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When to go gangbusters and when to stay conservative?

Lala329LLala329 Posts: 283
Ugggh, I don't know if this really fits here, but since it's a leg I figured this was the best match...

So I've been round and round with my leg pain. When it started I thought it was a hamstring pull, then when it started going into my foot we started thinking it was a radiculopathy coming from my back, and now after a weird EMG we're back to the hamstring theory (the EMG showed denervation only in the hamstring and a few nerves below the hammy so it doesn't point to any nerve root involvement).

As confident as I am making treatment decisions for my back I'm a little lost deciding how to proceed with this- The orthopedist is recommending an MRI to be 100% sure that it is tendonopathy. Then he wants to do a platelet rich plasma (PRP) injection which I had never heard of. Poking around on the internet it seems to be a new hot thing in sports medicine. It makes big promises, but being so new I don't think there is a lot of evidence for its efficacy. The other option is to skip the MRI and to proceed with some trigger point injections into the hamstring and to continue conservative management with PT, massage, etc...

I'm going on 7 months so I'm really just ready for somebody to tell me what the heck is wrong with my leg and to tell me how to take care of it. The benefit of the MRI is that it should for sure show what is wrong with the tendon (nice to have a body part where the MRI is straightforward), but at the same time I've had so many MRIs recently it feels like overkill to now be doing a hammy MRI. With the expense involved I'm not sure how necessary it is because I'm not exactly sure how the outcome will change my treatment. It would basically just confirm the diagnosis, which the orthopedist said after 7 months it is reasonable to take a closer look. I know these days doctors tend to over-order on the tests, and even if it confirms the tendonopathy I'm not really sure how I'll feel about the PRP injection. I don't normally see an orthopedist, so while I like this doctor and he has excellent credentials I'm not super familiar with him. But, having been in PT for this darn thing for the last 6 months and getting nowhere I feel like perhaps it is worth it to get more aggressive with tests and treatments. Uggh, how do you decide when to stay conservative versus going all out with testing and treatments??


  • I tend to be a "do it now" person. I am known for getting authorizations and appointments immediately. Which can be great but has also back fired at times. I'm trying very hard to make myself slow down - in all things in my life. Being a NYer this is very hard.

    But 7 months is too much. My feeling is that you need to get the opinion of another orthopedist. Sounds way too long for a hamstring to me. If you were in NY I would send you to my ortho - he's outstanding!! Any chance this is an imbalanced caused by your back problems? We all compensate for the aches and pains by leaning, shifting, etc. Maybe this is causing the pain.

    I don't think getting the correct diagnosis after 7 months is being aggressive. I think you have waited long enough!! Now about the tests... if you are like me your insurance has a life time max. If you have been having lots of spine tests you need to keep this in mind. I've been lucky to have the same insurance since I was 25 and hope to have it into retirement. THe max on my policy is one million that sounds like alot but after two kids (one c-section), tubes tied, knee surgery, and all those other misc things I do worry. So make sure the MRI is necessary and will give some real info.

    Can't wait to hear what you find out.
  • I know exactly how you feel. I've been looking for an answer on my leg pain and burning for 9 months now. The doctors don't seems to know and it is very frustrating. I would love to hear how you are doing and what treatment if any, you try. Hang in there.
  • I agree with Kris on the time frame. 7 months, my goodness you have more patience than I could ever have! Support *HUG*

    I think Kris, in 2014? the lifetime caps are canceled? So if that is true, you won't have to worry about having it for retirement! :)

    Lala, please keep us posted on how it goes!!! *HUG*

    PCTF C4 - T2, Laminectomies C5, C6 & C7. Severe Palsy left arm/hand.
  • Well you are definately at a crossroads with decisions. Like Kris I am kind of a lets try it kind of person. You mentioned they have had pretty good results with the procedure but you wonder about the accuracy. How long was the trial/testing? They had to have tested it pretty good before coming onto the market. What are the risks of the procedure? I wish you luck in trying to make the best decision "for you".
  • With hamstring tendonitis, it is quite common that when conservative treatments and RICE fail to resolve the pain, an MRI, CT or x-rays are done. There can be adhesions or a tear that just hasn't had a chance to heal properly. If there are adhesions, these can also irritate the sciatic nerve and then create confusion as to whether the sciatic pain is being generated from your spine or your hamstring.

    With the way your mind loves to chew on things, break everything down and analyze it, I would think going for an MRI would be the only way to help pacify the mind's curiosity and need for information.

    Then if you decide to go for a second opinion, you already have the MRI films to take with you. Saves time.

    Good luck,

  • DDD of lumbar spine with sciatica to left hip,leg and foot. L4-L5 posterior disc bulge with prominent facets, L5-S1 prominent facets with a posterior osteocartilaginous bar. Mild bilateral foraminal narrowing c-spine c4-c7 RN
  • Finally a subject that I can tell you something about and give you my 2 cents. I am not sure if this goes back to your cyst issue meaning it is no longer that but could be the hammy issue. I am ot sure but the hammy issue seems much more easier to deal with.

    But back to my experience. If you remember I am the PRP poster child at HSS for my herniations. All I can tell you is that I am now on my 8th week and while I can not say definitely my cure I can say I have never felt this good in 2 years! I have come to the conclusion it is one of three reasons or a combination.

    1) The PRP is working well!

    2) I bought a strong lumbar support belt and while it can feel like a straight jacket when I put that baby on tight I can do almost anything with no issues. Only slight pains even at my worst.

    3) The Mckenzie is really working. I really doubt this is it as I have done much of this in the past but this guy is the best. He gave me some more key exercises that are great.

    I can tell you that my PT does small joint adjustments nothing like a chiropractor which always feel great but at my last appointment he told me, your spine is much more stable! I could in the past move your spine way too easy. But this time it is really set pretty well and hard to move. That is a great sign.

    In the past I could not ride my bike even on a trainer without pain. I have done 90 minutes most of this week. I do 30 minutes stretch and back on again. I have worked in the warehouse all week and been moving boxes and standing. The difference is quite dramatic.

    It was quite painful as they did it during the discogram so you would have a very different experience but I would go for it. I believe the worst case scenario is no effect? But you are correct is that PRP seems to be the hot thing right now for good reason. I would also get the MRI first but I would not hesitate on the PRP.

  • LALA did you see Dave's post about Lipitor? I think it's titled muscle spasm. He talks about joint and muscle cramping being a side affect of Lipitor. I thought of you right away. Any chance one of your meds has a side affect like this?

    SOmetimes the littlest things can bring us down.
  • You guys are awesome! You have definitely helped me process through all this...

    I feel nuts, but yes, I guess 7 months is a long time to deal with a routine musculoskeletal problem especially if something can help. I am going to go forward with the MRI, and if it confirms the tendonosis then I'll give the PRP a shot (jsirabella- so glad to hear you are finally getting some relief!). I hadn't really gone there, but there is also a chance that if the hamstring has scarred and is now pushing on the sciatic nerve they can also treat that. Really thinking it through, the MRI will open up my treatment options so I can stop wasting time and resources on things that aren't working. I'll give you guys an update once I have the MRI results and let ya' know if we figure this out at it sounds like a couple of us are in a similar place.

    Kris- thanks for the med heads up. I wasn't on meds when this started, and only in the last month have really been messing around with the meds so it isn't medicine related.
  • Glad to hear your're going to go for it!!! I wish you the very best and I'll be waiting to see how this goes....

    Take care, Renea'
  • I really hope this is the answer for you to get back some back...I am really pulling for you that this all works out.
  • Can i ask what your symptoms are?

    I also suffer with a feeling in my hamstring that i often think feels like a pull or a tendon, it gets sore and tight and is sometimes really sore right in the bum crease. It comes and goes depending on activity level and i also get soreness in my glute muscles on the left side. I also remember you saying that if you sat on your foot it helped relive the symptoms which is the same as me!

    I've been treating my symptoms as stemming from an L5/S1 mild prolapse and also the disc is mildly degerated. The MRI showed the disc is not pressing on the nerve root and there is only minimal loss of disc space. Also had an EMG which came back as normal so sometimes i do question the diagnosis and wonder if it is musculoskeletal, well what i mean is, could it be musculoskeltal NOW as i guess things have changed in 2.5 years!.

    So anyway, this is a little waffling but i'd be really interested to hear your symptoms and see if they are anything like mine.

    P.S If it were me, i'd get the MRI
  • I tend to want to know what exactly is happening, so tests are not something I am usually conservative with unless they are risky (MRI is not a very risky test, it's not like you're being bombarded with radiation. And since I'm already guaranteed cancer from all the x-rays I got on my shoulder, I give up anyway).

    And, yes, lifetime caps are going away. Anyway, usually you re-earn them every year- for as bad as my health is, I've barely dented mine.
  • So, I finally have all my test results...

    As expected the MRI showed tendonosis in one of the tendons of my hamstring. The tendon itself is not torn, but there is collection of edema around it. With that, my orthopedist said it's best to hold on the PRP. The PRP strengthens the tendon because the needle stick partially tears it, and without a partial tear already there he is hesitant to want to stick it. So, we wait and if another couple months of conservative care don't have me improving (ahhh, as if 7 months weren't enough already) then we'll re-visit the PRP. But, I'm glad that the tendon is not torn and that he isn't jumping on sticking a not torn tendon even if it is chronically inflamed.

    So, with that I did go ahead and have my PM doc do some trigger point injections into the hamstring muscle that has the tendon issue. He found a *huge* one and got it really good, and it did surprisingly relieve some of the pain around the tendon and so far the spasms have reduced. Not sure how long it will last, but hopefully the trigger point injections will help lengthen the muscle and pull some tension off the tendon. My PM doc was skeptical, but I think when he finished he was more confident that it may help. I was a little surprised too because I see an awesome manual therapist who beats me up pretty good pressing out trigger points, but clearly this was one that needed to be needled.

    All in all, I'm glad I did the MRI because it feels *really* good to know exactly what is wrong and exactly where the problem is. Chances are the edema is causing aggravation of the sciatic nerve rather than this being a true neurological problem. We also know exactly where the tendonitis is now, so that will help direct future PT, injections, etc...There were a couple replies with similar "mystery" leg symptoms, and I guess my experience just goes to show that even when the diagnosis is assumed (we assumed neurological because I am an L-spiney) there is room to question when things aren't adding up. I'm just glad I had a thorough enough team of doctors to not just dismiss this as neurological, because knowing it is a muscular injury impacts the way it is treated.
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