...bar the shouting.

I've had another physio appointment since my last post, and a short holiday.  I've have some additional exercises to do, but now I'm just waiting for an appointment (which I had expected to have already happened by now, but the clinic are dragging their heels to be quite honest) for a dynamic ultrasound from a London-based specialist to confirm what I suspect is pretty much a tick in the box, that I have an abdominal wall tear.  This is likely to be a tear in my abdominal oblique muscle on my right side.  This would probably explain why when reproducing the pain for a physio/consultant a sit up with a twist to the left hurts a lot more than just a normal situp.  It's possible that I also have Osteosis Pubis alongside the tear, which could have developed as a result of the subsequent weaknesses that have developed in the area.  My rectus abdominis on my right side has lost muscle mass, as shown in the MRI picture that I put in a previous post.  I' ve been working on my glut max and medius, as well as abductor strength, but to be totally honest I don't think it's going to make a blind bit of difference to me in the short term. 

It's highly likely to be torn and no amount of rest of exercise is ever going to fix it.  I read around and it says this is one of those career-ending potential injuries for sports professionals.  Even this week I read in the news that a couple of UK and England footballers are duffering with groin injuries which have all but ended their careers.  They have been all over the world for operations and not got any better.  This has pretty much left me pondering wether it's even worth going any further down the investigation road at all.  I'm certain it's damaged, and only some attempt of surgical intervention might (and I stress the might) improve it.  Then there is the risk of the operation itself.  Any surgery is risky, and let's face it in my case, this would be pretty much akin to getting cosmetic surgery.  I'm not a professional runner, and as long as I don't aggrivate the injury by running or doing sit-ups then I can live a more or less normal life.  So, I don't really need the operation.  What if I died? My little 5 year old boy with no father, just becuase I was selfish enough to want to be able to run.  So, I can just toss in the towel, not face unecessary risk through surgery and do something else.  Sport of pretty much every kind would be more or less ruled out.  The physio told me the number of people who could run the distances I have done, with the poor biomechanics (leg length difference, curved spine, twisted pelvis) that I have is small.  Most people would have probably given up soon after they started the sport.  I can't think of any good reason to risk and operation at the moment, so it's looking like that's it.

I started running just 4-5 years ago, and then after suffering knee and hip pain discovered I had all these issues.  I had some orthotics which seemed to help, but may just have shifted the problems elsewhere if I think about it.  Every year I have run I've suffered various injuries.  All runners get them, but I've been out for longer than most.  I think it's just my bodies way of saying, "you're not cut out for this, stop it".  I've been doing the exercises but the motivation for doing them is rapidly decreasing.  I'm not even sure I can be bothered today. 

I was away for a few days a week or so ago, in Tenerife, and managed to walk from the coast, sea level obviously, up to the top of the volcano in the centre of the Island at 3718M.  I did this over 3 days and my groin didn't cause me major problems.  I don't for one second think I could walk very long distances, but the odd 10-15 mile walk is within my capabilities I hope, so I think I'll just have to settle for that.  I don't really think there is anyone or anything to blame, it's just the way I'm built; not well enough for my body to suffer continuous overuse in ultra's.  Sadly, I can't even run a few miles now, so I can't even do any shorter distance events.  For the sake of completeness if I do every get a definitive diagnosis I'll post the details here, just in case anyone else ever suffers the same. 

Ateneo 21 review

Avoid this terrible Spanish language "school".

Whilst working (and injured, so no running) in London I decided to Learn Spanish to fill some time in the evenings.  I go to Spain and it's Tenerife frequently to train, and so it made sense to learn more of the language.  However, I classed myself as a totall beginner and google for langauge schools in London.  I found Ateneo21.

The Ateneo 21 website states that it is a Language School. As it transpired it was not a language “school” at all, but one Argentinean lady providing private tuition from her sofa in a small six floor flat in a tower block in Central London. So, the warning bells were already ringing, after clear misrepresentation from the website. I arrived and sat next to one only other student on the sofa, who it transpired had already had 3 lessons, but was back repeating the first lesson as he hadn’t been able to understand anything so far (he told me this afterwards). Without any introduction to the course content or methods I was thrown straight into a world of conjugating verbs, and tenses, and bewildering worksheets with complex Spanish phrases and not a single word on English translation on them. I thought “I must be in the advanced class”, but no, this was in fact the ‘breakthrough A1 beginners class’. I’m a clever guy. I have a well paid job in central London and studied French as part of my degree, but was left bewildered completely in an hour and 15 minutes of inappropriate level of instruction. I learned absolutely nothing at all.

Her next student turned up 20 minutes early and sat in the corner of the room, a further unwelcome distraction. Both me and the other beginner student left the class 15 minutes early, both realising we were wasting our time there. Outside the other guy told me the only reason he had gone back was because he couldn’t get a refund from her. He would not be going back either. He knew he had wasted his money, and had now booked onto a proper course at an actual language school in Regent Street. He had been to 3 lessons and he said they got no better, and he had felt as though he was stupid. He was very relieved to hear that I had thought the same. I had only paid for 12 lessons in advance. I emailed Carolina to complain about her teaching and ask for my second lesson fee to be refunded. Of course I got a reply in which told me to “refer to the terms and conditions on the website regards refunds”. So I threw my money aware. I feel as through the website is deceptive, the teaching very far below the standard we expect in the UK, targeted at an inappropriate level of difficulty, and I suspect just preys upon pre-payment of a (usually 4 weeks - £108) in order to make a living, as students will just cancel and can’t get money back.

The next day, I phoned a well known language school in Central London  to book onto a course.  I cited my experience with Ateneo 21, and questioned first lesson content and ongoing course structure.  I was assured that their first lesson and method are not remotely similar to Ateneo 21's  approach, which they said would, quote “scare off” and “cause a new student to lose confidence”, which is precisely what it did.  I suggest you attend a first beginners level class at a language school, and apply the method to your first lesson.

Do yourself (and your bank balance) a favour and book into a recognised language school, and not this bewildering amateur outfit run from a sofa!

The second diagnosis

You may have read last weeks post where I was diagnosed with an Rectus Addominis and Inguinal Tendon injury.  You may have also detected that I was a little pessimistic about my prognosis, and unsure of how just physio was going to fix it.  Well, today I went along to meet my physiotherapist and expected to be ushered in and given a raft of core strength and glut med exercises.  I was wrong.  The physio I think detected that I was a little confused by my diagnosis (it's all the big Latin words!). I guess I really couldn't understand why glut muscle weakness was giving me such specific pain in one small area by my groin.

He did provide a good explanation as to why the diagnosis could be the case, but then decided to take my case history and do some additional tests.  Many of the tests the consultant, who was very thorough, had perfomed last week, but also did a few extra ones.  The room was punctuated with "does this hurt?", "err, no"...."what about this?"...."no, that's ok too"...."and this?..."Ouch!!", for about half an hour.  I think I had been referred to a physio who was really up to date on the latest research in the area; he said was literally months old.  The killer pain-inducing exercise for me is a sit up, especially a sit up with a twist to the left, which aggrivates my right Rectus Addominis where it joins my pubic bone.  At least that's precisely what I told the physio, and demonstrated as such to him.  After several more tests the physio then said, I believe I know what could be wrong and it's not your rectus abdominis.  He squeezed my hips together hard, stabilising them (simulating wearing a pelvic belt apparently), and had me to another sit up. Amazingly, I had no pain.

He said, like others have, and everything I have read, that diagnosing groin pain is very hard because the area is just like spaghetti; everything meets here.  He narrowed it down to two possible diagnosis, saying it was impossible to nail it to one without an expert-guided ultrasound by someone who specialised in this problem.  He is going to refer me to a London specialist who he says is the only person he would send me to, to diagnose it; a doctor who deals with UK elite athletes apparently.  The physiotherapist went on to explain that I did indeed have Glut medius and abductor weakness as identified last week (which he has given me some exercises for), as well as chronicaly tight femoris muscle which I have to stretch.  The combination of all of this weakness and tightness, and the resulting twist of my pelvis (my right foot is currently twisted outwards, visibly), has out undue strain on the area and resulted in the damage (that's my lamens explanation, not the practioners incidentally). 

So, what is it?

Either:- A Conjoint Tendon Tear or an Abdominal Wall Tear. 

So, basically we are back to what I had half diagnosed myself a few months back, a hernia in effect.  Albeit kindly titled a "sportsman's hernia".  The doctor last week had initially diagnosed this too, and then second guessed himself.  The ultrasound may show his gut instinct may have been right first time.  We'll just have to wait and see now.

The specialist I need to see is away on holiday and also has is usually very busy, so right now I have no idea when I will get to see him.  I will however start work on the exercises I have been given.  I'm half clinging onto a vain hope that the diagnosis will change to conjoint tendonitis (you can tell I got home and started googling can't you) and may be resolved with 4-6 months physio.  Sadly, the more likely outcome (I hate to suspect it) is that I need surgery; maybe a surgical repair of the conjoint tendon and posterior inguinal wall, perhaps also an adductor tendon release done as well.  They may as well throw in an obturator nerve release at the same time, and make sure all bases are covered. 

So it's essentially doom, gloom and some extra doom. 

I am seriously considering taking up endurance knitting, but I suspect there are some nasty hand injuries that I could pick up.

Diagnosis

Last week I went in London to see a consultant in London about my groin injury, which has all but sidelined me for the last 5 months. It was worrying at the start, as after his initial examination he thought I had a hernia. However, subsequent tests proved otherwise, which would explain why the not few people that have seen me over the last few months have not been able to pin down a diagnosis. I ended up being evaluated over the course of an hour; I understand the appointments are usually 20-35 mins long, so I’m appreciative of the extra time the doctor spent with me.  The headline diagnosis is Right sided rectus abdominis and inguinal ligament injury.

An extract from the report is as follows:

On examination today your single legged balance and single legged stability were poor with a positive trendelenburg test on both sides. Certainly, in your eyes-closed balance the muscle activation of your lower limb was unstable with some over-active peronei and underactive Tibialis posterior. Your hip range of motion on the left was normal with a full active range of motion and a negative FABER and FADIR test. On the right side we were able to reproduce your pain a little on end range flexion and you were tight in right extension although, again, internal and external rotation were normal, FABER and FADIR were negative and these did not reproduce your symptoms. I could find no abnormality in your knees and your foot and ankle range of motion was normal with good power in flexion, extension, inversion and eversion. With respect to your adductors on the left side there was no adductor tenderness or weakness, the pubic tubercle was normal with no inguinal ligament irritation, and the left rectus abdominis and left rectus femoris were normal. On the right side you were tender over the insertion of rectus abdominis into the pubic tubercle but not tender over adductor longus at its insertion. However, the tenderness did extend up the inguinal ligament and there was some irritation over reproducing Tinel's sign over the ilioinguinal nerve. Resisted sit up and resisted rotational oblique sit up reproduced your pain which was not relieved by pressure over the ilioinguinal nerve. Your sacroiliac joints were stiff but not irritable mainly on the left and your lumbar lordosis was flattened but slump test and straight leg raise were negative.

In summary, I think the underlying precipitating factor here is your proximal core and gluteal functional

stability and I think this is the mainstay of our initial treatment. We certainly need to review your orthoses at some point but I think we can do that here at Pure, in terms of a temporary heel raise and deeper heel cup prior to having a formal orthotic review when your pain and symptoms settle down. We need to work on core, transversus and the abdominal insertion at the same time as working on your proximal gluteal control of your hip stability, and I think you are booking in with our Physiotherapist over the next couple of days to make progress with this. We discussed the possibility of a diagnostic local anaesthetic injection over the ilioinguinal nerve and if things fail to progress over the next two weeks that would certainly be my next step.

I had the opportunity to review your MRI films with you and these are really rather unremarkable but confirm the presence of some free fluid around the rectus abdominis insertion. I have not specifically looked at the ilioinguinal nerve or, indeed, the inguinal canal and it is difficult to comment further on these. I am delighted you decided to consult at Pure Sports Medicine and I hope we will be able to rapidly provide you an effective rehabilitation programme and map your rehab back to full distance running over the next four to six months.

So, that’s the verdict. There’s no mention of the micro tear diagnosed by the radiographer from my MRI. So, I hope that is the case and that the non-surgical approach is the right one. He did mention that footballers would typically just take the surgery straight away in an effort to be back playing in 4-6 weeks. However, I’m more interested with addressing the underlying biomechanics and taking a longer time to rehab. This diagnosis effectively writes off the rest of the year, which I had more or less assumed would be the case anyway. I can write off to the end of the year, but would have to be back training after Christmas to build up for an attempt at the Gobi in June, given I would be starting from square 1.  If the physio doesn't work, and I need surgery as well afterwards, then the Gobi could be out.  My orthotics have worn out too, and the doctor only saw the pair I walk in. The ones I run in are in a very sorry state indeed. He mentions getting a change to the prescription, and getting a deeper heel cup, so I’ll have to see about getting that arranged. My first physio appmt is tomorrow. I’m looking forward to starting but if I’m honest I think I’m pessimistic about the outcome of physio intervention alone. I guess I just fail to understand how doing glut and core strength is going to stop my chronic rectus abdmonis and ligament pain. I suspect I’ll end up having the ultrasound guided injection at best, but at worst am still suspicious that I’ll end up having surgery. If anyone thinks they can explain to me how that will cure the pain, then I’d love to know.

The doctor told me than no amount of rest was ever going to cure this problem, and I’d have to have phsyio, to walking, to running, so I assume that means no running. I’ll find out tomorrow, and maybe go for one short farewell run beforehand, in case that is going to be what’s prescribed.

I’ll let you know how I get on. Have a good week.