Putting It All Together—A Patient’s Perspective on the Core

ESRA ROAN, PHD

Editor’s Note: Totally unsolicited, one of my patients, a biomedical engineer, requested to contribute to this book. She wrote me this note:

“Dr. Meyers, during one of our many conversations, I heard that you were writing a book on the core. As you know, I am an associate professor in biomedical engineering, and I came to your practice through extensive scientific search and a healthy dose of serendipity. I think patients deserve better, and perhaps an easier route to a diagnosis! I would love to put this all together from a patient’s perspective. I have come across so many women that complain about similar problems. I strongly believe that this may affect many people who travel in circles trying to get a diagnosis on their lower abdominal pains. Even though I personally am very vocal about my experience, having this written may help patients, physicians, and physical therapists in how they approach a patient like me.”

I did not refuse the request.

The greatest evil is physical pain.

—Saint Augustine (354-430 AD).

It seems that I had been dealing with this pelvic injury for nearly 15 years!

Recently, I heard Dr. Meyers was writing this book, so I asked him if I could contribute a chapter. Over the years, when I shared my experiences with other women, I heard many of them say that they knew someone with a similar experience. People need to know about this new evolving field. It bridges medicine and health.

In this chapter, I will present my personal experience of what I shall now call core pain from its early onset to postsurgical recovery. The road was very long. At times, there was no hope!

Please bear with me. I want to tell this story. I think it is important and you may know someone who is experiencing it.

MY STORY

Over the past few years, much press has surfaced about famous quarterbacks, elite hockey players, and world-class pitchers with some sort of hip, “sports hernia,” athletic pubalgia, or other problem, and they all somehow seem to get fixed. That publicity is probably what kept my ears open to the possibility that I might have a fixable problem.

I now have to ask: What happens to those who are not elite athletes, but may be suffering from core muscle injuries?

This is my story. After you read it, I want you all to ask that same question.

Tennis Days

I was a high-performing tennis player. I played for the national team of my home country Turkey and in some professional tournaments as well. I decided to pursue a collegiate career and played for a small college—Tennessee Technological University (Cookeville, Tennessee). We played hard, and our seasons were long. I was able to get a top 50 NCAA Division I ranking once. In other words, I played a lot of tennis when I was young and got injured a lot as well. During my teenage years, I complained of back pain, while during college years more injuries piled on. But, my desire to maintain rankings and scholarship never allowed me really to take proper care of my body.

Sometime during my senior year in college, I began to have lower abdominal pain and complained of this to the team physician. Being a female athlete, I was immediately referred to an OB/GYN and was placed on hormonal drugs with the thought that I had endometriosis. Then, the first laparoscopy came, which did not alleviate the pain, so the physician suggested removal of my left ovary: I was 22!

I walked out hastily, went to a second physician, and had another laparoscopic surgery within a year of the first one.

In both circumstances, the physicians found low levels of endometriosis not commensurate with the level of symptoms I experienced. I went through my senior year of tennis with the same lower abdominal pain, but also experienced a serious shoulder injury, so I sat out a few months, and complained less of the abdominal pain. Afterward, I stopped playing for a while.

Pregnancies…Endometriosis

The next phase of lower abdominal pain (which never went away in the first place) began to creep into my life post-pregnancy in 2004. This time, I met an endocrinologist who did another laparoscopic surgery (my third!) before pregnancy and again confirmed that I had minimal levels of endometriosis. Once I was pregnant, I stopped chasing answers to my abdominal pain problems. However, my son Ben was born after a nearly 36-hour labor that ended with an emergency cesarean section. I remember, once I recovered from the procedure, my abdominal pain immediately flared up and I was at my doctor’s office.

At this time, she was convinced it was something other than endometriosis, and she sent me to a specialist acupuncturist and also a pelvic floor physical therapist. Both of these people were instrumental for me to understand that my problems were not necessarily related to OB/GYN or gastroenterology fields. It was unfortunate that I moved to Memphis, Tennessee, at about the time that we were probably approaching a diagnosis. Also, I was expecting my second child.

Once I gave birth to my second son, I decided it was time now to become active again. It was 2007. I began running, swimming, and playing mild levels of tennis. Immediately, my left hip got inflamed, and I showed up at the local orthopedic physician’s office. I was diagnosed with bursitis. A nurse walked in with a big needle, and I walked out refusing this treatment. I knew somehow that everything was tied together, but did not know how. I decided to rest.

A few years ago, again I decided that it was time to become active again. I started playing tennis, swimming, and running. Needless to say, 3 to 6 months into it, I was again in pain and could not continue with any exercise.

It is important to note that each time I started over with exercise, I did it at a reduced level, and despite that the pain worsened. In the last trial, I was unable to build up enough strength or courage even to jog. At this time, I was extremely frustrated and depressed. The pain was present not only during limited exercise, but my daily life also was being impacted. I did not know where to go, but I knew I had a serious chronic pain problem that was making life difficult for both my family and me.

More Doctor Specialists

When the pain was so bad that I actually made a visit to the ER, I decided to begin the same process that I went through in Cincinnati, Ohio, with OB/GYN, gastroenterology, etc. Late in 2012, I was put on hormonal therapy to see if it would help, thinking again that it was endometriosis. This was not helping and I refused to take the sixth month dose, since I was knowledgeable of the side effects of these drugs. During this time, I was sent to a GI specialist and also to a urologist. I underwent a colonoscopy and endured every test in the world that one can have done, and no definitive diagnosis emerged. In the end, all physicians looked at me and I felt as though they wanted me to go away. I was left with a lot of pain and no help. The only person who was again providing some help in the form of pain relief with myofascial release treatments was the pelvic floor therapist. She was also the one to say for the first time that I had a “defect” for sure in the abdomen and potentially pelvic floor.

The Lightbulb

During the latest cycle of treatments, I became even more frustrated, and partially from the statements being made by my physical therapist, I began reading voraciously. I ran across research papers talking about chronic pelvic floor pain, “athletic pubalgia,” pelvic floor muscle issues, etc.1,2 My therapist and I would share the articles and talk about them during my sessions. During this time, I remember a lightbulb going off in my head and thinking these articles describe my symptoms. Could I have this? I contacted a hip surgeon whom I know from work and inquired about the plausibility of my conclusion. I asked him for a referral to the orthopedic surgeon in town who treats the most athletes. Five minutes into that appointment, the physician was convinced that I probably had this condition and he referred me to a hernia specialist to rule out actual hernia. Then came more diagnostic imaging!

But, finally, I was in the hands of 2 savvy surgeons who knew something about the abdomen and pelvis. Dr. Guy Voeller knew that these were not hernia issues and also knew that most general surgeons tried to treat them that way. I am not sure he knew what the problem was exactly, but he knew where to send me. He and my other physicians in Memphis referred me to Dr. Meyers in Philadelphia, Pennsylvania.

My Symptoms

So, what were my symptoms that made it so difficult to diagnose?

My symptoms went from mild in 1998 to severe in the fall of 2013. They began with mild abdominal pain. I cannot recall whether it impacted my tennis performance, but I remember having pain. After my first pregnancy, I knew muscles were involved, because every time I sneezed or laughed, I began experiencing abdominal cramps. Another symptom for me was related to the joint laxity in the pelvic region, which represented itself when I began to play tennis at very low intensity in 2005. When I would run-stop-return (ie, change directions on the court), I began to feel laxity in my pubic area and also spasms in the pelvic floor muscles (Figure 39-1).

Transitioning from pain during exercise to pain during daily life occurred after 2007 (ie, after the birth of my second son). Until then, I experienced a low level of abdominal pain (2 to 4 out of 10) depending on the time of day. Sometime during 2008 and on, as I attempted to get more active, the pain levels during off times increased. I began to struggle sitting down for prolonged periods of time, and as my abdominal muscles began to spasm, I began to take more over-the-counter pain medication during this period, and it helped.

During the final stages, which began with an episode of trochanteric (hip) bursitis, I was unable to focus on my work and get any relief from over-the-counter pain medication. I experienced a high level of pain (9 out of 10) on the lateral side of the left hip, and I even felt feverish. Once the bursitis subsided, I struggled on a regular basis with lateral hip pain on the left in addition to abdominal spasms. Another symptom that began creeping in at this stage was a feeling of a bruised pubic symphysis. The levels of chronic pain did increase to the point where over-the-counter medications did not relieve pain.

Sleep has always been difficult with this condition. However, it was not until the latter phases that, even with pain medications, I could find a comfortable position to sleep. During the final stages, I would wake up in the middle of the night with abdominal spasms as I changed directions. These were always very painful episodes.

In the end stage, between the core injury diagnosis in May 2013 and the surgery in December 2013, my symptoms worsened drastically. The symptoms became more hip-related than abdominal or core muscle-related. In less than 5 minutes of walking, I would begin to feel a very sharp pain deep and lateral in my thigh that I was supposing was my hip. That would result in my eyes tearing up. About the time of surgery, I could not complete my lectures, which were 90 minutes in length, standing up. At the end of the day, the location where the left hamstring attached to the hip would be in so much pain that, again, I struggled with sleep and virtually every other activity relating to daily life.