Megan H.- Teenage Hip Arthroscopy
Dates of surgery: December '05, October '07, September '08
Types of surgery: hip arthroscopy for labral debridement, the second two also including femoral osteoplasty
Surgeon: first done by Dr. Dan Snyder, second and third by Dr. Mininder Kocher
Hospital: first at Newton-Wellesley hospital, second and third at Boston Children's
Prior to surgery
When did you first notice symptoms and what were they?
About 3 months prior to my first surgery (so...September or October '05 I suppose), I was rehearsing a piece that included a tombée coupé jeté to second. At the time, I was a naive, invincible, 17 year old who didn't fully grasp the concept of giving one's self a full warm up before rehearsal. When I landed, my feet remained planted while my body continued to rotate. I felt a snap and a pop and a sense of giving way in my right hip but shook it off and continued on. Later that night, I found myself in excruciating pain and I began to experience a painful catching sensation. I couldn't pull knee any further than 90 degrees to my chest and any internal rotation that I had was completely gone--even standing in a parallel position was next to impossible.
The first surgery didn't solve the problems with my right hip in it's entirety, though I did return to ballet shortly after. The catching and limited range of motion persisted.
With my left hip, my symptoms developed while I was on crutches recovering from the second surgery. Talk about bad luck! They were essentially the same--the catching, the feeling of it maybe giving out at any moment.
What was your medical diagnosis (traumatic osteoarthritis, congenital hip problem, avascular necrosis, etc)?
Each time, I was diagnosed with labral tears. Prior to the second surgery, I was also diagnosed with femoral acetabular impingement, specifically the cam-type, in both hips. In other words, my femoral head wasn't completely round and there was some extra bone at the head/neck junction. The cause of impingement isn't entirely clear at this point in time--there's some evidence that it's hereditary but there's also some evidence that it can develop in adolescents that have high level athletic involvement prior to skeletal maturity, particularly in activities that require lots of repetitive hip rotation (*cough* ballet anyone? *cough*).
At any rate, I had had the impingement for a good number of years without it causing too much of a problem. What Dr. Kocher ultimately figured was that it hadn't been a real problem until the first labral tear. When that was addressed, it created just enough extra space in the joint for the impingement to start chewing away at everything else in my right hip. With my left hip, it was just the stress of being on crutches that really did it in but it was bound to become a problem sooner or later, especially as a dancer.
What forms of treatment did you seek before considering surgery (chiropractic, acupuncture, medications, bodywork, physical therapy, herbs, etc)?
From the initial injury onwards, I had pretty consistently been in some sort of physical therapy. At first it was in the hopes of retraining my body to take the stress off the labrum and avoid surgery. Had I not wanted to return to dance, I might have had better luck in this department, but the labrum doesn't have a good blood supply and isn't all that likely to heal on its own. Once the impingement was taken into account, it became pretty clear that surgery was my only option if I wanted to continue dancing and not need some serious work done on my hips later on down the road and/or early hip replacements.
How did you change your work habits, lifestyle to accommodate the hip problem?
I didn't. That was a big thing for me all along. I was 17 when it started, a few days shy of 20 at the time of my third surgery--I wasn't ready, or really willing, to change my lifestyle. I just did my best to be as good to my body as possible but I wasn't about to give up my active lifestyle. I did cut back a little dancing and "quit" riding (I had also been a fairly serious equestrian) indefinitely while we were trying to get things under control but, for the most part, I was still dancing 6 days a week.
How long an interval was it from the onset of hip problems until surgery?
About three months from injury to surgery the first time around; the second surgery was two years later. With the third, it was just shy of a year from the onset of the initial symptoms until surgery. While we knew that I was headed for surgery fairly soon after the onset of pain, Dr. Kocher wanted to make sure that my right hip had every opportunity to be fully healed before we stressed it with the recovery of the left.
What factors, physical, emotional, financial, etc. influenced your final decision to have surgery?
I was young and really not ready to change my lifestyle. I wanted to continue dancing, I wanted to pursue dance in college, I didn't want to be faced with constant hip pain that required continual maintenance for the rest of my life.
Were there other dancers you spoke with that helped you?
When I was going through surgery the first time, I knew absolutely nothing and didn't know of anyone else that had been through anything even remotely similar. Leading up to the second surgery, I actually found myself in class with another dancer that was going through the same process and it was so reassuring to just know that there was someone in the same shoes--that it didn't make me any less of a dancer. Femoral acetabular impingement is relatively new diagnosis--even in the year between my second and third surgeries, the amount of information available on it hugely increased. I've also started hearing more and more about different dancers that have had the same surgery or will be--kind of a "oh, so-and-so had that done too." So, I guess my answer (in a really round about way of getting there) is no, I didn't really speak with many other dancers that helped me in the process simply because there weren't really any to talk to.
What influenced your choice of surgeon?
With the first surgery, I went with the first surgeon that offered me a diagnosis. I was so desperate to get it taken care of, I just did it as soon as I could. While Dr. Snyder was a fine doctor, I wish I had spent a bit more time finding someone that understood dancers a bit better. When I started the process for the second time, Dr. Snyder was no longer performing hip arthroscopies so I needed to find someone else anyway. It was at that point that I decided that if I had to do it all again, I was going to find someone that really "got" dancers and I started asking around for recommendations.
Boston Children's has an incredible reputation in terms of treating dancers--they provide services for Boston Ballet and are just all around regarded as wonderful. A teacher of mine spoke very highly of Dr. Kocher as she knew another dancer that had good results with him. The wait to get an appointment with Dr. Kocher was several months but the receptionist suggested I make an appointment with one of their primary care dance medicine specialists who could then refer me to Dr. Kocher. So I did that. I couldn't have been more impressed--never before did I have a doctor walk through different steps with me (by name!) while trying to establish what I could and couldn't do. Once we decided that surgery was an option that needed to be further pursued, he referred me to Dr. Kocher. Dr. Kocher was awesome--allowing me to continue dancing was always our goal and I was made to feel like I had a big part in the decision making which I really appreciated. While he never told me that I needed to stop dancing or that I would need to, he was also always very honest with me and gave me very realistic expectations about every step of the process while taking his time to walk through every possible outcome. It eased my hesitations about going through a second surgery A LOT. And, since he did such a fantastic job on my right hip, he was the obvious choice to do lefty too.
How long were you in the hospital?
It was done as an out-patient procedure. I had some difficulty with the anesthesia and pain management (took me several hours to come out of anesthesia, lots of nausea, unable to keep pain medication down even with food, etc...) after the first surgery so, for the second, we had anticipated that I would probably need to spend the night but I ended up being fine to go home.
Did you have any complications in the hospital?
Aside from the issues with the anesthesia and pain management with the first surgery, not really. It was noted with the first and third surgery (so the first scope for each hip) that they needed more force than expected to achieve adequate traction in my hip which led to surgery taking a little longer and some additional muscle soreness but otherwise, there weren't any real problems.
Anything else to say about your experience?
I wish I had realized going into the first surgery the importance of asking questions and speaking up. I was just so desperate to get it over with that I didn't really even think of it. Even though it was the least involved of the three and had the shortest actual recovery time (2 weeks crutches/6 weeks rest vs. 4 weeks crutches/3 months rest), the first surgery was definitely the toughest in terms of recovery, particularly in the first week post-op. That's not to say the recovery from the others was easy, I was just much better prepared to deal with the bumps along the way.
Did you have any complications, especially unexpected difficulties, after you got home?
With the first surgery, I couldn't keep the pain meds down. I literally threw up all over the car on the ride home. I later came to find out that percocet, what I had been given, is rather notorious for making teenage girls sick--that was the surgery that I really needed something for the pain with too. Ice and ibuprofen was my best friend that first week post-op. With the other surgeries, I barely touched the pain meds--I honestly felt fantastic. At the time of surgeries 2 and 3, I was also a college student which presented it's own set of challenges--I knew going into surgery that crutches on a college campus wasn't going to be fun but it was definitely more manageable that I anticipated.
What steps did you take toward recovery? (Physical therapy, chiropractic, acupuncture, medications, bodywork, herbs, etc.)
I spent a lot of time in physical therapy. A lot of time. That and just really learning to respect my body's limits. Dr. Kocher also had a really detailed and structured protocol for my PTs to follow that was more or less geared towards dancers which was really helpful.
How long did it take you to really feel recovered (6 months, one year, two years?)?
With surgery #1, I was out of dance for six weeks but I never really felt fully recovered. So we're not going to consider that one. Surgeries 2 and 3 had me out for 12 weeks and working my way back into the swing of things for another 6 or so. Coming back from surgery #2 was a little tricky since I was dealing with problems in the other hip at the same time, but I'd say it was about 6 months before I really felt anywhere near 100% again. Coming back from surgery #3 took a lot longer but understandably so since I was just really getting everything back when I had to start backing off again. I've also become a lot more cautious so regaining my attack and confidence has been a much bigger challenge than it had been in the past. At this point, it's been a year since the surgery and I'm finally dancing without any hesitations again--I had been in the 90-95% range for a while but only very recently have I really been attacking movement again.
Anything or any practitioners that you would highly recommend?
Working with both a surgeon and physical therapists that were familiar with dancers was the hugest asset in recovery. They knew how to push me in the ways I needed to be pushed to get back to dance and they were really able to help pin point specific areas that might need some additional attention before I headed back to class. For example, after one surgery (not sure what one, they've all started blending together now...) they noticed that while my hips were looking strong, my ankles had kind of been forgotten about so we worked on strengthening them back up too. That and just being really open with all my teachers about what I was going through and what I felt I needed--like recently just telling them that I was feeling overly cautious so they knew to push me for more and that I wasn't holding back intentionally.
About dance class: Do you take dance classes?
An emphatic yes. I'm in class about 18 hours a week (about 12 hours ballet/6 hours modern) with rehearsals and such on top of that.
How much facility do you have?
I have full range of motion and a little over 90 degrees of external rotation in both hips (so I've got more than 180 degrees of turnout). The only real limitation that I've run into is that I can no longer stretch my straddle to a full split--I'm sure I could get it back if I really tried but I don't want to push my luck. I gained a decent amount of turnout with the surgeries--I always had good turnout but it was never this good. I'm still learning how to use all of it though.
All post-THR patients are advised to limit impact on the joint and to avoid overcrossing the legs. Given that, do you actually modify your dance class? E.g., are there parts of the class that you skip (petite allegro, grand allegro?)? Do you use fifth position? Etc.
Well, I didn't have a THR so I don't have those same restrictions. I don't have any real restrictions other than to really try to respect my body's signals and to back off when things flare-up. I have some chronic issues with my right psoas that do flare-up from time to time. In that case, I usually skip out on grand allegro, reduce my turnout, and keep my extensions to 45 degrees or lower.
Do you do other physical exercise (e.g., Yoga, Pilates, biking, swimming, etc.)? If so do you modify what you do in these activities?
I do a good deal of yoga which has been really helpful in helping me to "let go" in my hip flexors a bit--the only thing I really need to watch there is that I'm not gripping my hip flexors and I avoid anything that puts me in internal rotation because that really flares things up. I've tried pilates but, incorrect as it may be, it really gets at my hip flexors and leaves them feeling tight and grippy so I tend to opt out of that. As far as other exercise goes, when I swim I've found that flutter kick gets the hip flexors whereas breaststroke is totally fine. I've also had really good luck with the elliptical. I've also gone back to riding. Not at the same intensity I used to but that was more on my own terms than in an effort to save the hips. I was really nervous about that and waited quite some time before jumping back into the saddle but I haven't had a problem with it.
How has the surgery impacted you professionally, physically, emotionally, spiritually, and financially? Is your life different now? Did you have any outcome, good or bad, that was different from what you expected? Any other thoughts to share?
I grew and matured so much as a dancer during my time injured and dealing with the surgeries and their aftermath. As I said, I was 17 years old when I was first injured. I never thought something like this could happen to me, much less at that point in my dance career--I was a junior in high school and I was just starting to think about and plan for life upon graduation. It really forced me to think about why I was dancing and what I wanted out of it all. If a positive had to come out of this mess, that was it--that and really learning to be more in tune with my body and learning how to respect it's limits. I never would have anticipated that this was going to happen to me--the first tear was my first "real" injury. It made me stop taking dance for granted when I saw how quickly I could lose it all.
As far as unexpected outcomes, I thought this was going to be a one shot deal--at 17, going into the first surgery, I never thought I'd be 20 and recovering from a third. So I've also learned to just roll with the punches and really take things one step at a time. I think I might have mentioned it earlier, but I have psoas tendonitis in my right hip that at this point, seems like it's going to be an ongoing problem. I can deal with it, it's just not something I really expected.
On a positive note, I never would have expected things to turn out as well as they did. I never would have thought that I'd be dancing as much as I am now after 3 hip surgeries. I never would have thought that I'd have as many "good" days as I do. I'm so glad I went through with it, it's really given me my life as a dancer back and let me keep chasing the dance dream. We had a scare almost a year ago now that I might have had another labral tear in my right hip so I went through the whole x-ray and MRI/arthrogram process again and it looked fantastic. I had no signs of any joint damage, no signs of early arthritis and that really cemented that this was all worth it. People have asked me if I'd go through with it again if I knew that this is the outcome that I'd have--things being good but not quite great and the answer is always a resounding yes.
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UPDATE May 2011
So, how are things now, a year and a half later? They have their ups and downs. My left hip has continued to be fantastic. I think we caught everything right at the perfect time before I could develop too many weird compensation patterns and before the impingement had a chance to do any significant damage. My right hip definitely has good days and bad days. All of last year and this past Fall, I was really dancing a lot--it was about 15 hrs/week of ballet, 10 of modern, and another 10 of rehearsals. Though my hips were holding up better than anyone could have anticipated, I was burning out and I was realizing that my heart was laying more and more in my other major (I picked up the bio major during my freshman year to fill credits while I couldn't dance and I fell in love). So I cut back this semester. I'm still graduating with the major but I'm not dancing as much (8 hours ballet, 5 modern, 5 rehearsal) and honestly, my body feels worse now than it did when I was dancing more because I don't think I'm as strong. And it's the strength and stability in my pelvis that really helps my hips because they're (especially the right) so hypermobile--I have over 180 degrees of outward rotation (measured by a PT. Backed up by a doctor, I'm the poster child for a weird body--my shoulders are the same way).
I recently took a bad fall off a horse (something that these surgeries have allowed me to do again also) and ended up having all sorts of x-rays and MRIs of my lower back and pelvis. I was terrified to see the current state of my hips on film but there actually haven't been any significantly bad changes--a little bit of early arthritis in my right hip but really, not much. A fellow in Kocher's office during one of my last appointments (this was close to two years ago) asked me if I would go through this all again knowing that my outcome wouldn't be 100% perfect and I think that was a very telling question, especially now as I'm moving away from dance. And my answer is yes, I would. It bought me many more years of dancing than I would have had otherwise. I had just turned 17 when I was injured; I'm now almost 23. At the time, I lived for dance and just stopping wasn't really an option. It's been hard knowing what I've gone through to be walking away now but I still don't regret going through the surgeries and the rehab. You know that rehab from this surgery can be really tough at times but I definitely think it's been worth it. I was able to come to my decision to start cutting back on dance on my terms, not because my hips just wouldn't let me anymore.
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