You can listen to this episode by clicking here.
Speaker 1 (00:00:00):
Hi everyone. My name is Dr. Shirin Towfigh. Welcome to Hernia Talk Live. This is our weekly question and answer session every Tuesday. As you know, you can follow me on Twitter and Instagram at hernia doc on Facebook at Dr. Towfigh. Many, many of you are live streaming with us right now, and at the end of the hour I will make sure that our session is readily available to you on YouTube. Our guest panelist today is Dr. Alexander Poor. He is a board certified general surgeon practicing in Philadelphia, and he is very unique in his practice because he focuses on cord medicine, which many of you may understand as groin injuries and sports injuries and sports strains at the very famous Vincera Institute. And you can follow him on Facebook at Vincera Institute. So I would like to welcome you now to Dr. Poor.
Speaker 2 (00:00:58):
Thanks so much for having me.
Speaker 1 (00:01:00):
Hey, thanks so much for accepting this. It’s late in the evening your time, so I do appreciate you donating your time. And you’re still in the office
Speaker 2 (00:01:10):
Here? I am, yeah. Didn’t quite make it home in time.
Speaker 1 (00:01:15):
So we have tons of questions that have been provide ahead of time. We’re going to go through those hopefully and as people come in we will make sure that their questions get answered. But I think as a general surgeon, it’s very, what you are doing is very much outside the scope of the average general surgeon. So I’d love to hear your story. How did your training go and how did you get involved with the Vincera Institute?
Speaker 2 (00:01:42):
Absolutely. So we’re here in Philadelphia in South Philly where Vincera is located. And so I’m actually, I’m from the area. Originally I went to Jefferson Medical College in Philadelphia for medical school and was looking at training programs and just down the road was Drexel. And one of the reasons I was interested in that program is I was really interested in surgical oncology and they had a strong program. And the chairman there was this kind of well known liver surgeon.
Speaker 1 (00:02:12):
Oh,
Speaker 2 (00:02:13):
Okay. William Myers, who had been down at Duke for a long time. And I had this vague understanding that he also had operated on a bunch of athletes, but I didn’t really understand that. So I showed up as an eager intern at Drexel and I was crushed to see that one of the Philadelphia Eagles was on his census. I was so worried that this guy had a liver tumor or a complicated bile duct injury only to find that he had a groin injury. And then I realized that really at that point in those days, Dr. Myers was really 75, 25 mostly treating groin injuries and a little bit of hepatobiliary. And so, okay, certainly gotten into this a little bit backwards. And so then obviously I gravitated towards taking care of the athletes. I was interested in it. And what I quickly found out was he was doing stuff that no one else in the hospital or any other rotations I went on really
Speaker 2 (00:03:08):
Any idea. And so some of the things that I thought were really interesting were just some of these techniques that he was using to manipulate the muscle. I would go see him sew muscle together and then I would go on another rotation and be taught, you can’t sew a muscle together. And I’d kind of ask, I just saw this other guy do it, he’s the chairman, what’s about that? And people would just kind of shrug and move on. And so I realized that there was something unique going on, so I really did gravitate towards it. I spent two years in the lab still kind of preparing for a surgical oncology fellowship. And sometime during those two years he asked me to join him on this venture, which is he was leaving academia setting up shop down in South Philly, down at the navy yard in a venture that he was kind of collaborating with some of the local health systems to build something new so he could do something that really kind of stepped outside the realm of general surgery outside the existing realm of sports medicine in order to treat these injuries in a comprehensive way.
Speaker 2 (00:04:07):
And so then basically I finished up my training as quickly as I could so I could come down here and did a two year fellowship with him and been partners with them now for about seven years. And
Speaker 1 (00:04:16):
No kidding.
Speaker 2 (00:04:17):
It’s been a lot of fun. That’s a
Speaker 1 (00:04:18):
Great story.
Speaker 2 (00:04:19):
Yeah. Fallen. Yeah.
Speaker 1 (00:04:21):
Yeah. So good timing on your part then. So I’d love to interview him one day and see how he went, made that leap. But yeah, so you did a fellowship with him as well?
Speaker 2 (00:04:35):
I did, yeah. And we have a fellow now, we have a two, two-year fellowship. It’s a leap. It really is leap to say for me, I’m going to go do this. What on one level really sounds like a small niche operation as opposed to everything else in general surgery, which made sense. This was a kind of mysterious realm. But then really once you dive down into it, you realize there’s this whole universe of variations and it seems like an endless field to me now that I’m here. And it’s really exciting to be a part of exploring it and kind of pushing the boundaries out in the different directions. And that’s what we need is more people really jumping in the two feet because that’s when innovation really starts to happen is when you get a lot of people exchanging ideas.
Speaker 1 (00:05:26):
So you and Dr. Myers are trained general surgeons, you also have orthopedic doctors and a rehabilitation doctors, I assume.
Speaker 2 (00:05:33):
Yes. Yeah. So we treat muscular injuries and so the people who we tend to collaborate with and get interact with tend to be orthopedic surgeons and the non-operative sports med docs as well as physiatrists. The whole realm of sports medicine is a whole bunch of people that there’s not a ton of general surgeons in that realm. And so it’s really fun kind of seeing all this stuff from the orthopedics perspective and then also very much from the ultrasonographer perspective. There’s a lot of radiologists and supports who see these injuries by ultrasound but never see in the operating room.
Speaker 1 (00:06:13):
Surgeons
Speaker 2 (00:06:14):
Understand they know what muscular injuries are, but they don’t really want to go anywhere near the groin. So it’s a fun place to just incorporate all these different perspectives and try to put ’em into one under one roof.
Speaker 1 (00:06:26):
So on that note, our very first question is more to just define what is a core muscle injury?
Speaker 2 (00:06:34):
That is a great question. And so I will try not to be too long-winded here. This could probably take up the hour, but I’ll just say there’s a lot of misnomers, there’s a lot of unfortunate language associated with these injuries and I think that’s why I’m doing well. I’m delighted to be here, but I’m talking about something that isn’t a hernia, that’s probably one important take home messages when we’re talking muscle injury that is a distinct entity from an inguinal hernia or a femoral hernia or some of these other processes that take place in the same part of the body. So what we call a muscle injury really we call the core is your chest to mid thigh. And the reason we have those boundaries is basically the most important muscles of the core from my perspective are, and if it’s ok, I’ll share my screen here.
Speaker 1 (00:07:24):
Yeah,
Speaker 2 (00:07:24):
Mess this
Speaker 1 (00:07:25):
Up. That’d be great.
Speaker 2 (00:07:27):
Really. So can you guys see this up here? Is that coming
Speaker 1 (00:07:31):
Through? Looks perfect.
Speaker 2 (00:07:32):
Okay, great. So the rectus of dominance, which is our six pack, which is there somewhere on some of us and more obvious on others, that originates from your ribcage from the lower edge of your Rives and that traverses down the anterior abdominal wall and it attaches to the front of the pubic bone, then your adductors, which are the muscles that allow you to squeeze your legs together. And they’re very important as a part of this apparatus, they extend from the front of your pubic bone down to the inside of your femur. So because that’s the most commonly involved apparatus when it comes to core muscle injuries and also it’s the vital central stabilizer of your core that creates the boundary of the core. So we define a core muscle injury as any muscular injury involving the body from the chest to mid thigh. And so that does include hamstrings, glutes, lumbar muscles.
Speaker 2 (00:08:27):
We tend to be more commonly working on the anterior musculature, but certainly the pattern of injury very often involves this apparatus plus some of the hip flexors. And then very often there’s kind of secondary involvement of the other muscles as well. And so really when we use that term core muscle injury, it’s a little non-specific, which creates a little confusion on its own. But what we’re trying to get people to thinking about is, well, if you said it’s a core muscle injury, which muscles are involved? And that’s a great question. Cause then you can start saying, well this injury involved the rectus abdominus, the attic and longus and the iliopsoas, and now we’re getting the specifics as opposed to these generalizations where you know, can gloss over and maybe not get specific about what we’re talking about.
Speaker 1 (00:09:13):
And you use imaging to help you in your evaluation. Absolutely. What imaging do you rely on?
Speaker 2 (00:09:20):
We rely very heavily on MRI.
Speaker 1 (00:09:21):
Okay.
Speaker 2 (00:09:22):
I think one of the main issues with, with the injuries involving the attachments to that pubic bone, which is again, that’s where this whole app tends to break down, especially
Speaker 2 (00:09:33):
Put a lot of load on that apparatus, which tends to be picking things up, twisting, turning, pushing, athletics, all of these things kind of load that apparatus in particular. And one of the markers is generalized inflammation around the pubic bone. And that’s fairly easy to visualize on something like a PET scan. But if you get a CT it’s very unlikely that you’re going to see a large enough disruption of any of this thing to really see it. So what we need to see is just inflammation around the muscular to the pubic bone and an MRI is proven to be the best in terms of sensitivity for this ultrasound is also very useful. The problem with ultrasound is it’s not as good as at visualizing the actual attachments to the pubic bone. It’s, it’s very helpful for seeing some of the secondary associated findings. But the MRI seems to be the most sensitive specific for identifying these injuries.
Speaker 1 (00:10:27):
Do you ever use CAT scan?
Speaker 2 (00:10:30):
Only when we’re concerned about either a fracture or when we’re trying to define the boney anatomy of the hip
Speaker 1 (00:10:37):
Better.
Speaker 2 (00:10:38):
Yeah, it’s pretty rare that we’ll ever use it for anything involving the, that’s more in the realm of hernias and certainly we end up treating some hernias just because people, especially athletes, like to go to someone who understands the recovery process. Real expertise is what?
Speaker 1 (00:10:56):
Yeah, I’m a big fan of MRI as well. I’ve seen in, cause I do mostly groin, I mean I do all hernias, but the majority of my practice is based on the groin hernias and groin pain. So the pelvis is just so much better visualized by MRI. The problem is that the most people dunno how to read MRIs or, and radiologists also dunno how to interpret it from a surgical hernia growing pain standpoint. So like specialties areas you probably do very well. I read my own MRIs, so that’s kind of how I got around it. And I have a handful of radiologists that I can kind of rely on. But I think because MRI has really not made it into our world in the general surgery that much that we just don’t use it. And then people get CAT scans thinking CAT scan will just see everything and it’s not true. It doesn’t necessarily,
Speaker 2 (00:11:57):
Yeah, absolutely. Differentiating the muscles, the abdominal wall, I think the MRI really opens up a new level of detail that you just don’t see on CT In addition, I think one of the things that’s important, if you’re, and you’re thinking about, well geez have, there’s actually a protocol if you just get a regular MRI of the pelvis, it’s a shame. It often will show you the ovaries and the uterus and your rec
Speaker 1 (00:12:20):
Sacrum.
Speaker 2 (00:12:20):
Yeah. And it doesn’t, and the sacrum and it stops on the back end of the pubic bone and it stops on the sacrum. And so what you get is everything but the muscular attachments to the pubic bone. I get a lot of people sending me their MRIs, Hey, what do you think? Is it worth trip to? And sometimes I have to say, well I dunno because unfortunately they missed by an inch.
Speaker 1 (00:12:41):
Yeah, it’s very correct. So order.
Speaker 1 (00:12:45):
Correct. Very correct. Thank you for that. We have some easy questions and some hard questions. I’m going to start with an easy question. All right. But we already have a hard question posted up. So one thing is that people get, when they get growing pain, they have hip pain or they get imaging and it’s shown they have a hip. So here’s the first question, which is how common given hip labral tears are the general population? How do you determine if the labral tear is a cause of groin pain? Do you have a way to help differentiate? So just his background, a couple months, three months ago or so we had, or the hip specialist that I use, and the reason why I’ve learned a lot from him is groin pain. Pain can be from hip problems and hip problems can give growing pain and hernias. So there’s a lot of overlap between hernia pain and groin related problems or hip problems. And you get an MRI or imaging and it shows labral tear hard to determine is that a real one that needs intervention or is there a growing disorder. So how do you determine if the labral tear is the cause of pain or there’s another reason for growing pain?
Speaker 2 (00:14:05):
That’s a great question. So in some research that’s been done, especially MRI, they’ve shown labral tear and impingement morphology in the hips of 85% or more of male athletes in division one or pro sports. And in my practice it’s pretty darn close to 100 percent of patients have some degree impingement and some degree of labral pathology. About 15-20% have symptoms that can be attributed to that anatomy and to that process.
Speaker 1 (00:14:41):
That’s a great statistic. So 85-100 percent of people that are athletic or come see you for groin problems or core injuries have a labral tear on imaging, but only about 15% will have a true labral tear related pain.
Speaker 2 (00:14:58):
Correct. And so the way that I like to differentiate the hip interarticular hip pathology symptoms from the other symptoms are in when we’re talking to you very often if you tell me it hurts to sit for too long or if it hurts to cross your legs or you use to put your shoe on easily, but now that right leg, it’s a little harder to get your shoe on, you have a hard time lying on your right side. Things that involve hip flexion will become more difficult. That’s much more of an indicator that the hip may be playing a role, in addition in males when you say that you have testicular pain, it’s very important to get specific. And I spend my career below the belt as do you I dealing with this area, it’s so easy to say, well, it hurt by my testicle.
Speaker 2 (00:15:49):
And so then everybody goes to the ER for their testicular torsion ultrasound, which is normal. Correct. And then if you really break it down and say, okay, let’s put our finger where this pain is, you realize very often it’s not the testicle. But if you really do attribute pain in the testicle in my practice, and this is very different than your practice, I imagine just because of the nerve that tend irritated by hernias. But in my practice, if they have true testicular pain, that’s actually more of an indicator that they may have a hip problem than a muscular
Speaker 1 (00:16:16):
Injury. That’s a very good point because no one thinks that hip can cause testicular pain. And it’s one of those what we call atypical presentations, which is actually not that atypical, but just no one, no one puts the two and two together. Very, very good point. Thanks for that.
Speaker 2 (00:16:35):
And I think one of the things that we’re finding is that you and I get atypical presentations more often than not. If it’s a typical hip pet presentation, they’re not coming to our clinics, they’re going to the specialists clinic right away.
Speaker 1 (00:16:48):
But also I feel that orthopedic surgeons, similar general surgeons, they learn something in a textbook and they also may not see that patients that they should be treating for a labeled tear or impingement because of the testicular pain. I mean they’re usually more than just test testicular pain, but that one detail throws them off, I feel.
Speaker 2 (00:17:13):
Right. And there’s a lot of hesitance to get too involved in the urologic or even potential hernia issues. A lot of orthopedic surgeons want to get cleared from the general surgery perspective before they’ll do their hip. And I think a lot of times that willingness to be more inclusive and be a little bit more aggressive, you realize, yeah, this, it’s not an uncommon complaint that patients,
Speaker 1 (00:17:34):
We had a question about this I think two weeks ago. If you had a patient that truly had hernia, like a true inguinal hernia, not complicated, but a hernia that was truly symptomatic and they a bad hip, not necessarily, let’s say they need a hip replacement. Sure. Which one would you do first
Speaker 2 (00:18:01):
Be because of the way I think the world works, I would probably fix the hernia first because most hip replacement surgeons want no potential for sepsis or bacteremia. And I think that the hernia repair does have this very, very low risk of infection or perhaps bowel injury or something like that, in which case most of it hip replacement surgeons, but I know want that healed and gone before the resurface anybody.
Speaker 1 (00:18:26):
I agree. I think that’s what I recommend too. Also, I think you need to go undergo some pretty good physical therapy after your hip. And so having a hernia, some people are reluctant to do much, it’s not you, it’s okay to do it, but there’s a general population reluctance to do any type of physical exercise when you have a hernia. So it’s getting, taking that out of the picture kind of helps,
Speaker 2 (00:18:52):
I think, especially the way hernia repairs go now. I mean I know the concept of waiting on a hernia is still, it’s less of a debate. People are more aggressive with repairs since the minimally invasive approaches come along. But frankly, when I counsel patients that have a hernia, they think, Hey, when should I get this done? I say, just do it because if there’s any limitations on your activity level, that’s going to have repercussions overall. Our whole foundation, our whole institute is built on just keeping people active. And so I think there’s anything that’s keeping you from moving, you want to get that out of the way.
Speaker 1 (00:19:25):
Very true. Okay. Now the hard question, so this lovely lady, she’s had three abdominal operations, Mesh put in, Mesh, take it out. So this is her issue. She feels that she cannot engage her lower abdomen. She also has a softball size bulge, but the CAT scan shows no recurrent hernia. I would debate whether that’s true or not, but I like to look at it myself. Sometimes if it’s not a humongous hole with a piece of bowel going through it, the radiologist will not call to hernia. But let’s say, let’s say she really does not have a hernia, but she does have bulging in the lower abdomen and this inability to engage her core. What do you think of that?
Speaker 2 (00:20:14):
Well, certainly that inability to engage the lower core muscles is something that people do complain about a lot. One of the things that I think people have had a bunch of, you get abnormal sensorium, you can’t quite feel what’s going down there as well, surgery. And so sometimes it really is as simple as feeling instability or an inability to engage those muscles. And that could be indicative of an injury there. And certainly when the rectus abdominus is starting to detach from the pubic bone, what to happen is there. There’s instability there. And the most common presentation with that is pain. But we certainly do see a loss of function as well. And that may be playing a role with what she’s having here. I think the bulge, that’s harder to explain. I would be certainly pretty suspicious of the recurrent hernia. I think sometimes if there’s been, anytime you’re taking Mesh out, there’s a larger risk for more kind of traumatic injury. And so if there’s bend denervation to a segment of that musculature for we see it in the obliques. I don’t know that I’ve seen it in the central rectus abdominus area, but certainly the obliques when they become paralyzed, then you can get that paradoxical movement. So you can get some protrusions related to that. Yes. So I’d be interested in something like that, but although, yeah, again, I’d love to see that CT as well.
Speaker 1 (00:21:35):
Or you may not have a true hernia, which is a hole, but you may have a stretching out of a scar tissue, which is more like a diastasis. So there’s no true hole, but so weakened and imbalanced I guess. Yeah. Okay. Next question has to do with age and sports injuries. So what are your thoughts on a 70 year old who’s not an athletic male that was diagnosed with a rectus tear and osteitis pubis? Would you operate on them the same way as a professional athlete? And do you tend to treat many seniors in your institute?
Speaker 2 (00:22:10):
Yeah, so my experience, our experience here at the institute is really about, there’s, there’s two peaks of the age of the population. The first peak is really that 18 to four year old athlete who’s at the peak of their performance and their training, and they’re just putting tremendous on their body. The other peak is more around 50 when your career and your family life has stabilized to extent that you can strap the boots back on and get back into shape. And that’s when we see a lot of people get hurt again. And frankly, for me, age is a, there are parts of the body that have expiration dates and I think cartilage is an important one. So certainly when you’re talking about having interarticular hip pathology, you know, worry about arthritis, you don’t necessarily want to operate on someone to fix their labrum if they have a labral tear, if there’s a big threat of arthritis.
Speaker 2 (00:23:02):
But when it comes to reattaching these muscles, yeah, there’s really no reason age should play a role. It’s overall fitness. Are you active? If you’re active and you enjoy exercising enough to injure yourself in this way, then you’re going to be able to handle physical therapy, which is the vital part of the recovery process. And so I wish I could show you the video, but I have a 82 year old former army gentleman who really enjoyed doing L pull-ups. And really two months after I repaired his big injury involving erectus on both sides, sent me a video and just cranking out 20 pullups. And I went and tried to do one and it was embarrassing. So
Speaker 1 (00:23:40):
What are your thoughts on overdiagnosis of sports injuries? I see women, they’re like mothers. They maybe walk with their friends and they’re told they have a sports hernia. What they really have is an inguinal hernia that no one can feel, or this gentleman, 70 year old, he probably has a recurrent inguinal hernia or something like that, but the imaging kind of throws you off because he may also have other findings or maybe there’s an overcall on the imaging. What do you think about people that are not into sports that are getting rectus tears or abductor tears or told that that’s what they have?
Speaker 2 (00:24:24):
That’s an interesting question. So I’m certainly biased looking for these injuries. And so I think one of the things that’s keep in mind is that there has been this concept that only athletes get these injuries. And I think there’s a lot of load even at complete rest has tremendous load on it. And so it can be something as simple as, well, childbirth is one. This vaginal delivery involves kind of putting your hips inflection and that downward pressure certainly can rip these muscles can also cause hernias. But then we have laborers, police officers firing, they’re using their bodies just as much as an athlete and it really is the more fit you are. There’s perhaps more load on this apparatus, but I also think people who have an accident or a slip or an odd trip who are not in great shape are probably more susceptible to these injuries.
Speaker 2 (00:25:21):
And so it’s a little bit of, I don’t think everyone has this injury, certainly not, but I think it’s actually really common to have these injuries. One of the things that I’ve noticed is once an athletic trainer at a school understands this injury and has a couple kids on their team present, get it fixed, realize that that’s been hurting ’em for a season or two, all of a sudden other athletes from other teams at that same school start coming realizing that maybe this is the problem with this person. I thought it only affected football players and soccer players. He was a gymnast. And so I think it actually is more common than maybe we realized. But then again, the question of overcall on MRI, I have not had that experience. I spent a lot of time reading MRIs that were read as normal, as abnormal, but I think it’s all about who the radiologist is and how you’re in a part of the country. I think where awareness is just generally better than other parts of the country. I think a lot of people who are at the forefront and there probably is a lot of sports medicine bias, but certainly I see people from all over the country who’ve been suffering with these injuries for years and kind of had a bunch of normal imaging that turns out to show a pretty obvious injury. So
Speaker 1 (00:26:37):
Good to know. Okay, next question. Also, someone’s father, I think they may be watching us. So this lady had an ankle hernia repair June, 2019 I believe open, I’m not sure if she’s on, hopefully she can let us know. He was in no pain from the hernia before surgery. He was told that may the cause of lower back pain. I like your opinion about that. Let’s just stop right there. So do you believe that lower back pain can be caused by anal hernias because I do, but
Speaker 2 (00:27:13):
Yeah, I think it’s one of those things where I think the classic concepts for people with low back pain is to strengthen your core. And so we get a certain number of patients every year who were told to do a bunch of sit-ups and then rip the rectus a dominance up in doing so to protector back. Wow. So certainly I think anything that inhibits you from being able to fire your abdominal wall normally can certainly affect your back and we tend to compensate in ways that hurt her backs. So certainly I always like to get the spine docs involved before attributing too much, but especially if it’s kind of minimal, perhaps non-operative low back pathology, which again is basically ubiquitous in our population right then fixing the hernia is probably the best way to get them strong enough to get out of pain.
Speaker 1 (00:28:03):
So after surgery, he was in a horrendous pain in the lower abdomen groin, especially with bending, he became bedridden and the following year, January, 2020, he had an ilio, inguinal neurectomy, which actually made it better, 85% better. Then later that year, August of 2020, he was playing golf and he took a full golf swing and immediately felt a tear in the groin surgery area. The pain is now constant and very sore and sensitive to touch. So he had a hip MRI, which shows a labral tear, and he had a pelvic MRI, which shows moderate degenerative changes to the hip on both sides. Thinning of the distal right rectus a dominance tendon approaching its insertion, but no defined tear or edema. So what do you think of those two imaging findings? Just first impression?
Speaker 2 (00:29:03):
Yeah, so again, depending on the age of this gentleman, I think degenerative changes and labral tears would be the equivalent of normal. So for me that’s again, more common than not. And then no defined tear or em at the pubic bone, assuming that’s correct, I always like to look at the images myself, but that that’s an important consideration. That’s important information there. So then certainly the labral tear could be the culprit. And the way I describe where you feel a labral tear is if you took a rope and you just kind of tied it in a loop around your leg and then just cinch it up as high as it goes around where your leg meets your body, you can have pain from a labral tear anywhere in that distribution. Classic, the classic pain is that seas sign where people say it hurts right here, and they kind of put their hand on their hip. But really that line has to go all the way in a circle all the way around your body for you to really understand the distribution. And frankly, history and physical exam are really important. But the other thing that’s very useful is if you just do an intraarticular hip injection of numbing medicine and if that alleviates his pain, that’s a really great indicator that that’s the culprit and it’s also a great indicator predictor of success if you were to have surgery.
Speaker 1 (00:30:24):
That’s a great point. So I love that analogy. So you’re basically pointing to kind of testicle and then the groin crease. Yes. All the way around the hip and then the upper buttock or kind of buttock area, correct. Correct. That’s a great one. And then with the injections for the hip to see if it makes a pain go away, how often does that actually, how predictive is that?
Speaker 2 (00:30:51):
Well, I’ll tell you from a positive predicted value, very good. And certainly there’s 85% of people who either get an increase in their pain or decrease in their pain from the hip injection. 85% of them have good outcomes from their eventual hip arthroscopy. That is to say they have basically pain scales and functionality scores and they’ve set a threshold on that modified Harris hip cord. And so 85% of those patients with a positive result from the injection have a positive outcome, which is great. And so that we have some people who do that injection and they can’t quite tell it’s really, you got to get really, so I’ll say, I don’t do the hip injections. I have a wonderful MSK radiologist, radiologist who I asked him to do all the injections because I know if he did it, if you stick the needle in a couple times, it just creates so much pain that the whole test is not going. Yes. And the pain response is just such a vital piece of the equation that it’s important to have a really talented person do it. A lot of the hip surgeons who it themselves for that reason, which I think is smart, but that’s one very, it’s not definitive, but it’s a nice piece of the puzzle. If you get no response, if it doesn’t affect the pain at all, then it makes it pretty unlikely that it’s the hip causing the pain.
Speaker 1 (00:32:12):
So that’s a really good study to do. It’s very low risk to just inject the hip joint with local anesthetic. If the pain goes away, it’s your hip. And this gentleman to, I’m confirming because he’s actually online live. Thank you. He had opening little hernia repair, I assume with mush, and he also had, he’s 69 years old, so we’re saying most likely the MRI findings of the hip are appropriate for his age or not unexpected for his age, I should say. Correct. And then I think that, what do you think of this story about the full golf swing feeling an immediate tear? I, I’ve seen the Mesh just pull away from where it’s been secured and that’s where the pain is.
Speaker 2 (00:33:00):
Yeah, I, I’d be surprised that they wouldn’t have removed the Mesh in that January surgery, but maybe that’s my own bias there. So if that Mesh is still in place, I would certainly think that it might’ve disrupted from its attachment.
Speaker 1 (00:33:16):
I mean, if it’s just purely, oh, the Mesh is gone now. Okay, Mesh gone, so there’s no Mesh. All right,
Speaker 2 (00:33:23):
Ripping up that scar. One of the things that I like to do to help diagnose this, I’m surprised there’s not some information somewhere MRI, it does make question, the MRI doesn’t information, let’s say if having him do a sit up really contracting that abdominal musculature. If that elicits some of that pain, then to help drive that point home, sometimes I’ll just another differential injection just to include that within that rectus sheath. And if he has disrupted some that scar tissue, that’s some information that’ll help confirm it. And then also sometimes that injection calms it down enough to give him some relief and it may scar down in a way.
Speaker 1 (00:34:09):
And also if the Mesh was removed, either he had no further surgery or he had a tissue repair that can also bust open and he could just have a hernia recurrence, which some oftentimes is not reported on an imaging study.
Speaker 2 (00:34:26):
Absolutely. Yeah. So perhaps an ultrasound good example,
Speaker 1 (00:34:30):
Unfortunately. Yeah. All right. These are really great questions. Thank you guys for asking. Okay, let’s do another kind of complicated one. So this has to do with just what are we talking about? What is the actual cause of pain of pubic plate disruption or groin strain? Yeah, why is there pain? Is it the muscle keeps tearing and it’s the load is not offloaded, is it there’s an imbalance between that muscle, like the rectus muscle and the other muscles? Are there bony pics?
Speaker 2 (00:35:05):
That’s great. That’s a really good question. This person’s done some reading. Is it alright if I share my screen? Can I do that again?
Speaker 1 (00:35:13):
Let me unshare so that you can share. Great. Yeah, go
Speaker 2 (00:35:16):
Ahead. I’m, I’m going to work off of this picture here. And so the answer is yes to that question. But the reason core muscle injuries involving the attachment so that people don’t hurt is there’s two main factors. One is when you develop these injuries, it’s an acute on chronic process involves just basically plucking muscle fiber by muscle fiber of the rectus a dominance and adapters off of this attachment to the pubic bone. And the way these muscles attach, it’s important to realize that there’s not like a true tendon in these attachments. There’s actually skeletal muscle, real muscle fibers all the way up to this big ball of dense tissue around the pubic bone. So you can just pluck off a couple fibers of rectus abdominus and they’ll retract and then just kind of seal in. And from the outside, the rectus muscle looks normal, it’s just its footprint is getting smaller and smaller on the pubic bone.
Speaker 2 (00:36:13):
And the same process occurs for the adductors. And so one of the reasons you have pain from these injuries is that as that muscle pulls off, you lose its function and you also, oh, get associated scarring. And basically if you just think about it, if you retract a significant portion of any of these muscles, it’s just going to get bulky. And so we like to use the analogy of a compartment syndrome for any runners out there we’re just the muscle’s getting squeezed by its own fascial containment and it just really has an inability to contract normally. And so sometimes people have pain kind of up along towards their belly button pretty commonly we see that. And that’s just related to the tearing of that muscle and how it’s kind of remodeled in a way that’s just too tight. But the majority of the pain that we see as related to the actual disruption of that fibrocartilage that tissue around the pubic bone, because once you’ve created imbalances in the pulling of the rectus a dominance and the adductors across the pubic bone, then that whole block of tissue becomes unstable and it shifts not in a way that we really can appreciate as anything other than pain.
Speaker 2 (00:37:18):
So that whole block of tissue shifts and fluid accumulates there, and that’s what we can see on the MRI. And that’s what’s sometimes referred to as osteitis pubic.
Speaker 1 (00:37:28):
Yes.
Speaker 2 (00:37:29):
Sometimes that’ll show up as extra fluid in the synthesis and it’s kind of tracking in different places, and it kind of tracks wherever that whole fiber cartilage pulls off from the bone and it creates this space that fills in with fluid that shows up really nicely on MRI. Yeah. And there’s nowhere for that fluid to go. It’s under tremendous tension. So it hurts and eventually it gets pounded into the substance of the pubic bone. So then the signal of the pubic bone and MRI gets super bright. And you can see that a lot of times, and that’s pubic and that’s, so it’s a muscular injury, but then it’s also that kind of the attachment to the bone that gets swollen and that can hurt as well.
Speaker 1 (00:38:03):
Yeah, that’s really good information. Can you explain osteitis pubic? Yeah. So I’ve seen osteitis pubic, there’s also these pics. You see where the bone looks like it’s got these crowns on it. Yes. Almost like spikes. What are those and what’s the treatment for them?
Speaker 2 (00:38:25):
So osteitis pubis is just a finding. I think it was first used when the nuclear medicine studies were being used and all of a sudden you would see people coming in with just an increased signal on their pubic bones. And the most common cause is the muscular injury causing that fluid to accumulate there. Thees really, if you do a cadaveric, if you dissect a cadaver and you look at the attachments, the fibrocartilage around the pubic bone is densely adherent. It’s really hard to pry off. But if you artificially make that plane, when you peel it off the surface of the bone is, it has specs like that. It’s very irregular and spiky. And so that’s often what you can see on the MRI. And also if you’re there in a big avulsion injury when everything’s that fiber cartilage plate ruptures and the whole thing retracts, you see this variant, irregular, bony surface and it, yeah, so those pics are usually an indicator of that inflammatory process because it just allows you to, the fluid kind of allows you to see the contour of the bone there. And so the treatment for the pubic bone edema, the osteitis pubic and that kind of pics of the periosteum is really just to reattach the muscles. And then it’s amazing once you restore the balance and the pulling from above and below, your body’s able to seal that whole apparatus back down and those findings go away.
Speaker 1 (00:40:01):
It’s so interesting, and I noticed that the more athletic you are, the more you notice this imbalance that you’re referring to. There are patients that have diastasis hernias all messed up body, and they don’t even know any better. And then an athlete will have a hernia this big and they’ll be like, I can’t do my activities. I feel like I can’t engage my core. Sure. And you fix the hernia, they get better, but you’re just restoring the core. It’s kind of interesting how that is. Yeah,
Speaker 2 (00:40:35):
I think the hernia is also create a very visceral sensation that doesn’t necessarily trigger, oh, there’s something poking through here when I do this movement. But you just very quickly learn that you don’t like that sensation and your body tends to shut down whatever creates it. And so I think a lot of people who have true angle hernias or disruptions of the attachments to the pubic bone without even realizing it, they just stopped using that muzzle because it doesn’t feel good. And pain is probably months down the line, but they’ve already stopped using correct body mechanics.
Speaker 1 (00:41:10):
Yeah. Got it. Very good. Okay. Let’s see. Question about laparoscopic surgery. What are your thoughts on the use of laparoscopy and also the use of Mesh when dealing with these strains, these tears, these plate disruptions?
Speaker 2 (00:41:32):
So one of the most important things to understand about the injuries involving the attachments to the pubic bone is that these muscles attach on the front of the pubic bone. When you place Mesh laparoscopically, it goes behind the rectus abdominus and behind the pubic bone. And so I think when we’re talking about just restoring normal anatomy, when we’re talking about reattaching these muscles, I think it’s important to do so on the front of the pubic bone, there’s actually this common attachment where the rectus abdominus comes down and the adductors come up and you just restore this attachment. I think that’s really important. And if you’re behind the rectus abdominus behind the pubic bone, you can place Mesh across that gap. And I think it will stop the process of that muscle peeling off if it adheres to the muscle adequately. But I think from a repairing a muscular injury, it makes much more sense to me just to reattach it in addition, because these muscles are opposed.
Speaker 2 (00:42:33):
They’re pulling across the pubic bone. Very rarely it does happen, but it’s very rare that only the tors or only the rectus abdominus is involved. And that’s okay. Just the nature of how this apparatus is constructed, the pulling from above relies on the pulling from the below. And if you only correct one very often, you’re not going to get the results you’re looking for. I think laparoscopy is ideal. I think it’s an amazing tool. It allows amazing visualization. The main issue for me is that the surgery to reattach things to the front of the pubic bone takes place in a part of the body where there’s skin, and then you start naming vital structures, nerves, blood vessels, and so you know, toy with the idea of making a five millimeter incision, inserting a dissector balloon, but that, that’s the delicate part of the surgery.
Speaker 2 (00:43:24):
It needs to be done carefully. So through a three, four centimeter incision, we can get access to the that part, do the dissection, get down to the muscles and reattach. I don’t think that that’s something where you can allow the dissection to be done any other way until perhaps we can do everything on an even smaller level and do it. Yeah, do that dissection through a tiny incision. And I don’t think it’s helpful. And just really quickly about Mesh, I’m, I am biased against Mesh. I have the injuries that I treat don’t really require Mesh. I mean,
Speaker 1 (00:43:58):
That was going to be my next question. Yeah.
Speaker 2 (00:44:01):
The treatment of,
Speaker 1 (00:44:04):
Go ahead. Mesh is quite an inflammatory product and a lot of what you’re dealing with has inflammation associated with it already, with the tears and so on. So what are your thoughts of that interaction where you’re adding an inflammatory implant to an already inflamed angry area?
Speaker 2 (00:44:22):
I think I will tell you that there are lap, very talented laparoscopic surgeons who place Mesh for these injuries and have success. I mean, I’ve seen it, but I also know I take out a lot of Mesh and I deal with people who’ve had Mesh repairs and injuries, and now here they are, they have Mesh and they still have their injury. So I think just from a mechanical standpoint, it just makes sense to reattach the muscles, the presence of the Mesh when it’s really well placed, talented surgeons are placing this Mesh. It really is mentally invasive. I mean, it’s amazing how you could slip the Mesh in the inguinal region and people are feeling great afterwards. The problem is if it’s not correct and the problem, that’s where we run into trouble. So I think probably inflammation associated with the Mesh is pretty minimal as opposed to the information from the injury. But my bigger concern is in especially really thin people who enjoy to do doing athletics,
Speaker 1 (00:45:21):
Ballerina,
Speaker 2 (00:45:22):
Twisting, turning, they are the ones that I think tend to feel the Mesh. Yes. If you sit and you lay down and you don’t do a lot else, I don’t think you’re going to get bothered by the presence of Mesh. But these people you’re talking about that feel something, these minutiae associated with their muscles are not going to like having a foreign object sitting next to their rectus abdominus. And for the true core muscle injuries, it’s just not necessary.
Speaker 1 (00:45:48):
And then talk to me a little bit about the options of suturing, which is kind of repairing versus cutting and releasing. Both are done, right?
Speaker 2 (00:46:01):
Yeah. Well, okay. So the real name of the game is just restoring the normal balance. What tends to happen in these injuries is that you have a combination of, if you just imagine you’re fraying a rope and the strands are pulling off, what’s left tends to be under tremendous tension. And so especially in the adapters, the portion of the muscle that hasn’t given way yet is really tight. And so there has been a whole lot of understanding that if you just cut those things, it takes some of the tension off the pubic bone and the inflammation gets better. The problem is you’re not restoring the normal anatomy, the normal forces across the pubic bone. And what tends to happen is as you get back into activities, you build up the inflammation again, that fiber cartilage is still shifting around. And so really if you restore the balance from above and below, then that’s what really allows it to heal. But certainly there are people doing addict or releases, and I think in many cases it makes the situation better because it takes that tension off. But there are people who have that functional weakness and then they still have the instability of the pubic bone, so they still get the pain associated with that. Makes a lot more sense just to reattach everything to me.
Speaker 1 (00:47:18):
And then as a general surgeon, you’re probably trained in residency not to put any B sutures in the periosteum when you do a hernia repair, but you are doing that now, right? So where is the disconnect?
Speaker 2 (00:47:36):
I will tell you that periosteum, that’s really thickened on the interior aspect of the pubic bone. You can suture that without any issue. I think the old school hernia surgeon’s idea of taking the giant prolene and driving it through that tissue, once you go deeper than the fiber cartilage, once you go deeper than the periosteum, you’re going to create edema of the pubic bone and pain. But there’s a layer that in that picture that I showed, that baseball cover, you can suture that without pain. And so I think that’s the important layer to use and it holds suture really well.
Speaker 1 (00:48:14):
Okay. This question has to do with the lady with who couldn’t engage her abdominal wall. If absorbable sutures were used to close the diastasis rec eye and asphyxia umbilical hernia, should myofascial release to help with adhesion pain be more, there’s a such thing as adhesion pain when it comes to abdominal wall. What are your thoughts about use of absorbable sutures?
Speaker 2 (00:48:43):
I think when you’re talking about a true hernia, I worry about it. I think there’s more of a concern depending on what suture you’re using, but I think recurrence is more of a concern. Certainly diastasis is another one where you’re using attenuated tissue.
Speaker 1 (00:48:59):
Yeah,
Speaker 2 (00:49:00):
I think I, I’d worry about that thing recurring unless you used some sort of biologic or something to reinforce it.
Speaker 1 (00:49:08):
Yeah, I agree. I, I understand that there may be in instances where permanent suture can or shouldn’t be used in patients, but the standard is to use permanent suture and not using permanent suture always has a risk that once the suture is absorbed, that strength is no longer there. Okay. Let’s see.
Speaker 2 (00:49:33):
Can I raise one other point just about the diastasis? Yeah, I think diastasis, I was taught very clearly that they don’t cause pain, so you don’t really have to do anything about it. And I think you’ve seen mean, it sounds like a large part of your practice is helping people with this problem and they develop hernias, but then there’s also some symptoms associated with the diastasis, not just cosmetic, but I think also the penetrating nerves that go through the rectus as it slides laterally, I think they get stretched and you can get some of what’s also called that anterior cutaneous nerve entrapment syndrome. And I think
Speaker 1 (00:50:07):
Yes,
Speaker 2 (00:50:08):
Correcting the diastasis helps people with some of that pain, not too uncommonly. And so I think perhaps this woman’s diastasis is coming back apart and she’s just getting a stretch
Speaker 1 (00:50:19):
Again. Yes. Yeah, diocese is a big core instability issue. Let’s go back to the groin again. Can a core injury, rectus tear, adductor strain, can that cause the appearance of an inguinal hernia or how can it mimic an inguinal hernia or can you have both? Do you repair both?
Speaker 2 (00:50:41):
Yeah, it’s a great question. So yes, it really depends what we’re talking about, but I, I’ll say the larger rectus abdominus injuries, the rectus is kind of a central attachment to the pubic bone, and the obliques really rely on that attachment for their position. And so as the rectus slides up, basically the floor of the inguinal canal starts to slide up with it if the injury gets severe enough. And so we certainly see people with large rectus abdominus injuries that have a direct hernia. And that process is where this gets really confusing because if you just reinforce the floor of the canal, the hernia goes away and maybe that rectus injury stops progressing and they feel better. And that’s where there’s a tremendous amount of overlap. The majority of the muscle that I see on the rectus side, there’s not enough sliding back to cause a hernia, but that process, there’s some point where it reaches that point.
Speaker 2 (00:51:34):
The other thing is if you put an ultrasound probe over the inguinal canal and as that floor of the canal is getting thinner, as the muscle slides away, you’ll see it start to bow to bulge out when they bear down. And that’s a really interesting finding. And so some of the ultrasound tech ultrasonographer that I work with who do all ultrasound based, needle based techniques, they say, oh, this is a hernia. You see this thing, it’s all, it’s bulging out, and part of this is semantics. I say, well, maybe, but it’s just from their muscle injury. And they say, no, no, no, it’s a hernia, fixed the hernia. And so, yeah, I don’t know who’s right on that one. That’s just a little bit of a screwdriver versus a hammer discussion. But certainly the majority of the hernias that I fix, I find incidentally it’s a tiny little sack that’s a congenital indirect that’s been there forever and it’s completely unrelated to the muscle injury. Every once in a while in a severe enough muscle injury, there’s a direct hernia that’s perhaps contributing to the symptoms, but I think it’s usually the muscular injury, whereas if they just have an obvious true hernia, I think they’re usually getting that fixed before they get to me.
Speaker 1 (00:52:46):
If they, let’s say they don’t go to you, they go to their local community surgeon and the ultrasound shows exactly that and they say, oh, you have a hernia, and they go to the surgeon, the surgeon does a hernia repair. Is that a bad thing? Have they burned any bridges? Are they going to have more chronic pain or can that actually treat and stabilize their injury?
Speaker 2 (00:53:10):
That’s a great question. So I think that’s something that I would love to look at prospectively. Cause I dunno, the bottom line is, I dunno, I only see the people who’ve had Mesh placed, who still have their pain and they clearly have a muscular injury. Got it. If you place laparoscopic Mesh, well, it, it’s amazing. It’s such a benign procedure that in some cases people have just used that as a part of their diagnostic workup. They said, well, maybe I have a hernia place, the Mesh and my pain’s still there, but there’s literally no drawbacks to having the Mesh there then I think that’s great. The problem is if someone places the Mesh and it wrinkles up and now it’s pushing into their abdominal wall, then that creates all this new pain that can make things worse. And I think that’s frustrating, but I think in the hands of a really skilled hernia surgeon, minimally invasive inguinal hernia repair is a very safe procedure.
Speaker 1 (00:54:01):
The question is, does the Myers repair address the lock city in the inguinal canal that you just discussed?
Speaker 2 (00:54:07):
It does, yes. So restoring the normal attachments corrects that.
Speaker 1 (00:54:11):
Okay. And do you use Mesh for your hernias or
Speaker 2 (00:54:17):
For I’m pretty biased against Mesh just because I have to take so much of it out. And I will also say
Speaker 1 (00:54:24):
Hybrid Mesh, not necessarily synthetic, pure synthetic, but some of the hybrid out products out there,
Speaker 2 (00:54:30):
I’ve played around with it a little bit. Okay. I think it makes sense. I think the problem is I don’t think that the Mesh itself is usually, unless it’s placed in a way that again, it’s bulging out and causing mechanical issues. Usually it’s the scarring from the Mesh, which like you said, the Mesh is designed to create fibrosis. That’s part of its strength. And I think the scarring from the Mesh, if that gets too close to a nerve or creates enough rigidity of your abdominal wall, then it becomes uncomfortable. That’s the problem. And so I tend to shy away from use of Mesh. I’ll use probably a smaller amount of Mesh than anybody who trained me how to do hernia repairs would want if I do end up using it just to try to just reinforce my suture holes as opposed to Got it. Broad coverage.
Speaker 1 (00:55:13):
Yeah. Got it. I understand that. Okay, last question is kind of a comment as well. She says, thank you for explaining this so well. This sounds so much like the pain I’m having. I was first diagnosed with the hip tear and F A I, which is femoral acetabular impingement. I developed a bulge after I did a plank and developed back pain and pubic pain, and they did the angular hernia repair without any imaging first. The pain has been off the charts ever since. Ever since. And I been debating on having the hip labral tear repaired and the F A I repair, not sure if it will make my pain worse or not. I mean, the bulging doesn’t make sense. Right,
Speaker 2 (00:55:53):
Right. Well, I mean will say you’re the hernia specialist, but I don’t think imaging is necessary if you’ve got a hernia on exam. Correct. I don’t see any reason to do anything else. So I hope that that was the logic for the hernia repair. But it sounds like there’s a diagnostic workup that needs to be done. Yes. And I would not rule out the hip, but certainly I would want to put you through some physical exam or potentially some numbing up different spots to make sure we identify what’s causing your pain and then fix it.
Speaker 1 (00:56:23):
Yeah. What I would want to know is what kind of pain are you in now? Is it different than the pain that you originally underwent hernia repair for? Or did the hernia repair not address the original pain? So if it’s the former where you had a hernia repair and now that pain’s gone, but you have new pain, then something is related to your hernia repair. And if you’re an athlete or a thin that you’re more likely to have symptoms from a more standard repair. And then if it’s the same pain, it just didn’t change, then yeah, we should look at all these other reasons for groin pain besides your hernia, which could be cord, what’s the right term? What terms should I be using? I’ve been using everything today. Sports hernia, groin strain, rectus tear, plate disruption, what do you use?
Speaker 2 (00:57:18):
Those are all great words except for I’m, I’m really trying to kill sports hernia because it’s confusion, but I like core muscle injury because it’s a little bit of a catchall. But if you say rectus tear, I think people understand. And the issue is that most rectus tears have a reciprocal addict or tear that gets overlooked and that’s part of the problem. So I like core muscle injury just to keep it. The other thing is we haven’t even gotten into it, but especially a women, very common to have iliopsoas involvement. Rectus femoris is another one that’s commonly involved. And so
Speaker 1 (00:57:49):
Yes,
Speaker 2 (00:57:50):
If you got that stuff, especially iliopsoas impingement or when that, that’s a big hip flexor in your back, that crosses into the front and attaches on your inner thigh, that can cause inner thigh pain. And when it’s inflamed, it can create things like pelvic floor dysfunction especially. We see that yes, absolutely. Diagnosed more common in women, although I think it’s just as common in men. We’re just still figuring a lot of that stuff out because of our anatomy being different. But I think that’s the point is to find the entire extent of the injury before doing anything. I think that’s really,
Speaker 1 (00:58:22):
Yeah, it sounds like the hernia repair did not fix their original pain and added to new pain, so now she’s got two problems. So I would look at someone to deal with your hip as well as someone knowledgeable for groin. Yeah.
Speaker 2 (00:58:36):
Can I make one other comment?
Speaker 1 (00:58:37):
Yeah,
Speaker 2 (00:58:37):
Absolutely. Just about that. Sorry. I think it’s important to hard to go to a hip specialist and say, is this my hip? And then go to someone who might be able to diagnose the [inaudible] and say, is this a muscular injury? And then someone else to say, oh, is this pain from my Mesh? It’s, that has to be a coordinated effort, and I think there’s different places around the country where you can get that done, but it’s more often than not. It’s something that I think stepping out of the existing university system was important to get that done here, but I think it’s popping up in different places around the country where we can get the general surgeon, pain management specialist and the hip surgeon kind of all talking to each other at the same time is really helpful and important.
Speaker 1 (00:59:22):
I agree. I agree. But not everyone has the luxury of having all the specialists in one area or even in one city. True. True. Yeah. We we’re very privileged to have access to some of these people. On that note, I think we’ll end it. Thank you very much for your time. I hope you have a great evening and I hope that I can interview more people from your institute because I learned a lot tonight. So thank you, Dr. Poor. I’ll make sure that this is available for you all to watch over and over again and share on YouTube. Thank you for following me. For those of you that are on Facebook at Dr. Towfigh, I’ll make sure that the link to the YouTube is also available on Twitter and Instagram to all of you. See you next week. Thank you, Dr. Poor, for your time. And we’ll do another session of her talk Tuesdays in one week. Thank you very much. Thank you.
