treatments for that problem are extensive PT/stretching (which you have done) and steroid injections around the greater trochanter (unless the ITB is snapping over the femoral condyle at the knee, in that case, the injection would be a the knee).

In patients without a total joint, if nonoperative management is a total failure, there are several surgical procedures to release/lengthen the tensor. But, again, the surgeon may be reluctant to do this.


So, hopefully, the surgeon will be able to find out what is going on with your hip, and it can be treated easily (or at least treated).


Hang in there. Wishing you the best.

Good luck.
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replied January 12th, 2013
Gaelic,
Saw my surgeon yesterday, had blood tests done to check for an infection. She also wants me to have a bone scan. Today, the blood tests came back normal Surprised)
So, should I still have the bone scan done?
Thanks for your support and knowledge!
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replied January 12th, 2013
Especially eHealthy
far40us,

A technetium-99m bone scan is a pretty easy study (and fairly inexpensive) to have done and it can provide quite a bit of information. It is a very sensitive study, being able to detect all sorts of inflammatory processes.

Unfortunately, it is not very specific. Again, it is sensitive, picking up just about any inflammatory process, but it cannot tell what is causing the inflammation.


So, if you have an infection, inflammatory process (tendonitis, bursitis, arthritis, etc), tumor, metabolic process, etc the bone scan will detect that. It can’t tell you what it is, but at least you will have a place to start.


Again, I do hope you and your surgeon can figure out what is causing your discomfort, or at least find a way to manage it so that you can continue to do your job.


Hang in there. Good luck. Wishing you the best.
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replied June 12th, 2013
I too had a THR about five years ago. Soon after, I began having knee pain. Xrays and cortisone injections had no effect. I then started having groin pain. At that time my orthopedic surgeon did various tests and determined there was no infection. Under floroscopy, he manipulated the hip and injected a steroid which lasted about 1 1/2 years. The pain in my hip has worsened and now the groin pain and thigh pain has begun again. He believes it is the iliopsoas muscle which he wants to cut to relieve the groin and thigh pain. However, will this end my severe knee pain (same side as hip replacement)? I don't want to start with narcotics for pain, but it's getting me down.
Suggestions?
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