Answers finally . . But

Today was the big day. I had an appointment with Dr. William Meyers at the Vincera Institute in Philadelphia. Dr. Meyers is a highly regarded surgeon who specializes (these days) in muscular core injuries. I was hoping to finally get answers about the unresolved groin pain that slowed me practically to a crawl in Boston, and has kept my paces short and slow ever since.

Rewinding for a bit (but not too much, I wouldn’t want anyone to doze off), my ordeal began on March 17 with the giant snow/ice storm that all the winter people were so excited about. We got 12-14 inches of snow and sleet creating giant icebergs in the driveway after the plow came by. I resorted to moving the big chunks by hand as shoveling was fruitless and even the biggest snow blowers could not cut into the glacial masses blocking our road to freedom. (And we were dangerously low on milk, bread, and eggs.) While moving said ice balls, I noted that something didn’t feel right. A week later during an attempt at a pre-Boston interval run, my groin decided it had had enough and locked up as if someone had clamped on an especially tight pair of all-iron briefs. If I had had my phone I may have called for Uber to get back to work.

Since then, I have seen 4 different doctors, had 6-10 X-Rays, an ultrasound, and an MRI. I have rested. I have taken anti-inflammatory medication, I have worked informally with a physical therapist . . all with zero results. While the rest and anti-inflammatory meds made things more tolerable, the fact is you can’t sit perfectly still in daily life and you use your core for virtually everything. Once in a while I’d have a hopeful day or two where there wasn’t some nagging pull in my nether regions but a bit of lawn mowing or car washing and the ache came back. It was starting to remind me of the cat in the kids camp song. Go ahead and give a listen. I’ll wait.

Ready? Okay now back to today. I’d waited patiently for this appointment since Dr. Cook abandoned ship from Commonwealth Orthopedic leaving me without a plan. I was a little excited because they start with the MRI so you have real evidence to see when speaking with the doctor. My MRI appointment was the first of the day. 6:30 AM in South Philly, actually in the grounds of the old navy yard.

Upon arrival I filled out the normal paperwork and was taken back for MRI #1. At this point, there was only one planned. Stay tuned. After my first open MRI I was much less worried about my claustrophobia kicking in. While this machine was not “open” it had a high ceiling and wasn’t bad. I was rocking a pretty stylish pair of scrub shorts (sadly, the picture didn’t come out) and they had music for me to listen to. I chose classic rock and may or may not have dozed off during the rather noisy procedure.

After the MRI, we did a few X-rays and then it was off to see the doctor or rather doctors. I began with Dr. Alex Poor who works closely with Dr. Meyers. I was a bit worried I was being pawned off on a subordinate but that was certainly not the case. Dr. Poor did a thorough interview and exam and told me I had done “a good one”. It turns out that, despite the discomfort being mostly on the left, I have a bilateral injury. (Bilateral is a .25 cent word meaning I hurt both sides of my groin.) The muscles involved are the adductor pollicis, adductor longus, and rectus abdominis. In all cases either slightly detached or torn from the pelvis. It turns out there is also some impingement in the left hip due to a slight labram tear. Generically, this sort of injury is known as athletic pubalgia. After our consultation Dr. Poor went off to talk with Dr. Meyers who would see me next.

Time passed. A lot of time. I tried to remain patient but was beginning to regret the little cup of coffee and tiny bit of breakfast I ate at 4:30 that morning. It was nearing 9:00 and my stomach was growling. I was beginning to think maybe Dr. Meyers might be just another doctor in a hurry and always behind schedule. Just when I had it in my mind that he’d blow into the room like a wind gust, rapidly go through surgery and blow out again, the door opened and a very kindly, older doctor walked in.

I was still on the exam table from Dr. Poor’s examination and after he introduced himself, conducted a similar examination. When he finished, he told me to get dressed and he’d be back in a few minutes. He wanted to spend some time looking at the images from my MRI.

Back to waiting but not terribly long. Dr. Meyers reappeared sat down, asked me where I was from, where I grew up and then spent 5 minutes telling me about his background and how he came to where he is today. He is actually a thoracic surgeon who started a hobby of working on abdominal sports injuries with players at Duke University. It was so successful he has made it his regular practice. Funny what people do for hobbies.

Then we got to me. He asked me to go through the story again if I didn’t mind. He sat and listened patiently as I recounted the snow, the interval run, the steel briefs, and the on-going issues since then. He stopped me now and then for important questions.

At this point, I think he had a pretty firm diagnosis in mind and it concurred with what Dr. Poor had said. Dr. Meyers was very thorough in explaining anatomy, the injury, and what can be done in layman’s terms. Perhaps the best example was when he said to picture the pubic bones to be like a baseball. The muscles (I’m not spelling them all again) are connected to the cover of the ball. Essentially, with this injury, the cover begins to come loose.

This all made sense but there was that pesky hip impingement thing. Dr. Meyers, in his gut, recommended not worrying about the hip right now and just fixing the core muscles. But it could be that that torn labram, no matter how small, was contributing to the problem. The best thing to do would be to do another MRI with contrast (an arthrogram). While we were at it, it would be good to shoot some steroids in there. Not only would the arthrogram provide more information, but the very act of anesthetizing the hip joint for the injections would allow us to see if that alleviated any of the pain. This would indicate that the hip was more of a contributing factor than we thought. Dr. Meyers asked “Do you have time to do that today”? My reply was immediate “Heck yeah! I want to figure this out and I’m here”.

So it was back to MRI but first a visit with Dr. Johannes Roedl. If you are scoring at home, this is doctor #7. This time instead of the spiffy scrub shorts, I got to undress from the waist down and go with a  glamorous one-size-fits-all gown possibly made under a contract with Omar the tent maker. I was not taking a picture this time. Dr. Roedl was yet another pleasant staff member with a great bedside manner. That’s good because injecting dye and steroids into the hip joint kinda hurts! Before the injections he did a quick and similar examination to what Dr. Poor and Dr. Meyers had done so  He used an ultrasound machine to make a mark on the hip joint, then injected the anesthetic. Simple enough. He said “This will still be pretty uncomfortable”. I concur with that statement but it was tolerable. He commented that I was a pretty tough guy. I thought “Well, I’ve done a few races that hurt worse than that”.

Then it was back to the MRI tube with more buzzing, shaking, and 70-vintage rock and roll. There could have been a short nap too because it seemed to go fairly quick. Once done, Dr. Roedl redid the same exam to compare between the not anesthetized hip and with anesthesia. (Author’s note: anesthesia is really hard to spell consistently correctly.) On the pre-exam, I had a bit of outside hip pain that was no longer present. Probably due to the labram tear. On the anesthetized exam, the hip pain went away but the groin discomfort remained.

I got dressed again and made my way back to see Dr. Meyers one more time. He was satisfied that the labram tear was playing a minor part and we should ignore that for now. His recommendation was to just fix the muscles and the best way to do that was surgery. He explained what it entailed and it is a very simple repair. I could be up and beginning to run again in about 6 weeks with normal daily activity returning much sooner. This all seemed good to me. I knew definitely what the problem was. I knew how to fix it. Even better the fix got me back to being healthy and fast. But . . .

Before I get into the gory details of the “but“, let me say I am immensely impressed with Dr. Meyers’ staff and the Vincera Institute. The facilities are new, clean and beautiful, and the people that work there are awesome and caring. They listen. They look. They touch. They feel. They test. They repeat until an answer is found. Yes, if you have an appointment there it will probably be a long day. You may wait a long time to get through each step. But unlike busy practices where a doctor visit entails the doctor whipping into the room, listening to your heart, telling you to take ibuprofen, and sending you a bill, the folks at Vincera are actively working your case. They seem to want to help you find an answer as much as you do. The receptionist’s and tech’s days started really early. When I left this afternoon, I was sent off with a smile and a kind word.

But . . Insurance won’t pay a dime for the surgery. Dr. Meyers clerk and scheduler went through the paperwork with me right down to the insurance. She slid the Cigna policy on surgery for athletic pubalgia across the table and explained “They are pretty firm”. There is an appeals process, but she hasn’t seen them overturn their decision.

Later this afternoon, I read the policy. It is a bit unbelievable.

“Cigna does not cover surgical treatment for athletic pubalgia because it is considered experimental, investigational, or unproven”. The next paragraph begins with “Athletic pubalgia is a painful strain or tear of any soft tissue in the lower abdomen or groin area”. So they acknowledge it’s painful. They go on to cite several different studies clearly showing that rehab/therapy and/or rest and medication does not solve athletic pubalgia, and nearly all subjects who receive surgery fully recovered to full athletic ability, in short periods of time, and without remission. But supposedly the studies were too small and poorly organized.

Cigna seems to indicate throughout that surgery should only be used in the absence of success of more conservative treatments including rehab, therapy, rest, and anti-inflammatory medications. It occurs to me that while all of these things are perfectly fine and can be helpful, none of them will magically reattach a detached or torn muscle. It also seems Cigna has spent a potful of their precious dough already on doctor visits and tests. The recommended course of therapy for athletic pubalgia is months of therapy. Cigna is willing to pay for that. Oh and let’s remember that according to the studies they cite in their argument against paying for surgery, the therapy and drug options proved ineffective. Essentially, once I’ve tried rest/rehab and drugs and still have pain, according to Cigna I’m just out of luck. Perhaps it would be better to stop moving, eat myself into a state of morbid obesity and let them pay for the consequences of that. ‘Cause that’ll be cheaper.

So the outcome is that, if I want to go the surgery route and fix this correctly,  I’m likely doing it out-of-pocket to the tune of . . get this . . . $13000.00. It doesn’t even count toward an out-of-pocket maximum. That’s a big cash layout. I don’t know if I will do this or not. There is a lot to think about. About 13,000 things to think about.