Did labral tear surgery reduce your PN/pelvic/perineal pain?

[Faith]

I was thinking about it tonight and I wonder if labral tears really are the cause of PN pain (obvoiously they seem to be for some, but then again they aren't for all) or if those who's hips/pelvis are shaped a certain way are more prone to labral tears and PN - as two separate issues. It's one of those questions of course you don't know for certain until you have surgery to repair the labral tear and even then if the pain remains is it a result of true PNE or muscle spasm from years of living with bad hips and biomechanical issues!

[Lernica]

I think it's an interesting question with no clear answer. I still don't know for sure what caused my PN even though my recent hip surgeries seem to be clearing it up. Was it my three very difficult childbirths involving hours and hours of pushing? Was it my multiple pelvic surgeries? What came first, my pelvic floor dysfunction resulting from the above, causing my pelvic floor muscles to pull on my hips in unnatural ways? Or instead did my hips lead to my pelvic floor dysfunction thus leading to muscular compression of my pudendal nerve? What role did endometriosis play in all this? Did my hip surgeries "fix" my PN, or was it the intensive post-op six months of PT (both sports and pelvic) that did? Or was it the four sessions of ESWT that I did? Or my new orthotics? Or the "nerve calming" antidepressants I was on?

I will never know the answers to these questions. But I think I can safely conclude that it was a combination of multiple treatment modalities that has helped me get better. I don't think that there is a "single" answer to resolving PN.

Wishing you all the best. Never give up hope!

[Elmwood]

Hi Lernica and Faith

Thanks for your reply. If I had to choose a side that is worse for PN it would be my left but since it mainly effects my privates its pretty much both sides. But it is only the left side of my scrotum that gets numb. My left hip is the worse of the two hips so maybe there is a definitive connection. As for arthritis, my ortho said its just the way I grew. I'm not sure of the name of the surgery but I know he wants to pop out the hip, fix the tear and shave off the deformed bone which I also have. If this isn't the answer I don't know what could be. Hearing stories like yours though definitely give me hope.

Two additional questions if anybody out there has the time. 1) Have 3T MRI's shown any connection with people's hips? 2) Why would labral tears cause PN? Is there swelling associated that could cause it? I suppose I would have more hope that it could be fixed through hip surgery if I new of a definitive connection.

Thanks!

[Lernica]

Elmwood,

Four things:

1. It concerns me that your doctor says you got OA because "that's the way you grew". To me, that says that you might have hip dysplasia, a condition that cannot be corrected by a hip scope (which is what you described above). Instead, you would need something called a periacetabular osteotomy (PAO), which is basically breaking the pelvis and resetting it so that the socket realigns with the femur head. Some folks on Hip Chicks Unite went to scope doctors not knowing they had dysplasia. Unfortunately their scopes did not resolve their hip pain and so they had to later go to a PAO specialist for a second surgery. I would hate for that to happen to you. Please confirm with your surgeon that you do NOT have hip dysplasia before proceeding with the scope.

2. Yes, the fact that your worst pain is on your worse hip side is significant. That was the same with me.

3. No, typically "pelvis" MRIs do not include an analysis of hip pathology. Faith can attest to this. She had two or three "pelvis" MRIs, including one with Potter (if memory serves) and not one of them picked up on her labral tears. She had to have an orthopaedic surgeon specifically order a labral tear MRI before it was finally detected.

4. What is the connection between hip pathology and PN/pelvic pain? It's all in the muscles. Tight pelvic floor muscles can pull a pelvis out of alignment which can put stress on hips, thus causing the hip joint to wear down. Conversely, a bad hip, which cannot support the pelvis, has to recruit other muscles, specifically the pelvic floor muscles such as the obturator internus, to support the body. This can put undue stress on those muscles, causing spasming and pain, and those muscles can in turn compress the pudendal nerve. The connection between hip pathology and pelvic floor pain/pudendal pain is supported in the literature. All the relevant articles are listed on the Pelvic Pain Hipsters Group Page of the aforementioned website.

I am no hip expert but I picked all this stuff up from talking to many hip patients on Hip Chicks Unite (just as we learn about PN here). I understand that there is also a Facebook group for femoroacetabular impingement (FAI) which is what it sounds like you have. Most folks with labral tears usually have FAI, which is a bone spur digging into the labrum and causing it to tear.

Again, good luck in resolving the source of your pain, both hip and otherwise.

[Faith]

Yes, you are right Lernica. I had 3 Pelvic MRIs including Dr. Hibner's 1.5T MRI with contrast and Potter's 3T MRI. Unfortuantely pelvis MRIs are not specific enough for the hip thus a 3T MRI with attention to the left or right hip (or in my case both) or an MRA of the hip is needed to diagnose labral tears.

To add to what Lernica said I think labral tears can cause PN pain because the obturator attaches to the hip and is a primary hip rotator so when the hip is unstable and the biomechanics are "off" the obturator internus becomes spasmed (as does the piriformis - another hip rotator - and eventually other pelvic floor muscles). The pudendal nerve runs through part of the fascia of the obturator internus (OI) so it's not surprising that pelvic floor pain occurs. I do wonder why not everyone with hip pathology doesn't have at least some pelvic floor pain. Of course then we go back to my question (that can't be answered) did the PN cause the OI to spasm and pull on the hip causing improper biomechanics and thus a labral tear (of course if one has FAI then that is most likely the cause of the labral tear) or vice versa. But in my opinion it's a lot more likely that a labral tear occured first than someone randomly started having pain with intercourse (as in my case) or one day just started having sitting pain. In most cases of PN (aside from a direct surgical trauma, i.e. mesh surgery, hysterectomy, etc) biomechanics and lumbopelvic/hip pathology is to blame.

[Lernica]

To substantiate what Faith said, here's an excerpt from Hunt, Clohisy and Prather, Acetabular Labral Tears of the Hip in Women, Phys Med Rehabil Clin N Am 18 (2007) 497 - 520, at 503 (not available online unless subscribed to the PubMed):

"Unique in women is the possible concomitant pelvic-floor pain that may occur in association with labral tears, hip impingement, dysplasia, and early and late arthritis. Because these hip disorders are more common in women, a thorough history should include the discussion of pelvic-floor symptoms. The obturator internus is considered one of the primary musculature sources of pelvic-floor pain that often presents with the complaint of deep vaginal pain. Because the obturator internus is a primary hip rotator, a hip-related cause of pelvic pain should be considered in the differential diagnosis when the pain is determined to be originating from this muscle and when other causes have been excluded."

[Elmwood]

Thanks again for your replies ladies. I value your insight and time.

Some of the information I've given about myself comes from two different surgeons as I've seen two. They both say that I had FAI and I just had an MRA and it confirmed a labral tear in my left hip. The surgeon I'm going with still wants to do more xrays before proceeding. But I feel like i'm in good hands with him. His name is Scott Martin at Brigham and Womens in Boston. Has good credentials anyway.

Sounds like the Hip Chicks Website is something I should check out.

[Griff522]

LERNICA FOR PRESIDENT!!!

I need you to please send me that study to show Dr. Z. I finally have a sense of calmness about this whole pain situation, and it's something that I've never had before regarding it. I always felt that every dr I saw was just kind of guessing at what might be causing the pain and not really all that concerned about it. Let's just treat the nerve with meds or surgery. Well, that didn't work -- EVER! But when I felt relief from this hip injection I had last Friday, I started to believe I might be pain free one day. Initially, the injection took away my hip pain but really that was pain that I could tolerate because I could just avoid movements that caused pain. But later in the week, my perineum pain (caused by the OI muscle) began to subside a bit. It's probably about 50% less.

I've got my ultrasound scheduled for Tuesday. I'm not really sure what to expect with that. Dr. Z told me he wanted it for the adductors, but when I was scheduling it the chick said hip so we will see. Then my MR Arthrogram and CT scan are scheduled for Nov. 23 (the day after Thanksgiving). I'm finally going to get some answers and treatment after suffering with pain for 3 years and not knowing exactly why! And I have you to thank Lernica. I am so grateful for you urging me to get my hips checked, and I will never be able to thank you enough.

I encourage anyone that has not been checked out by an orthopedic dr to put that on their to do list. Do your research, and know what you want from your dr when you see him/her. I wasted 2 months seeing a dr that just dismissed my information and tried to pacify me with an MRI that showed nothing!! He didn't care to help me and that was very apparent in the 5 mins he spent with me. I did a little research on the Hip Chicks site to find a good hip os and now I finally feel like I'm getting the care I deserved all along. THERE IS HOPE!!!!

[Lernica]

Gosh, I'm so happy for you Linda! What a relief to finally have some reduction in pain and to have a sense finally as to what may be causing it! So excited for you!

To clarify for everyone else: Who you need to see is an orthopaedic surgeon who specializes in hip preservation (not replacement) via arthroscopic surgery. They are far and few between since this a fairly new medical subspecialty. In contrast, there are quite a lot of surgeons who do shoulder and knee scopes and sometimes hips. But if you want the best, you should go to a scope doctor who specializes in hips. The "master" of hip scope surgeries is Dr. Marc Phillipon, a transplanted Canadian who practices in Vail, Colorado. (I'm Canadian too so that little part of his bio is important to me!)

Linda, I've sent you the article by email. If anyone else would like a copy, please contact me.

[Faith]

This is a very good article on labral tears. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2697339/ One thing that is very important I think before deciding to have surgery is to know the cause of the labral tear. This article says, "It is now proposed that there are at least five etiologies of labral tears—trauma, FAI, capsular laxity/hip hypermobility, dysplasia, and degeneration.

I am very concerned that laxity/hypermobility might be the cause of my labral tears and if so I worry that even if I have the labrum repaired it might re-tear. I am actually considering seeing a geneticist to rule out Ehlers-Danlos syndrome hypermobility type (though my hypermobility is mild compared to most with EDS- I do not sublax constantly).

This article as says:

"The search for biomechanical predisposing factors may be of benefit in cases of labral tears. Janda has described a predictable pattern of muscular imbalance in the pelvis, known as the lower crossed syndrome. Tightness of the hip flexors and lumbar erector spinae and weak, inhibited gluteal and abdominal muscles characterize lower crossed syndrome. The resultant imbalance leads to anterior pelvic tilt, increased hip flexion, and a hyperlordosis of the lumbar spine. Hip flexion contracture might lead to increased weight bearing on the anterior acetabulum and labrum predisposing to tearing. Many patients presenting in the primary setting with low back pain due to lower crossed syndrome can be rehabilitated to correct these aberrant pelvic mechanics."

This "lower crossed syndrome" describes me to a tee! Unfortuantely rehabbing my aberrant pelvic mechanics is not easy due to the involvement of my pelvic floor. My SIJ is always "out of alignment" and I cannot strengthen my core at this point. So what does one do?