Piriformis Syndrome

Welcome back to the wonderful world of medicine.  It's awesome to be back with all of you so soon.

Allow me to recap where we are for today's episode.
Two years ago I was Dx'd with a minor hamstring tear. 
New MRI last week shows no such tear.  Looking at the old MRI's, we're not sure there ever was a tear.  It's pretty doubtful.

That basically means all the pain I've been dealing with is undiagnosed.  It took me 6 MD's to get to that point.  Awesome.

So I saw a new doctor last week, after having that MRI taken.  We talked about things for a bit and based on my symptoms she thinks it is Piriformis syndrome.  For those of you that did play guess my Diagnosis...Mark was the winner.  Although its hardly fair as he is also my PT.  His big prize is getting me as a client...again.  Congratulations!

http://en.wikipedia.org/wiki/Piriformis_syndrome

So first let me say, anytime you see the word "syndrome" in a diagnosis...it means they don't know what the hell the real problem is.  Just sayin...

Having said that, this at least gives me a plan of attack. 

Today I went in for a corticosteroid injection right into the piriformis muscle.  (Not to be confused with the performance muscle.  Those are two completely different things!!)  It was actually more unpleasant than I expected.  Having crohns disease I lost any semblance of pride long ago.  But as I was lying on the table with my left cheek hanging out, one of the fellow's comes in and starts talking about getting pictures.  Being an immature idiot I get a little laugh going.  The doctor doesn't get it because clearly this fine medical professional is talking about ultrasound pictures as that is what they are using to guide the needle that is in my rear.

Of course this laugh causes movement.  Do you think it is a good idea to move when there is someone holding a needle in your body?  No, of course not.  I don't think I need to explain why I chose this movie clip.....

Anyway...as I sit here writing this, the pain killer they also injected has worn off.  I am quickly discovering that jabbing a specific muscl (repeatedly) with a needle actually hurts.  On the bright side, if the location of the pain is any indication, this is the problem I have been having.  I am currently sore in exactly the location I've been hurting in all this time, and the pain is shooting down my leg in the same way it did while working out. 

I have to take the next 5 days off.  And I mean completely off.  The doctor was very explicit and left me with no wiggle room.  Apparently the injection makes me more susceptible to tears.  Wouldn't that just be ironic as hell?  After the last couple years of thinking I had a hamstring tear that I was rehabbing, I finally find out it is piriformis syndrom.  I get it treated and that treatment actually causes a tear of some kind.  The more I think about it, that sounds exactly like me.  I should probably get some crutches just to be safe.

Anyway, nothing for 5 days and then I start rehab.  At this point I do not know what the rehab will consist of, what kind of biking and running I can do, or anything else for that matter.  Hopefully I'll know more in a few days.

The good news is that I'll likely be racing this season.  And I don't think my bike fit has to change dramatically.  So hopefully I can get back a lot of the gains I made and stay strong for the season.  And no quad cramping would be fantastic as well.  I'm not sure what will happen to my race schedule at this point.

Operation Diagnosis

Alright, I've tallied everything up regarding this hamstring/back/glute/etc issue. Over the last 3 years I have seen 6 doctors, I've had 2 MRI's (read by two different radiologists), multiple x-rays, and a ridiculous number of manual tests. I've seen multiple massage therapists. An A.R.T. practitioner, a chiropractor, and multiple PT's.

Despite all that I am still undiagnosed and a little tired of the ordeal.  I'm wishing Dr. House was real.  And I do find being pushed from doctor to doctor a little irritating.  So, in the interests of getting diagnosed, I thought I'd post my symptoms online so that the 'big giant brain' that is the Internet can assist.  Maybe a prize will go to the winner.

So here are the details.

The issue presents itself with sharp pain in the middle of the glute. Left side only. Very rarely higher, however the pain can and does go down the leg to the back of the knee. Very early on (2-3 years ago) it presented with a burning type sensation that felt like fatigue in the glute and hamstring. When I didn't give it the rest it needed it was debilitating sharp pain when I walked/ran and did other side to side motions.

 

It still does that today, but lately it seems to tighten up the entire hamstring. The actual issue started back up after I'd changed my bike fit back to an optimal fit (according to retul) from what was a fit by my PT that took a lot of pressure off my hamstring. So the seat was a lot more forward and lower with my PT and the retul raised it back up. I noticed some mild pain when I made the change and hoped I'd get used to it. I even lowered my seat a little bit to help. But on New Year’s Eve while doing a 10k run the entire hamstring basically locked up. The next day the same old pain in the glute came back.

The injury, when not symptomatic, can take the pounding of running without any issue, however as I just described, when coupled with cycling (retul fit vs. PT's fit) the symptoms flare up quickly and cause problems with running. When symptomatic running is not possible without further aggravating the issue. I can typically feel it within a minute or two of starting the run.

Sitting seems to aggravate it now; I don’t recall that being the case when this originally started. The injury also appeared to respond to hamstring rehab, however the rest may have been enough. Sometimes ice and heat on the back/glute/hammy helped. Prednisone seemed to help on occasion as well…but not always. I don't take NSAIDs and Pred only when the crohns flares up.

Injections in my lower spine were ineffective.

A.R.T. is very effective for short term relief. She works on the hammy, glute, and hip flexor area. I can feel things loosen up immediately, however that usually only lasts for a few hours.

Okay, those are the symptoms.

I'm thinking about starting up a pool and taking bets. Right now I have one person who has guessed IT Band Syndrome. I am currently guessing there is an issue with my sciatic nerve.

All diagnosis ideas are welcome? 

Hamstring update

So the last couple times I've posted I've alluded to an upcoming hamstring surgery.  Now I'm not so sure that said surgery will actually take place.  It's not that I've changed my mind per se, rather the doctor isn't so sure I'm a candidate.

Apparently hamstring surgery is not typically done for partial tears which is what I originally had.  It isn't that surgery couldn't be done, or even be successful.  However the overall prognosis isn't all that much better than simply doing rehab.  A new MRI is needed to see what we're really dealing with.

With a partial tear, after some rest and rehab the injured area will scar over and that scar tissue will provide a certain degree of strength and stability back to the muscle.  Unfortunately the injured area is generally not as strong as it was prior to the injury and is never as flexible.  Surgery for both partial and full tears comes with its own list of risks and potential complications including a ridiculous amount of time in a brace and on crutches.

What this means for me: 
I don't know yet.  I had another MRI on Thursday last week to see what additional damage I did to the area.  I see the surgeon this Thursday to talk about the results.

Based on how I am feeling, I doubt surgery will be the recomended solution.  I'd like to think that I'd know if I had fully torn my hamstring.  I think the giveaway would be the muscle gathering around my knee...and I am of course assuming a certain amount of pain.  While I've been known to stupidly push through pain in the past, I'm guessing it would be more difficult to push through when there is absolutely no hamstring muscle remaining.

So, we'll see.  In the mean time I've been swimming a fair amount, but that has to stay somewhat limited due to shoulder issues from high school swimming.
I've been biking, but its all been easy stuff.  I will have to modify my bike fit to take the pressure off my glute and hamstring again.  Hopefully we won't go quite as far as we did for last season...I don't need my quads cramping in every race again.  I have not been able to run at all yet, but I've been doing a lot on the eliptical and other rehab type exercizes.  I'm hoping to try a light run in the near future to test things out.  We'll see.

So, this is both good and bad news.
I was hoping that surgery would be the long-term solution that would get me back to normal once and for all.  That doesn't appear to be the case.  So this is something that I will always be dealing with.  Having said that, I will most likely be able to race this season.  I won't need 6 months of rehab.  And I might be able to start slowly running in the next few weeks.

Stay tuned.

Update:
I saw the surgeon today and no longer have a diagnosis of any kind.  The MRI showed no evidence that a tear ever existed. 
So now I am off to a new doctor to see if we can figure out what in the hell is going on.

On the bright side, no surgery as there is nothing to repair.  On the negative, I don't know what's wrong. 

Proximal Hamstring Repair Surgery

So, the time has come.  In my mind anyway.  We'll see if the surgeon agrees or not.

I really took it easy last week.  Lots of swimming and other easy work that didn't involve the hamstring.  Very easy bike riding, no running.  Overall the hamstring has improved, but not nearly enough.  At this point even a light ride aggravates things.  This would lead me to believe that it would take several weeks, if not months of no working out coupled with rehab to get back to a good place.  And at that point there is no guarantee that I'd be back at 100% and it seems more likely that I'd just aggravate things again.  So, it is time to get this repaired once and for all.

For those of you wondering how this surgery happens, here you go:

Warning:  This video is disturbing and nasty.  View at your own risk.

I have no doubt I will be an absolute pleasure to deal with during my recovery.  As far as rehab goes, from what I've heard it sucks.  Here are some of the highlights I've gotten from my PT.

Days 1-7:
I'll be given an ankle pump.  For some reason that sounds dirty to me, but I'm pretty sure it is to make sure my feet and ankles don't swell up.  This is probably a lot like compression socks.  I have friends that enjoy that fashion no-no.

The biggest issue for days 1-7 is that I can't do anything.  I am expected to lie prone or on my side the entire time.  When I asked how I go to the bathroom...the words bedpan and standing toilette were used.  At that point I asked if a medically induced coma was possible.  I don't think that request was taken as seriously as it should have been.  Apparently there are risks to the brain.  My obvious response is that the risk of brain injury is much higher because I'll be bashing my face against something hard after about 2 days.

Days 8-14:
Still pretty restrictive.  Not sure about sitting or anything like that.  But lots of range of motion work.  If its anything like the ROM work I did after tearing my ACL in college...it will royally suck.  I'm not sure if it is still like this...but back in Eau Claire where I did all my rehab it was horribly painful.  I went through the surgery with 2 other kids and they had us on a table cranking on our legs.  For some reason it wasn't bad for me, but the other two had it bad.  They basically needed to be given a wooden stick to bite down on while they basically screamed in agony.  Awesome!  I couldn't find a youtube video of that, instead I have this:

Weeks 3-5:
On crutches.  From what I've heard I can't drive for 4 weeks.  Not really able to sit for about that long as well.
Not sure when I can go back to work.

Weeks 6-9:
Walking with normal ROM.  From this point on things don't sound too bad.  I'm able to do most normal stuff.  I can start very light swim/bike/run.  But no intensity of any kind.  I probably won't be able to push off the walls in swimming.  Biking will have little to no resistance.  Running will be on a zero-gravity treadmill or in very short durations.  Not sure at this point.

Weeks 10-24:
More of the same with increasing durations and intensity.

At that point I will hopefully be cleared for full training.  But I'm pretty sure this is all a best-case scenario.  If I do anything stupid, or in other words, if I am myself, there will be complications delaying things.

I don't know when the surgery will occur.  If it were up to me it would be tomorrow.  Lets get this show on the road.  I am hoping we'll get this moving sometime the week of Feb 18th.  But I am not sure. 

I'm wondering who thought this "healthy lifestyle" thing was actually healthy.  I feel like I should run down the list of surgeries and medical issues that have been caused by athletics again.  I think I blogged about it once before.  I'll have to dig that up.

On Sunday as I was sulking and somewhat depressed, (while eating a 1 pound bag of sour jelly bellies and drinking 20oz of coke) I was thinking about how I might actually be better off being lazy and getting fat.  It may be healthier for me and it seems to work for a huge segment of the population.  Who am I to judge?  In fact, once upon a time I was 265lbs.  I could go back to that pretty easily.  In fact, I bet I could get back up there before my rehab is complete!

I'll have to ponder that.

I should add...I will be taking pictures and logging my progress along the way.