Julie Arkison FAI Arthroscopy 12/14/10 Dr. Larson in MN

Article 1:
Spending large sums of money on  a dressage schoolmaster  is the dream of many dressage riders.  Being able to sit in the saddle to enjoy a schoolmaster is a small but important detail  to that dream. After spending over 40 years  of my life riding, teaching and training, in August of 2007 I found myself  unable to put my right leg over the cantle to mount or dismount without extreme pain.  At one point,  when my right seat bone contacted the seat of my saddle, the pain almost caused me to pass out.  Four years after that awful day, 19 doctors and  health practictioners  and 2 hip surgeries later, I have spent upwards of  the $25,000 on my hip that I had saved for my schoolmaster and am finally able to sit in the saddle  again.

I was also hoping to write an article about the things I had learned about hip joints and our sport and share the success of the first arthroscopic hip surgery I had  in 2009 to remedy my pain.  Instead, welcome to the real world.  Here I am, a year later, recovering from a “re-do” of that surgery.  This time, it worked.
In these articles I will share what I learned through this medical adventure that began in August  of 2007.  I will discuss : 1)diagnostics for hip and back pain2)insurance issues that affect choices in treatments 3)surgical and non surgical options  for hip pain 4) the outcome of my four year medical journey.  My hope is that others can benefit from the information I have gathered as I made decisions that affect my profession, which happens to be the thing I have loved doing the most: riding horses. 
Julie HerbertPhoto of Julie with Herbert Seiberl

First, some background about the event which brought my riding to a standstill.  In 2007, I was dismounting from my horse when I suddenly buckled from pain upon landing on my right leg. My leg  simply gave out as soon as it touched the ground and I grabbed the  saddle so as not to fall.   It had been an uneventful ride except for a small sideways spook that had left me standing in my right stirrup while my horse moved abruptly to the left.   During the spook, I felt a twinge on my right side in the hip and lower back area, but believed it insignificant.  That is, until I dismounted.   I managed to walk far enough to untack my horse, put her in a stall and make it to the phone to call the doctor.
His diagnosis was severe groin pull or labral tear (the labrum is a type of cartilage that lines the hip socket).  One required rest, the other surgery.  He felt unqualified to make the diagnosis of labral tear and referred me to specialist.I knew my health insurance options were limited and with the deductible high as is the often the challenge of being self employed. As a result, I chose the conservative “ resting “ option.

I  supplimented my treatment with a body alignment therapy called The Rolf Method of Structural Integration ( RSI)  that I have used successfully for many years for other problems.  .  RSI works to  straighten  misaligned body parts that have been damaged or shifted  through accidents  or surgeries.  It also works to  change patterns that have developed through repetitive  movements  that  can create imbalances in the body over time.  Just as a wheel that is misaligned on your car can create all sorts of compensatory problems  to your vehicle, misalignment of body parts that have been injured or overused can create compensations that ripple through your whole body and leave detrimental effects as we age.
Side Bar to article:  RSI is a ten-session treatment that aligns and balances the body by lengthening and repositioning the fascia (covering around the muscles).  The practitioner will apply pressure to the body with their hands.  When restricted fascia is released and lengthened, the body can return to its structurally optimal position in relation to gravity.   Gravity is a force that effects every object and RSI practitioners’ techniques work with gravity so that, as alignment creates balance, the net result can be felt as an ease of movement and, often, a reduction of pain.  One benefit of RSI is that, by rebalancing the whole body, stress to the cartilage in any joint is reduced.  When  uneven pressure is alleviated (through balancing the whole structure of the body, much like a contractor would straighten a sagging roof  by fixing the collapsed wall that is causing the roof to sag) compression can be reduced , which in turn reduces   the pressure which over time, can result in cartilage wearing away.  For more information visit : gravityheals. com
My husband, Jim, is an RSI practitioner and years ago, when we were  dating,  I had  sought out RSI to help me with some positions corrections I had been unable to make in the saddle and had found it very effective in reducing pain and helping me achieve the position corrections I had been trying to make.  I  pleaded with him to get the work.    Not only did it help him, he decided to go back to school to become an RSI practitioner and has been in practice for twenty years .  So lucky for me,   I have an “ in house” RSI practitioner. Between  the  anti-inflammatories and some RSI sessions, the  hip pain initially  decreased enough for me to continue riding.  However, there was still an underlying discomfort that was getting progressively worse.  I began to suspect the problem was very deep and complicated.  It took another year two more doctors,  two sets of x-rays and two MRIs with contrast   for an official diagnosis: Femoral Acetabular Impingement syndrome, otherwise known as FAI. ( see side bar)

Side bar: The Anthem Medical Policy Blue Cross Blue Shield states that “Femoroacetabular impingement syndrome (FAIS) is an anatomical abnormality of the hip in which there is abnormal contact between the acetabular rim of the pelvis and the femoral head at the extremes of joint flexibility.  Over time, this contact may result in damage to joint cartilage, possibly leading to degenerative joint disease.  Surgical treatment for this condition has been described and may involve either an open dislocation approach, arthroscopic surgery, or a combination of the two. 
FAIS may be due to trauma, surgery, developmental deformity, or underlying disease. It is most common in young , active patients in whom a proximal femoral  abnormality is aggravated by activity involving excessive range of motion of the hip joint.  It is also seen in midde-aged women with abnormal morphology of the acetabulum.

FAIS refers to  abnormalities in the socket and ball of the hip joint  that can cause wear and tear in this joint. In layman’s language FAIS refers to  the acetabulum (rim) which is the socket part of the hip (you can locate it by finding the bony point of your hip on the front of your body) and the ball and neck of the femor  that fits into this socket  (see illustration). In my case, I had a “rim” that  was not smooth because of extra bone that protruded into the joint.  This made the socket rough  and  compromised the joint.    In addition, the ball had extra bumps (bony abnormalities) that also contributed to the narrowing of the space between the ball and the socket.  With specific motion of the leg, the bony protrusions on the ball and socket would collide and causing a  pinching motion that resulted in pain. The lining and cartilage can also be damaged as a result of the pinch which includes more permanent tears. The etiology of the  pain in FAIS can include torn cartilage, bony abnormalities, joint derangement or resultant arthritis. Eventually, FAIS progresses to severe  joint degeneration which causes pain in mobility and multiple positions including sitting, walking, lying down or  bending over ( let along riding ) . At that point, a total or partial hip replacement becomes the only effective treatment for debilitating pain.  

Many activities , such as riding  can cause aggrivation of FAIS and  are thought to contribute to boney abnormalities. However, more research is needed to understand the cause and effect relationship of  hip flexion and compression activities and underlying hip abrnormalities.  The doctor beleived  that my pain was   from normal wear and tear on an abnormal joint structure that I had or developed early in my childhood.   He was amazed that I hadn’t experienced problems even earlier in my life, given my profession and a history of club feet as a child.   I attribute this to RSI helping me maintain good body mechanics over the years and many of the doctors I saw agreed.

Of course , as I searched for answers , and treatment options,   I wanted  to know why this had occurred. I found that many activities  that require repeated  hip  flexion and compression , such as riding, can cause underlying bony abnormatlies to worsen.RIders can be more susceptible to developing  problematic hip joints due to the motions they must make to follow the horses movement. And since the sacral Illiac joint (  The SI joint  is the  space between the pelvic bone and the spine) can compensate for hip abnormalities and vice versa, diagnosis can be difficult.  More research is needed to know if these activities create the problem or if most problems in the hip are  a result of underlying defects exaacerbated by activity.   The important thing to remember is that  FAIS is a condition that  can effect males and females of any age and may be due to congenital defects or bony and soft tissue  changes that occur because of repeated micro stresses to the bone .The labrum ( lining in the joint ) can be torn  when the hip joint is abnormally torqued for any reason (such as fall or severe internal or external rotation of the leg)  which can lead to the development of  arthtritis.  Riders are prone to movements that can put high torque on hip joints   so when pain continues despite conservative  treatment, further work- up may be warrented.
At this point in my journey it was becoming clear that I was one of the people who fall into the category of having a painful hip that still has a certain amount of healthy cartilage left, but also has bony abnormalities and soft tissue changes that were producing pain.  This gave me options other than a total  or partial hip replacement. 

Medicine has come up with several options for people in my situation that have pain but do not have enough deterioration merit joint replacement. Open dislocation surgery and arthroscopic repair are procedures that fall under the catagory of joint preservation surgery and are  used when FAIS is present and there is still good joint space (when cartilage wears away, joint space diminishes to the point where bone touches bone). Open dislocation surgery, which provides full access to the joint, has been the gold standard until recent advancements in arthroscopic instruments and techniques have made it possible, in some cases, to use the arthroscopic approach to address FAIS.  Avoiding a full or partial replacement, or at least delaying it, is the primary goal of both open dislocation and arthroscopic repair. 
If one of these surgeries is able to address the underlying issues that cause pain and excessive wear in the joint and are rectified early enough, it is postulated that hip replacement surgery can be avoided or at least postponed.  That is why these procedures fall into the category of joint preservation surgeries which are designed to help a person keep their natural hip functioning as long as possible.
In my pursuit of dressage, I have sought instruction from as far away as the Spanish Riding School and have many theory books in my home library.  I attacked my medical dilemma  with the same fervency that I have my dressage education.   In order to avoid any kind of surgery, I had tried everything from drugs to PT to body-alignment therapies known as Structural Integration.  After my research and multiple consultants,  I chose an arthroscopic repair called a hip scope for my problematic hip in 2009.  This was surgery number one.

Article 2:

My husband calls me The Research Queen and, during my medical adventure, we got high speed internet.  I found the joys of “surfing the net”.  I read seven articles from the AMA (American Medical Association) about the long-term studies  for arthroscopic treatment of hip pain in people without deteriorated cartilage in the hip joint.   I familiarized myself with the differences between open dislocation and the arthroscopic procedure through these articles.  I  found other information by joining support groups for folks dealing with hip issues.  I knew that open dislocation (where the doctor cuts the femur in half to have full access to the hip joint) would give the best chance to do a full removal of the offending bone.  However, I had also been given advice that the arthroscopic procedure (no femur cutting would be involved) could possibly do the trick as well.  During one of my searches, I found Vicky Marlow, a patient advocate, who became instrumental in helping me navigate the sea of options and opinions I found before me.  Compassionate and knowledgeable people like VIcky who also have personal experience and volunteer time and resources to help others like myself who are affected by hip issues, are a rare find.  I think she also saved my marriage at one point since there is only so much listening a caring spouse can do.
Vicky’s web site http://hipresurfacingsite.com/  helped me to connect to sources and professionals that allowed me to research both types of surgeries for FAIS. She even helped me obtain opinions  from specialists  as far away as India. In addition, during my research, I also began to understand both types of hip replacement surgeries that are available:Traditional Hip Replacment and Birmingham Hip Resurfacing.  Birmingham Hip Resurfacing is an option for younger, active patients and can be converted to a total hip replacement in the future if needed.  It allows for a greater range of motion and less restrictions and has been used in other countries for years before it came to the USA. The choice of total hip replacement vs a hip resurfacing is many faceted. If I ever have to make that decision in the future, I know, thanks to  web sites like Vicky’s and  the caring doctors I have been working with, I”ll be able to make an informed and good decision for myself.

So, two years after the onset of my hip pain, I had  accepted the fact that I would not be able to avoid the “ s” word and determined which surgery might benefit me. Using the internet and recommendations from many health care providers,  I found t one of he best known surgeons for arthroscopic repair of FAIS, who was both out of state and out of network.  I made the journey to Colorado and felt hope for the first time.  That is until I began researching insurance issues which, sadly, made the specialist of my choice out of reach due to the 40k price tag.  Again, using the internet and help from Vicky and my team of health care consultants,  I found a doctor with a good reputation and a conservative approach who was in state and in network.  I also knew from my research that, since these surgeries were “experimental”, some doctors were more radical.  I wasn’t sure I agreed with some of the more radical approaches of cutting certain muscle groups during the surgery.  I felt comfortable that the doctor I eventually found was experienced and conservative.  He also understood my hesitancy about some of the more radical approaches.
Side bar on health insurance issues: Being a self employed riding instructor and farm owner, we have an individual BC policy whose loopholes I have explored with the same zest I once applied to understanding what made horses crooked. With this policy hip replacement surgeries are covered after the deductable is met.  Unfortunately, High deductibles are the hallmark of the policies available to the self employed.  My research uncovered the fact that the best policies are only available to large corporations with many employees and are, again, sadly out of reach to the self employed.  At the time of my surgeries, joint preservation surgeries such as arthroscopic procedures fell under a category known as “unlisted” in procedure code jargon.  These codes control the pay outs.  When push comes to shove, “unlisted” gives the insurance company all the leverage they need to shove the bill squarely on the patient.  It took over a year of phone calls and writing letters before I was able to obtain an estimate, as well as a letter from my insurance company stating what would be covered prior to the surgery. My state does not have a pre-authorization department for what are considered ambulatory surgeries and, as a result, do not pre-authorize such surgeries. Fighting bills after they occur is not the way I do business.  I lost valuable time in researching costs up front, but was at least assured that the procedure would not be denied and knew my costs ahead of time.  As of January of 2011, I am happy to say that, thanks to doctors and patients like me, arthroscopic hip surgeries are now covered by most insurance companies and no longer have an unlisted procedure code.  They do still require pre-authorization, which, depending on your state, can be hard to obtain.
The surgery I had takes about an hour.  I left the hospital on the same day.  After that I spent three weeks on crutches followed by six weeks of not riding or doing barn chores. Then,three more months of only “light work” in each area.  Rehab took its physical, mental and emotional toll.  I had extensive PT, all payed for out of pocket, and some RSI sessions.  After six months, I could say that I had some relief from the surgery but, sadly, not as much as I had  hoped or expected.  I was able to return to riding, but still had some pain when I moved my leg into certain positions.  I could function by adapting many things from how I mounted to how I rode and what kinds of horses I rode.  I had resigned myself to the downhill slide to a hip replacement that I knew was the only other option when, ironically, I took a fall that lead to more pain than ever before.  My sixth-month-old puppy had come tearing around the corner of the barn and we collided, causing me to fall sideways onto my hip (actually it was the non-operated hip I fell onto).  The pain on the operated side was greater than the initial incident in 2007.  But, since it also involved the right side of my lower back much more severely this time, near my SI joint, I went to four more doctors to gather opinions on what was causing the pain this time.

At this point I was experiencing a wide range of symptoms that  could be consistent with a sacral iliac , back or hip problem.  Some of my pain was in my lower back in the lumbar and sacral area on the right side. Sometimes, I had shooting pain down my buttocks and the back of my leg. I also had pain in the front of my thigh and in my groin.  At Other times, the pain radiated to my ankle and knee.  When I swung my leg over the saddle and sat down, the pain moved upward and inward  into the middle of my hip joint. When I dismounted, there were days I couldn’t bend or move my leg ( I even tried putting it over the pommel) and feared I would be stuck in my saddle for good! I tried dismounting once on the other side and almost passed out.
During this stage of my medical adventure I learned that, over time,  when there are  problems in a hip joint, it  stiffens to protect itself and, when greater range of motion is needed, a joint called the Sacrial Illiac Joint tries to move instead. (picture needed)  The vertebrae in the lower lumbar spine can be affected by hip joints that work unevenly also.  The x-rays and MRI of my spine had  been  mostly negative and no one seemed to think my lower back was root of  the problem but I continued to have pain in that area. It was suggested that it was referred pain ( pain that originates elsewhere and is felt in another part of the body)   So, three years after my diagnosis, and after my first hip scope, I was sent to a pain management clinic for an injection into my sacral illiac joint in an attempt to isolate the origins of the pain.  Veterinarians perform these kinds of tests on our horses for diagnosing lameness  but, instead of lounging myself for the doctors, I started bringing my saddle and  a saddle stand into their office so I could show them the position that was causing pain on my right side.  Sacral Iliac joint problems can cause lower back pain on one side or the other of the lumbar area and, by doing a numbing injection into this joint, we were able to see that it had no correlation to the pain I was feeling when I swung my leg over the back of the saddle and my right seat bone made contact with the seat. I was still unable to position my right leg without severe pain even after this injection.  Since the sacral iliac joint and lower back can be affected when one hip has a different range of motion than the other, the diagnostic team of health professionals can become confused between lower back problems, SI problems and hip issues.  This is why getting the correct tests, knowledgeable doctors and body workers will help you correctly assess the root problem in these three areas and to pick therapies and/or surgeries that will benefit you.

A real benefit to traveling this medical mile was my fantastic  physical therapist , Ann Herbert , who is  a  dressage rider, a friend and an old student of mine.  She also has had RSI and so was able to work with me during my rehabilitation in ways that made sense  to my body  and helped facilitate a new range of motion in my operated hip.  Being an accomplished rider herself, she  was able to relate to what I needed to do in the saddle and could understand when I told her that I couldn’t use my right leg in certain ways when I wanted to do a right shoulder in  and that when the horses rib cage pushed against my right thigh in a certain way, I would almost pass out from the pain. She didn’t  miss a beat when I brought my saddle in to her office after my puppy collision and showed her how the position of my right femur when in the saddle was excruciating.  We had some good laughs about the fact that our roles were reversed and she was giving me position lessons now! We also had many talks about how important it is for riders to understand their bodies and to seek professional help when they feel there is a problem that is not resolving. In my adventure I learned that  when recurrent treatments for SI or lower back problems are not yielding lasting results, it was prudent to look at FAIS as a contributing factor.

Ann was actually the first person who suspected FAI   as the underlying  problem. In order to navigate the medical maize, in relationship to health insurance and doctor’s offices, there are many steps that must be followed. For example, a prescription from your doctor is  required before you can see a PT. Seeing a PT is required in many instances as a therapeutic regime that must be tried before surgery is discussed as an option. In my case, Ann was able to send my progress notes as well as letters stating what she believed to be the problem to the orthopedic  sports medicine doctor to  whom I  had been referred. Doctors must legally make the official diagnosis but often PTs are more aware of your specific problems. If your doctor and your PT communicate well and jointly review your case, many unnecessary tests can be eliminated and time and money will not be wasted. Therefore, a PT who is a rider and is knowledgeable about underlying conditions that affect the range of motion and flexibility of a joint can often help doctors avoid  tests and save time when decisions need to be made regarding surgical intervention.  Hip issues are often misinterpreted and communication between your PT and physician can be a valuable asset to proper diagnosis  and treatment.

Each of the 15 doctors I consulted were specialists and also compassionate, caring individuals who respected the work I was doing to understand my medical options and my desire to be financially responsible in regards to bills that were not covered by insurance. In addition,  I am married to an RSI practitioner and have access to a wonderful, knowledgeable and caring PT,  so I can say  I feel  truly blessed . It takes work, but anyone having physical pain that is affecting your riding will benefit greatly from finding the right individuals to put on your “ healing “ team to help you  diagnose and choose the best options  offered in both the traditional and alternative fields of medicine.

By 2010 I had decided to undergo another hip scope, but this time with a different  doctor who I found in a most unusual way.

Article 3:
After my puppy collision, this next round of doctors had included a visit to the surgeon who had done my hip scope, a pain management specialist, a sports medicine doctor, as well as an out-of-state doctor who did BHRs.  It was determined by the doctor that had done my original surgery that the pincer portion (bony prominences on the rim of the hip) had not been sufficiently removed but there was still adequate space to the joint (meaning there was enough cartilage) to keep me out of the hip replacement category.  He suggested another arthroscopic procedure to smooth the rim, but there were no guarantees, and I was leery of doing the surgery again.
Digesting all the information I had gathered, and not being able to ride or even walk much without severe pain, I worked hard not to spiral into depression.  I decided to consult a BHR specialist that Vicky had referred me to in another state.   Ironically, an old student lived an hour from the BHR doc in WI.  I had already seen the specialist near my home that was in state and in network who felt that it was time for a BHR.  Vicky suggested I get a second opinion from a highly-respected doctor who had many years of experience.
I hitched a ride with my old student, when she came back for a visit, and lugged a saddle with me to see Dr. Rogerson.   I borrowed a saddle stand from her instructor when I got to WI and traipsed into the doctor’s office with my gear and my 2-inch-thick medical file.  I have rarely met such a caring and compassionate doctor as Dr. Rogerson.  He spent over an hour with me pouring over my very neatly arranged paperwork and watching me mount and dismount from my imaginary horse.  I was in so much pain at that point; I almost passed out when I sat in the saddle. 

“I think you should see Dr. Christopher Larson in Minnesota”, Dr. Rogerson said after much consideration of the evidence presented in my extensive files.  “He specializes in FAIS.  His approach was very scientific and thorough. And arthroscopic acetabular rim trimming is one of his areas of expertise.   By taking x-rays while the patient is under anesthetic, he can make sure the impingement has been adequately removed.  He is one of the best, in my opinion, and I have personally attended many surgeries of this type with various doctors.”   As luck would have it again, my dear friend and fellow instructor Alicia Byberg- Landman (who had taught some of my lessons for me while I recovered from my first surgery) had just moved to Minnesota.  She was 15 minutes from Dr. Larson’s office. 
I took the train home and, on my trip, made calls to see when I could get an appointment with Dr. Larson.  Usually it takes three months to get into see a specialist.  I explained my dilemma and that, due to my deductible, I wanted to see if surgery before the end of the year was possible.   That was in Sept. of 2010 and by Nov. of 2010 I had flown to Minnesota, borrowed my friend’s saddle and stand and I was able to show Dr. Chris Larson exactly what the problem was.  After a thorough  PT exam and an exam by Dr. Larson’s  PA and Dr. Larson , more x-rays and a 3-D CAT scan, it was determined that I was a candidate for another hip scope. Over a three-year period I had twelve sets of x-rays and  three MRIs (two with dye) to assess the health of the hip joint.  It wasn’t until I met Dr. Christopher Larson that I was given a 3D CAT scan which showed, without a doubt, the bony prominences on the rim of my pelvis that were causing the pain.  In my opinion, all the tests that were used prior to the 3D CAT scan were a waste of time and my money.  None of them were covered due to our high deductible.

It was clear to me that  Dr. Larson had put much thought into hip issues with athletes and answered all my questions from both a practical and theoretical standpoint.  I was frustrated with myself that I had not noticed his name when I had done all my research. He had co authored some of the articles I had read but   I had checked with seven other  arthroscopic doctors from those articles.   It takes a minimum of three months to get an appointment and about $1500 (including travel expenses and tests) to go for one consultation.  My husband gently reminded me that we could not afford to see ALL of the doctors who perform arthroscopic hip surgeries before choosing one.  Dr. Larson read my composite three-page medical history that highlighted all the opinions I had gathered and kindly summarized what he thought were my options.  He reassured me that if he did not think it would help, he would not suggest surgery.   He told me that my left hip (the one that has been asymptomatic) actually has some arthritis, some FAIS symptoms but is not a candidate for any kind of FAIS surgery due to decreased joint space ( translation: not much cartilege left) .  My right hip still had enough joint space and was relatively free of arthritis despite the intense pain I had when I put my leg in certain positions.    He could not assure me of the outcome but felt that, given the views he saw on the 3-D CAT scan, by removing the pincer (rim of the hip socket) problems, I might have some relief that could last for a while.  Compassion, skill and passion are the hallmarks of great surgeons and Dr. Larson exemplifies these qualities.  I remain grateful that doctors such as Dr.Larson care enough to really look deeply into the specifics of a person’s situation and help them choose beneficial options.  His office staff made scheduling and getting any questions I had answered simple.  This was not the case with all the doctors’ offices I dealt with and again, a good “office team” makes the reality of surgery so much easier. 
Dr. Larson wanted me to undergo another hip block just to be assured that the pain I was experiencing originated in the hip joint itself. I had a previous numbing injection into the hip joint done when I returned to see the surgeon    that did my first surgery.  It was  origninally not done correctly and clouded the picture for a while.   He suggested a hip block using x-ray guidance this time.   Upon returning home, I took my saddle and stand in again to see the doctor who had performed the SI block.  Done thoroughly, with x-ray guidance for the needle, the test offered a very positive result.  Again, paid for out of pocket, this test was clear evidence that the pain was indeed coming from the hip joint.  The numbing medication lasted for about six hours, during which time I rode all my horses and walk, trot and canter without the pain which had been ruling my life.  But just as with our horses, masking pain with medication isn’t a cure and, when the medication wore off, I was in more pain than ever.
Surgery was scheduled for Dec. of 2010 and I, once again, prepared for all the realities that accompany surgery and rehab.  Dr Larson was in network but out of state.  I think it is important to note another ironic event that helped me obtain information  about my bills prior to surgery.
The morning of the my appt. with Dr. Larson,  my friend  Alicia and I made a trip to the Mall of America  so I could distract myself from the anxiety that was building.  While in the dressing room at Cold Water Creek, I explained to the sales girl that was helping me that I needed a certain kind of pants that didn’t put pressure on my hip and began to cry as I explained that I was in Minn. to see if I would undergo a second hip operation.  Suddenly I heard a kind voice coming from the room next door.  Michelle introduced herself and offered to help.  She told me that, since I was not getting the answers I needed in a timely manner, I could ask for a Case Manager to help navigate the steps in between diagnosis and treatment options.  Not one of the many people I talked to at BC told me that this service was available, at no extra charge.  Michelle was a case manager at a hospital in MInn. and kindly gave me her number, offering to help in any other way she could.  Without that piece of information, I would have faced having a surgery without prior approval that would cost over 20k.
Despite the first great winter storm of the season that came the night before I was to fly out, and the collapse of the Minn. Metrodome the day before I was scheduled to leave, I made it to Minn.  We had gotten stuck on our unplowed back roads and my husband heroically pushed us out and got me to the airport in time for my 5:30 am flight.  After surgery I was told how lucky I was that Dr. Larson was able to get back home to do the operation.  Not being a sports fanatic, I didn’t realize he is the team doctor for the Minn. Vikings..... and he and the team had flown to Detroit (I live about an hour from there) to play their game just before my surgery.
Immediately after surgery, I was able to feel the difference.  As soon as I woke up, my PT had suggested I start my exercises and to my amazement, I was able to move my right leg into positions that had previously caused great pain.  I flew home two days after my surgery and began rehab once again.
As true friends do, Alicia took great care of me after the surgery and even flew back a few weeks later to teach lessons to my students for a week so I wouldn’t be tempted to push things too fast.  And my wonderful non-horsey husband did a fabulous job of taking care of me, 15 horses, various dogs and cats and the house during my recovery.  Four years from the onset of my hip issues, I can say that without oodles of research, talented doctors, caring staff, and the love and support from my wonderful husband, students and friends, I would not have fared as well in this medical adventure.
Three months after surgery I signed up for a clinic with one of my favorite instructors from the SRS.  I was still on  some  restrictions, but I was bound and determined to do what I love to do the most again: ride dressage and ride with one of the best instructors in the world.  My PT and doc gave their blessing as long as I didn’t overdo it.
The horse I took to ride with the SRS instructor, Herbert Sieberl, is named Magic Moment.  I have ridden her for Heir Sieberl many times in the past.  I have known the mare since she was six months old.  She is 17 this year.  A client and dear friend had purchased her as a foal and allowed me to train her.  When my friend was dying of breast cancer, I bought “Magi” since she had proven to be a bit too fiery for my friend, Sue Ann.  I have done all Magi’s training.  Ironically, she has had a club foot since birth and was diagnosed with a neurological deficit of unknown origin in her right hind leg.  Between my hip issues and her leg problems, we have had a hard time sorting out flying changes.  A few of my other horses and I learned changes easily.  I do not know if it is because of how our collective deficits have affected each other, but we have been struggling with the changes being a half a stride late for many years.  In March of 2011, three months after my second surgery and my four year, 25k plus medical journey, I had the most magical lessons of my career and got all clean changes.  Perhaps my newfound range of motion in my right hip was the reason or perhaps it was the days and weeks I spent imagining clean changes when I couldn’t ride.  Whatever it was, I was thrilled.

JulieMagi has always loved piaffe.  On top of our clean changes, Heir Sieberl said, “Her piaffe is as good as we do in the school.”  I beamed.  We had also gotten our first real steps of Passage.  “Her passage steps were good also.  More will come with time.  She looks very good and correct in her gaits and the half passes this year are very good.  “Tears of joy slipped onto her neck as I hugged her and then  Heir Sieberl.  When I got home, I called Dr. Larson’s office to thank him and sent him a picture of my magic moment. ( I have a picture of this )
 We are still recovering financially, and I don’t think I’ll ever be able to buy my dressage schoolmaster.  I have learned a lot about health insurance and about navigating the medical system in relation to health challenges.  I continue to ride with almost no pain on the surgical side.  My other hip has some issues and I do not know how long either hip will last, but, for now, I truly enjoy being in the saddle again on my homemade schoolmaster.  I spent my dressage schoolmaster dream fund on medical bills, but last month, when I rode Third Level and got scores in the mid sixties with clean changes and no comments of unlevel steps, I felt like I had achieved the impossible.  That is, after all, why most of us dream of having a schoolmaster some day.  Magi doesn’t have a lot of suspension, and I don’t have alot of flexibility, but we are truly partners that trust each other and are striving to do our very best.  And that is, after all, what riding a schoolmaster is all about!

Dr. Larson FAI Arthroscopy 12/14/10

Timeline updated December 4, 2011

Julie Arkison: 48yr. old Female Self Employed Horseback Riding Instructor and Trainer .
Sept. 2007 :   Unable  to work  due to pain in right SI and hip.
Began riding at age 4 yr.s as therapy for  severe Bilateral Club feet. Many surgeries and casting until age 18yrs.   Last surgery on feet at age 18yrs :  Bilateral Triple arthrodesis
Consult is for right hip pain

History of pain and treatments follows:

Aug. 2007: Was riding and a horse stepped quickly sideways. Did NOT fall off. Felt a twinge in right lower back area. Not much else.

Sept. 2007 dismounted by swinging right leg over back of house and upon landing searing pain- unable to walk, dragged leg.

Sept.  to Oct. 2007 Severe pain while mounting and dismounting from a horse from a mounting block ( could not at all from the ground). Unable to ride ( so unable to work).

Oct. 2007  Saw Dr. Federonko ( family doc) who refered to Dr. Walper Sports Orthopedic specialist

Oct. 2007 to July 07 Dr. Walper prescribes:  PT, anti inflamatories ( Allieve ) , rest, exercises per instructed . Not much change. Rolfing ( Structural Integration ) provided most relief. Eventually ordered MRI of spine which showed no significant problems.

July 2008  Dr. Zaltz evaluates and diagnosis FAI and tear.  Still having pain so sought out hip specialist on my own. Does MRI arthrogram and  xrays and suggests open dislocation surgery. Says arthroscopic can’t work.

Nov. 2008 Dr. Phillipon in Colorado confirms FAI/tear and suggests arthroscopic repair. Says too early for BHR and suggests joint preservation approach.

Dec 2009  to May 09 dealt with insurance issues regarding coverage for surgery. Due to experimental code and in/out network hoops, realize I can't afford to go to Phillipon.

May 2009 email consultations for BHR vs arthroscopic  via Vicky Marlow  with :  Dr. Bose, Dr. Rogerson, Dr. Su, Dr. Desmet .  All differed but  mostly said  too early for BHR due to good joint space. Mixed ideas as to success of arthroscopic.

July 2009 Dr. Schmidt consultation for  decision on BHR vs. arthroscopic repair. Suggested was early for BHR but would do it . Didn’t think  arthroscopic would help.

Aug. 2009 Dr. Farjo consult to decide BHR vs arthroscopic.  Suggested arthroscopic  over BHR because of good joint space but said it might fail but there was a good chance it would help.  Chose Farjo  for surgery because : local,  more conservative than  Phillipon  in approach and covered by insurance after 3k deductable.

Nov. 2009 Dr. Farjo performed FAI/tear repair surgery. Removed Cam and smoothed labrum. Did not suture any labral tears. Said he took off some pincer but hadn’t expected to have to do that.

Feb. 2010 Dr. Farjo evaluates left hip pain that developed  during recooperation from surgery on right. Suggests FAI/tear surgery even though joint space is significantly less. Did MRI arthrogram and x rays to diagnose.  Said it wasn’t too bad so if I wanted to wait since right hip was still healing and not pain free, that it was ok.

Aug. 2010 Fell on left hip after colliding with puppy while walking in the barn.  Right hip ( surgical one) began hurting and immediately following fall, couldn’t walk without severe pain. Rolfing helped relieve acute symptoms.  UNABLE to ride at all after this. Pain WORSE than pre-surgery.

Aug.  2010 Dr. Harwood  Sports Rehab  Doc suggested by family doc to rule out spinal issues.  Diagnosis SI strain sends to PT. Most relief found from Rolfing.

Sept. 2010 Dr. Farjo agrees wih SI diagnosis  but notes that acetabular rim trimming might be necessary due to pronounced Pincer seen on x ray. Does ultra sound guided injection of maricane and cortiizone into right hip to rule out hip pain. Does not provide any relief. Refers to Dr. Shaluab at Michigan Pain clinic.

Sept. 2010  Dr. Shaluab agrees with SI diagnosis. Suggests SI injection in 2 weeks .

Sept . 2010 Dr. Rogerson reviews and examines ROM and watches me sit in a saddle I brought to the office. Suggests that SI pain is caused by severe restriction in  ROM right hip . ROM restrictions  caused my inadequate removal of pincer leison  from Nov. 09 surgery and old , established patterns of restriction.  Refers  me to Dr. Larson for evaluation for rim trimming and  possible capsule release.  Said if not a candidate than would remove Pincer and do a BHR on right hip.

Nov. 2010 Dr. Larson does 3D cat scan and x rays.  Says  that not enough pincer was removed during first surgery. 3D CAT scan was  MOST awesome diagnostic I had thus far. I couldn't understand why no one else had suggested it.  PIncer and cam lesions very evident on right hip.  Left hip is not a candidate for arthroscopic  and doesn't have the same pincer/cam severity so he says to " use it up". Right hip still has good joint space so suggests surgery to redo cam/pincer removal. Said labrum is ossified so nothing to suture. Larsons surgery is very thorough since he takes x rays DURING the surgery and puts the hip in different positions to make sure impingement is gone.

Nov 2010 Dr. Larson orders a numbing injection under xray guidance to make sure pain is mostly in hip joint.  Since the ultrasound procedure done  did not  yield positive results he wanted to make sure it was redone using xray guidance.   

Nov. 2010 Dr. Shaluab does injection and had immediate relief for six hours.

Dec. 2010 Surgery done. Fly home  2 days later. Felt immediate difference  in pain level and on ROM after surgery.

Current:  Have been back to work since May, 2011.   SI pain almost entirely gone , have stretching and strengthening routine done daily developed by PT.  Used  Structural Integration to help with compensations that resulted from traction during surgery.  Made a HUGE difference  in helping  to  re-develop symmetry.  Using Alieve and an occassional 1/2  percoset  when I overdo it.   Dr. Su  reviewed records and did exam and xrays 10 months after surgery and   says  not time for BHR. Dr. Bose confers after looking at x rays in remote consulation.

Extra note: As of Jan of 2010  FAI  surgery  has a legitimate code and is not listed in the experimental category .  However , do thorough checking to understand what is covered for an ambulatory surgery (in state and out of state are different )  and if the doc is in/out of network.