Complex hip/pelvis injury - PN vs PHT: seeking advice

[CR31]

I’m an otherwise healthy 29 year old male. Nearly 2 years ago, I suffered a traumatic injury whilst playing football, whereby I heavily impacted another player while shooting the ball. Over the next months, the injury turned into a total nightmare which has made my life miserable. Initially it was diagnosed as bursitis (GTPS) and tendinopathy in several gluteal tendons. I began PT with a trusted clinician. Despite progress, the pain kept transferring to other places and I basically ended up with some form of tendinopathy in pretty much all of my tendons in that region, incl. pain in lower back and around my pelvic area. This was made worse by sitting for long hours (writing PhD thesis). The general consequence of this injury has been near-constant discomfort, stiffness, pain when mobilising my hip, an inability to sit without my trusted cushion, and an inability to do sport (running, cycling…etc). This has significantly impacted all aspects of my life, which used to be very outdoorsy and active...

Eventually, we agreed there may be an underlying issue that is halting progress, so I began getting scans, tests, and seeing various experts. This led to me finding out that the initial injury caused one of my distal hip tendons to tear badly, and then ossified. As well as that, I discovered I had pretty severe hip dysplasia. I was explained that together, these explain most of my hip pain. I’m currently booked in for major hip surgery next month (PAO surgery + removal of ossified fragment causing impingement). I’m certain the surgery is something I need to go through to get my hip in order (+ to avoid future damage, replacements and arthritis) because I have tried EVERYTHING else, but my greatest concern is that it doesn’t result in improvement of the pain near my ischial tuberosity, which is kinda separate from the rest of the pain.

This ischial tuberosity pain has been with me for about a year, and it is by far the most inconvenient and debilitating pain of them all. It has been at it’s worst for the past three months: I have been unable to lift even light weights, especially bending down, and have re-injured it countless times doing the most innocent activities or movements (i.e. picking up shopping, carrying a 15kg bag down 5 stairs - FYI I am 95 kgs and 6ft4). My physios and osteopaths have given me contradicting diagnoses, and the surgeon’s opinion on whether my structural hip issues are responsible for the pain is a very unsatisfying “maybe?”. In my mind, it is probably one of two things: proximal hamstring tendinopathy (PHT), or Pudendal Neuralgia (PN). I have symptoms which lean both ways.

Symptoms leaning towards PHT diagnosis (put forward by physio):
- Pain lifting things, bending down forward.
- If managed without re-injury, gentle PT helps with the pain.
- After re injury, the pain profile reminds me of tendon pain i.e. builds slowly, especially 24 hrs afterwards
- Physical swelling in the entire area

Symptoms leaning towards PN diagnosis (put forward by osteopath):
- After re-injury, I usually go through 2 weeks where any contact with the perineal area is painful (eg even wearing underwear is too much)
- I have had some bladder issues which often (but not always) align with re injury: feeling like I need to pass urine all the time. I have had STI tests, ultrasound and cystoscopy ruling out any bladder damage or infection, so the pain is so far unexplained.
- Often when it’s at its worst, swimming breast stroke has provided some of the best pain relief.
- MRIs have shown my hamstrings to be fine.

Is it possible I have both? eg maybe I keep re-injuring my tendon, and the near-chronic swelling causes pressure on my nerve, resulting in an all-star team-up?!

I have so far been focusing on PHT rehab, progressing very gently with simple exercises, but unfortunately I can’t manage to last more than 4 weeks without re-injury, which returns me back to square one via 2 weeks of constant pain. In April/May, I also spent two months trying my osteopath’s management plan (focusing on remobilisation and stretching), but this didn’t result in any improvements. I don’t know what else to do, and the experts I’ve seen have never given me any successful advice; they rarely seem keen to focus on my pain in this area because my overall hip injury is/was so complex. I have resorted to seek management tips online, but they seem to contradict each other for PHT vs PN:
- PHT tips include strengthening exercises with e.g bridging or kegel exercises whilst avoiding stretching
- Meanwhile, PN tips focus on stretching and relaxing the muscles whilst avoiding kegel exercises!

Therefore, I am completely lost, and am desperate to find some answers so that I can manage my pain, especially with this surgery coming up.
Looking for any advice from people who have suffered from structural hip injuries, PHT, PN, or have struggled with overlapping symptoms such as mine. How have you gotten out of the cycle?

[Violet M]

Hi CR31,

As I was reading through your story I started thinking to myself, maybe you have both PN and PHT. Then I saw your question asking if you might have both. I can't say for sure but it happens often with people who have PN that there is more than one thing going on, especially when you have structural issues. And you could be in a viscious cycle of pain where what helps one of the problems makes the other problem worse. Another thing to consider is that sometimes when you have pain in the pelvis, the surrounding muscles tend to go into spasm and this can put pressure on the PN and cause symptoms of PN.

So, what to do? It's a really tough decision. For me, the pain became so unbearable I had to stop all weightlifting, kegals, and exercise, and just heal. But, it you have a nerve entrapment as I did, any kind of movement causes continued damage to the pudendal nerve, typically within a few hours, or a delay until the next day. So all of the resting in the world didn't bring about resolution for me. I am 95% better after having PNE surgery (20 years ago). But you would need more diagnostics before going that route because PNE surgery isn't the answer for everyone.

One way to tell if it might be the pudendal nerve is whether there is tenderness when the PT presses on the pudendal nerve via the rectum -- at the ischial spine or along Alcock's canal. Another diagnostic tool is a pudendal nerve block. If the hip surgery doesn't relieve your symptoms, you might want to consider a pudendal nerve block for diagnostic purposes.

Wishing you all the best with your upcoming surgery.

Violet