How can I best prepare for an appointment with my sports medicine doc?
February 14, 2017 10:11 AM   Subscribe

I’m a former runner who has been in and out of PT for over a year, and it turns out the issue is with my hips, especially the piriformis. My issues aren't resolving (or at least it seems that way). Given the time I've been dealing with this, I'm a little at a loss as to how best to prepare for my upcoming appointment.

I’m a former runner who has been in and out of PT for over a year, and it turns out one of my major issues is with generally my hips, and specifically the piriformis. I thought I could go back to running but even the elliptical causes pain and such extreme tightness throughout my entire hip and glute area that I’m extremely sore even just getting out of bed the next day (i.e., can't get out of bed without stretching). Stretching helps temporarily (pidgeon pose is my favorite), but has not fixed the issue. While it's true that exercise makes it feel like I'm the Tin Man, my hips feel just.... loose and “floppy” meaning when I turn my knees out, it feels completely wrong and I hear a clicking and popping. Sometimes the popping is so extreme it’s really painful. Kind of like cracking your knuckles, but with my hips. I am somewhat hyperflexible in some joints (elbows, feet, possibly hips). I just can’t understand why months of strength training with resistance bands hasn’t fixed this problem. If I just get stronger, it should fix it, right? I had surgery for compartment syndrome a year ago and my body still hasn’t cleared out all the fluid from that. My lower leg muscles are sore to the touch. So... I have multiple issues going on.

One of my main complaints is the burning in my ankles when I walk too fast, and certainly when I run. My ankles literally feel hot, and I have to slow down. I was cycling for a while, which was OK except for the extreme tightness, so my PT approved my request to bump it up to do the elliptical, which completely screwed up my lower back and hips after a couple of weeks. I’m at a loss. I need exercise to sleep well, and this problem is affecting my sleep which impacts several areas of my life. I’m a wreck when I don’t sleep, and I don’t sleep well unless I wear myself out with exercise every day. Swimming is the only option for me at this point, which really is a PITA to do before work.

I’m wondering if there is an underlying issue with my joints (arthritis or something like it?) impeding my progress. At this point I feel crazy because I’ve been dealing with this for so long. I’ve seen this sports doc before, but I’m trying hard to be proactive before I go.

YANMD, but is there anything I’m overlooking in terms of who I should see? Is a sports medicine doctor enough? Are there more questions I could be asking?
posted by onecircleaday to Health & Fitness (5 answers total)
Ask about your transverse abdominis. The lower back pain especially triggers alarm bells here. Well, the glute and hip pain, too. You could be using the wrong muscles to do the TA's job, hence the pain.
FTR: even people with insanely ripped six-packs could have very weak TA muscles.
posted by Neekee at 10:31 AM on February 14, 2017

Thank you. Not to thread-sit, but your post reminds me that I thought I had a strong core because I can see my abs, but I can barely do supine scissor kicks. For years I was trying to do them without realizing that my lower back needed to be flat. Now I can do them when I keep my back flat, but just barely. Is that the part of the transverse abdominis? In other words - weak core?

Also, I forgot to mention in my question and comments, that I've had a near-constant, aggravating inner thigh pain (groin?) for months that makes itself known when I lay on my side, if it's relevant. Seems to have flared up after cycling.

Good times!
posted by onecircleaday at 10:49 AM on February 14, 2017

Visible abs is less to do with core strength and more to do with low body fat. Are you getting enough calories and good nutrition to heal? Is your protein intake at least 1.2 grams per kg of your body weight?* You say that you're doing a lot of work with resistance bands, but are you showing noticable improvement (I.E. can do more reps with less fatigue, have made clear progress to tougher bands), or are you treading water?

You're hypermobile in some joints; how are your ankles? Anywhere that you're hypermobile you need to be *stronger* than someone with more normalized joints to be as effective. You'll need to be very conscious at all times about your form. Is your PT working with you on form for fast walking and elliptical? How often are you seeing your PT and what did they say when things started to fall about on the elliptical? How long did you persist with the elliptical when poor symptoms were starting to mount? Ask your sports doc what their opinion is of your ankles.

You're still in discomfort from compartment syndrome. What do your docs/sports doc think about this. Have they said you should be better at this point? Could the burning ankles be related to this? How is the biking with your lingering compartment syndrome symptoms? How is the biking with your thigh pain? Again, are you possibly throwing too much against your body?

How's your rest (both sleep, and inactivity) and stress? These impact your healing. Yes, you just said that you need exercise for sleep, but I think you need to first aim for the safest exercise you can get. You might be pushing for more than your body is capable of currently. If cycling isn't killing you/making it worse, I think go back there for at least a few months while working on strength. If the sports doc nixes biking (thigh/groin pain, plus continued compartment syndrom issues), ask about an arm bike, or what else would be safe for you? Perhaps if the bike is boring you ask about other exercises which might be ok for a hypermobile person still working on building up strength.

What's your age? Around 40, the body starts taking more time and requires more rest in order to heal.

Sorry that this was mainly a lot of questions; some might be worth clarifying for others (age, sleep, nutrition, ankle mobility). Some might be better to ask your doctor, or just as yourself (I.E. possibly trying too much combined with how long you continued trying on the elliptical when back issues were starting to present). If you'd previously been given the all-clear from the sports doc instead of this being a followup for continuing treatment, definitely don't fear getting a second opinion.

*Cite: recommended protein consumption and timing. Cite: protein spacing/timing. Cite: recommended protein consumption. Cite: protein and kidney health.
posted by nobeagle at 12:11 PM on February 14, 2017 [2 favorites]

I wouldn't think arthritis is the cause of this. If you have the groin pain, clicking, and popping of the hip, your worst case scenarios are something like FAI (femoral acetabular impingement) or tear of the acetabular labrum. A better problem is bursitis of the hip (hot pain when lying on it being a symptom). MR-arthrogram would tell you what is the story here if the issue is contained to the hip joint.

Strength training with resistance bands isn't really going to cut it here. We are talking about big muscles. Also the resistance band training is boring. Maybe you could do pilates reformer or weight training that focuses on squat, lunge, deadlift with a kinesiologist. You could try clipless pedals for cycling and see if it helps with the tightness, this will allow the hamstrings to contribute more work and take some pressure out of the hip flexors.

Also do not assume the problem is the piriformis. The piriformis is quite often just a victim of other larger muscles in the area. Dysfunction in the hip area can be caused by the gluteus medius, certainly this can cause issues with abduction (such as scissor kick). There are 30+ muscles in the region responsible for all sorts of things ... hard to pick out just one offender.
posted by crazycanuck at 3:52 PM on February 14, 2017

Yes, that is absolutely a TA issue. Learning to do certain exercises using the TA instead of back, butt, or thigh muscles that compensate (for weak TA) is exactly what good PT should be helping you with.

Maybe try a PT place that specializes in spine issues. Helped me tremendously.
posted by Neekee at 7:22 PM on February 14, 2017

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