Over on the Penn Medicine News Blog, we frequently write about what it’s like to work for or experience life at the University of Pennsylvania Health System. What we don’t get the chance to write about very often is what it’s like to see it from the other side: as a patient, just trying to figure out what’s wrong – and to get better. Fortunately (well, not really), I’ve now got one such story to relate.


Prologue (or: Five Years of Bad Decisions)

Winter, five years ago: I’m doing some weightlifting, putting in time at the squat rack, when I notice a mild, sharp pain on the outside of my left hip. I don’t think much of it, since squats are supposed to engage your hips and I’m pushing my­self. The pain goes away by the end of the night.

It then returns and recedes repeatedly over the next four-and-a-half years. Sometimes there are months between recurrences. Sometimes it sticks around for a few days, sometimes it’s gone within seconds. I make a mental note of it each time, but it’s consistently either mild or brief enough for me to not bother getting it checked out.

Six months ago, I’m running on a tread­mill when I notice the pain is back again. It’s mild, as always – but this time it doesn’t go away. In fact, it sticks around for the better part of a week, despite my taking it easy. It starts bothering me outside of exercise, too. Sitting too long? Hip starts to hurt. Standing too long? Hip starts to hurt.

It “catches” a few times, too, which is a feeling both bizarre and difficult to describe. Imagine cracking your knuck­les. You know how there’s that one mo­ment, mid-crack, where you feel a ton of tension or stiffness in the joint and know it’s a millisecond away from popping? Now imagine that on a much larger scale, except in your hip. And when it finally re­leases, you aren’t left with a satisfyingly loose knuckle, you’re left with a mild tingling in and around the entire joint – as well as the unease of knowing something down there, to use a technical term, just ain’t right.

Two months ago, I made an appointment to see an ortho­paedic physician here at Penn Medicine. “You’re twenty-nine,” I’m told as they’re finding me a physician, “that’s too young.”

I’m inclined to agree.

First Appointment (or: But That’s a Problem for Old Guys)


Waiting five years to get hip pain checked out is a big enough error on my part, but it’s made particularly bad by my history with orthopaedics. Before landing here at Penn Medicine, I wrote news and covered conferences within the orthopaedic field. I was able to coherently explain to my fiancé what was likely (but hopefully not) going on in my hip, but unwilling to do anything about it.

What was likely going on: The femoral head was doing all sorts of terrible things to the acetabular la­brum, which is the cartilage rim that protects the socket from the ball (and vice versa) in the ball-and-socket joint that is the hip. It’s called a labral tear, and it’s the sort of thing that doesn’t tend to go away on its own.

“Maybe it’ll go away on its own,” Past Rob told himself.

Past Rob was kind of a moron, Present Rob thinks to himself while waiting to be brought in for a simple hip X-ray at Penn Medicine University City.

It’s uneventful, with two excep­tions: One, I find out that I look pretty good in the nifty wraparound gowns they give patients going in for imaging. Two, when I’m on my back under the X-ray machine and I’m asked to bring my left knee up slightly while turning my leg outward, I’m rewarded with a catching sensation and a jolt of pain to the entire hip. I let out an “oh-ho-HO,” which to my ears lands somewhere on the spec­trum between “a noise of pain and sur­prise” and “the noise my dad makes when he’s proven me wrong about something.”

“Maybe don’t move so quickly,” I’m told by the radiologist. Noted.

After the X-ray, I reluctantly exit the fashionable but weather-and-per­haps-work-inappropriate gown and make my way to an examination room, where I’m to sit and wait until my phy­sician’s available to see me.

Something I learned while writing orthopaedic news (and had reaffirmed by my experience getting a broken an­kle taken care of two years ago): These physicians and surgeons waste abso­lutely no time. Mine swoops into the room, white coat billowing behind him, introduces himself, and shakes my hand before sitting down and getting right to business.

“Five years of pain, huh?” he says. “You’re too young for that.”

I’m inclined to agree.

I’m told that nothing on the X-ray really stands out as being problematic. No obvious bone spurs, no trouble areas in the bone structure itself. The imaging report – which I look up on myPennMedicine a day or two after the appointment – re­fers to the hip as “grossly unremarkable,” which is one of those things you love to hear about your body in a doctor’s office but absolutely nowhere else.

Since the X-ray doesn’t reveal anything of note, I’m told that the next step is to get a contrast MRI. The MRI can inspect soft tissue, which means it’ll be able to pick up on abrasions or tears within the acetabular labrum – which, I’m informed, is what the physician thinks the problem might be.

The English language is versatile, but I don’t know if a word exists within it to express the feeling of being right precisely when you didn’t want to be.


Prep Work (or: “You’re Gonna Be More Full of It than Usual”)

I’ve always wondered if physicians sometimes feel like they have to walk a tightrope between two distinct patient experi­ences. On one hand, I imagine you want each patient to feel as if they are your only patient of the day. You want them to feel like they have your most undivided and meticulous atten­tion to detail. On the other hand, I imagine you also want the patient to know that this is not even remotely your first rodeo. 

That’s crossing my mind again as I sit on a chair in an imag­ing suite at Penn Medicine University City, the well-fitting hospital gown doing its very best to keep me modest as I stare at the massive fluoroscope across the room. It looks like a big “C” wrapped perpendicularly around a long table, with a cam­era sort of thing on the end of the “C” dangling overhead. There are several monitors attached to the whole contraption.

An X-ray tech walks in and asks me a few questions, in­cluding one I’m about to get very familiar with: “Do you have any sort of metal in your body? Implants, screws, rods, shunts, a pacemaker, anything?”

I’m able to confidently say no. He asks again, this time rat­tling off an even longer list of metal objects that could find their way surgically or otherwise into the human body. I say no again – but less confidently, because I’m thinking back on every dumb way I’ve ever hurt myself and wondering if maybe there’s any way I’ve forgotten, I don’t know, a stray bullet or something. The tech seems satisfied and jots something down on his clipboard.

He then walks me through what’s about to go down. I’ll get up onto the table under the fluoroscope, have a sterile drape placed over a significant chunk of my torso and legs (“You need to make sure not to touch that,” he says, which I don’t even think twice about until a little bit later . . . but we’ll get there), and receive a small injection of lidocaine. 

Lidocaine is a numbing agent, which is of great importance because the step immediately following it involves a large nee­dle being driven directly into the hip joint. Through that par­ticularly invasive needle, I’m going to receive injections of ra­diographic and arthrographic contrast (two separate fluids). I’m told all of the prep for the procedure is longer than the procedure itself.

They inject contrast fluid into the joint because more than a century of development and advancement of imaging tech­nology still can’t really make up for the fact that joints like the hip and shoulder just don’t give up their secrets easily. Con­trast fluid helps out by lighting up under a fluoroscope or MRI, making defects and whatnot far easier to spot.

“Your hip’s going to feel . . . full,” the tech says. “It’ll be a day or two before the fluid is absorbed by your body, and then you should be back to normal. Just don’t do any running or anything strenuous on it in the meantime.”

Just then, one of the technicians who will be performing my MRI in a few minutes swings by. “Really quick,” she says, “do you have any sort of metal in your body? Implants, screws, rods, shunts, a pacemaker, anything?”

Injections (or: I Guess We’re All Friends Here)

As a musculoskeletal imaging fellow and the attending ra­diologist enter the room, the latter grabs the clipboard and begins to ask me a few of the same questions, as well as some new ones. He jots down my answers quickly, then looks up at me and begins walking me through what’s about to go down. I realize the reason I’m being walked through this procedure several times is to make sure I don’t feel surprised by some­thing and freak out while they’ve got a needle or two buried deep in my hip joint. Once again, I’m told the prep for the procedure is much longer than the procedure itself.

Next, I’m told to walk over to the table under that big “C” arm and lie down. I do so, and rest my folded hands on my stomach. I’m a little nervous, but the team is moving like clockwork and making every single step as clear as possible along the way. It’s calming, which is good, because the next step involves pulling my gown to the side so they can sterilize the entire area of the joint.

I consider myself an easygoing guy, but it’s hard to maintain one’s chill when you’re one small shift of a hospital gown away from three complete strangers seeing, like, everything. The sterile drape that’s going to be placed over me is brought out of its packaging, and I’m told I can’t let my hands rest on my stomach anymore because they’d be in direct contact with the drape. I adjust, and they go about their business while I awk­wardly try to figure out what I’m going to do with my hands. I end up folding them behind my head – the ultimate position of repose, which strikes me as entertaining given my sudden and notable lack of modesty. I chuckle to myself, and the tech checks in to make sure I’m doing okay.

“You all right?” he asks. “Nervous about the needles or any­thing?”

I tell him I’m not. The fellow holds up the first needle. “Lido­caine,” he says, making sure I understand we’re about to get un­der way. I feel a slight pressure, and he pulls away with the nee­dle before I even realize he’d pierced my skin. So far, so good.

“You’re numbed up, but you’re going to feel a bunch of pressure,” I’m told as the second needle comes into view. I guess there’s only so much we can expect lidocaine to do.

I don’t really feel it when the needle enters, but I absolutely feel it when the needle gets close to the joint itself. “Pressure” is a good way to put it. Take your pointer finger and push it hard – I mean hard – into your hip. It doesn’t hurt, but it cer­tainly doesn’t feel good. That’s what it’s like.

The injection of the contrast fluids goes quickly. The team grabs some radiographic images of the joint, which I stare at on the monitors. I’ve always been fascinated by X-rays of my own bones. I think people have a tendency to forget that ev­eryone’s really just a walking skeleton wearing a meat coat.

I keep that particular thought to myself.

Just like that, the procedure’s over and I’m free to get up and walk over to a private waiting room while the MRI machine is readied. The hip does, in fact, feel “full.” It’s tough to explain. Nothing feels like it’s going to burst, and nothing’s all that pain­ful – especially since the lidocaine’s still doing its thing – but there’s absolutely a sense of pressure within the joint that wasn’t there before. My first few steps are extremely tentative, but af­ter that I’m moving only slightly slower than usual.


MR Arthrogram (or: Sound and Fury)

Years and years ago (around 1994), I was sitting on my bed playing Aladdin for the Sega Genesis when I noticed I was having trouble seeing the screen. It was like a blind spot near the middle of my visual field, a distortion or void that my mind tried ineffectually to fill in with nearby colors.

I was experiencing my very first visual aura – a precursor to my very first migraine.

I get migraines to this day, with rather startling frequency. I’ve seen I-don’t-even-know-how-many doctors about them over the years, and the very first thing they all do is order an MRI. That’s standard procedure, as far as I’m aware, but it also means my very first migraine was followed quite closely with my very first MRI.

I’m going to nerd out about how an MRI works for a little bit, so if you don’t really care, just skip the next paragraph or two. MRI stands for “magnetic resonance imaging,” and, as the name implies, relies on the use of large magnets. Hydro­gen makes up about three-quarters of all the mass in the uni­verse, and about ten percent of your body mass. Each hydro­gen atom has one proton – and therein lies their importance here, because a proton is essentially a very (very, very) tiny magnet. By running your body past a giant magnet, we can make all of those protons line up in the same direction. Hit­ting those protons with radio waves knocks them out of align­ment, and their ensuing re-alignment creates radio signals. Those radio signals get picked up by receivers in the machine, and suddenly we’ve got a detailed image of the inside of the human body.

Consider for a second how amazing it is that we, as a spe­cies, even figured out we could do that. The first transatlantic phone call happened in 1927. The first MRI was performed in 1977. In the span of just fifty years, we went from being amazed at the concept of ringing someone in London . . . all the way to figuring out we could play with the alignment of the body’s atomic building blocks to get a better picture of whatever’s going on in there.

So, anyway, MRIs: I’ve had a bunch of them. As I’m in a small room off to the side of the machine itself waiting for my turn, one of the techs comes over and talks to me a bit about the procedure.

“Do you have any sort of metal in your body? Implants, screws, rods, shunts, a pacemaker . . .?” she asks. I can’t help but snicker as I say no, no there is not. She asks again, be­cause I guess snickering the first time made it look like I was trying to pull a fast one. I say no, this time with the straightest face I can muster.

It’s an important question. As you might imagine, metal and MRI machines are not great partners. Or, more accurately, they’re incredible partners that you can’t allow to occupy the same room. When the MRI is switched on, metal objects will fly at or into it with potentially deadly speed. A metal object in the patient’s body probably wouldn’t be ripped out, but the resulting damage and pain would nonetheless be something worth avoiding at all costs.

The tech goes through a few basics, then walks me over to the room with the MRI machine itself. The entrance of the room is guarded by two large, lit posts, one on either side. There’s cautionary signage on the floor. The real feature, how­ever, is the door. It’s huge – like, bank vault huge. It swings aside a little, and I’m able to view the 13-ton MRI machine in its full glory.

It’s basically a large, eggshell-white rectangle with a hole in the middle. Sticking out of the hole is a table, upon which the patient is placed and then wheeled inward. The whole con­traption takes up a huge chunk of the room.

The tech ushers me onto the table and begins some basic setup, which mostly involves positioning me and my legs so the most useful images can be obtained.

“It’s going to be about 20, 25 minutes, times two because we need two different setups,” she tells me. “You need to stay completely still. You’ll probably feel a little warmth as the ma­chine works. It’s also going to be really loud, so we’re going to give you earplugs.”

I’m offered music, but decline. The tech does one final pass to make sure I’m comfortable – an uncomfortable patient’s not going to be staying perfectly still for an hour – then hands me the earplugs and walks out of the room. The earplugs are maybe a little too effective, because once the tech is at her station and communicating with me through the intercom, I realize I’m only just barely able to hear her when she says they’re going to get started.

I feel the table start to move underneath me, and slowly I slide into the machine. When I was getting my very first MRI at the age of eight, this was terrifying. Now, though? Can’t say I’m terrified. More fascinated. Maybe a little itchy.

One thing they really can’t prepare you for is just how loud the machine actually is. It’s one of those things that you know is working if it sounds broken. Loud bangs, clangs, buzzes, and hums fill the air around me, and I’m grateful for my ear­plugs. After a while, a pattern starts to emerge. It feels a little like when you hear a car alarm for so long that you start at­tributing a voice to it.

The next 25 minutes pass quickly and uneventfully. The warmth the tech said I’d notice is barely noticeable – especially in comparison to the oddly full feeling my newly injected hip is generat­ing. The tech’s barely audible voice comes over the intercom to let me know they’re done with this set of images, and soon I’m repositioned for another set. 

“You did great!” the tech says as I’m al­lowed to get off of the table, and for a second I’m filled with pride at my ability to stay perfectly still and do nothing whatsoever. 

I get changed and make my way out to the front desk, where I set an appointment in a week’s time with the orthopaedic doctor.

Finally, Results (or: Ayup, that’s Your Problem Right There)

It’s a week later, and I’m waiting in the office of the doctor who first sent me down this road. The images– X-ray and MRI alike – have been brought up onto the monitor for the doctor’s perusal. I’m looking at them and suddenly feel­ing self-conscious, because one thing the MRI shows very effectively is a nice layer of fat. I try to ignore that and pick out the troubled part of the joint. It feels good to know I’m about to get some answers.

There’s a quick knock at the door. Just as he did the first time around, the doctor opens it quickly and sweeps into the room, white coat trailing him with just a little bit of majesty.

“Hello again,” he says cheerfully as he sits down. “How are you feeling?”

I tell him I’ve actually been feeling pretty okay – which I have – and he nods as he scrolls through the images on the screen.

He stops at one image that looks, to me, like just about ev­ery other image. I’m still trying to figure out which way the joint’s even facing when he gestures for me to move in closer and points to a small white-ish spot on the screen. He tells me that’s where the contrast fluid managed to make it through the labrum. 

I’m reminded of when I go to the mechanic and he brings me into the garage. Yeah, see that? You, uh, you got a busted flange there. You’re gonna need a new flange . . . and maybe a new gas­ket. We’ve got one in the back, but it’s not gonna be cheap.

The fluid leaking through the labrum, the doctor explains, indicates an injury. There are a few points of concern, in fact, and he scrolls through some of the images to show me how different cross-sections of my hip display different levels of tearing. Long story short: It’s pretty much exactly what we thought it was.

“Well, okay,” I say. “What’s the next step?”

Quick flashback: About three years into college, I managed to mess up my shoulder. It required an MRI – as these things are wont to do – and resulted in a conversation with my doctor at the time that went just about the same as the conversation I was about to have with the doctor in front of me.

See, the shoulder and the hip are similar in that neither gets particularly good blood flow. Which means those areas aren’t all that great at healing themselves. I got away with not having my shoulder operated on, but my hip’s not likely to be so forgiving. Think of it like a hangnail: If you’re not pushing or hitting it against something, you might not notice it – but then you do, and it makes itself very noticeable.

“So,” I say, “I need to get it operated on?”

The doctor looks at the images, then looks at me. He folds his fingers in front of him and sits back in his chair. He then tells me that if this in­jury isn’t impacting my daily activities, isn’t caus­ing me much pain, and isn’t keeping me from doing what I want to do, he doesn’t see it as necessary. There’s a certain lack of urgency, he says, because this isn’t something critical like cancer or appendicitis. It’s mostly a quality-of-life thing.

Ultimately, you do a cost-benefit analysis: Does this injury currently bother me enough to warrant going under the knife?

The answer then, as it is now, is no. I’m actually doing pretty well. I’ve still got a full range of motion. I don’t jog anymore, but there’s plenty of other cardio to be done and I always hated jogging anyway. Some days are worse than others, but most days are just fine with only a few minor aches and pains here and there. Like a bad roommate or a clingy friend, it’s one of those things that’s just going to be there until I finally decide I’ve had enough.

Sound anticlimactic? I’m inclined to agree. But one thing I’ve learned in my time around medicine and its practitioners is that an anticlimactic answer is not necessarily a bad thing. Thanks to Penn Medicine and my doctor, I can say with certainty I know what’s wrong with my hip. That’s enough for now.

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