Episode 122: Sports Hernia, World Cup Edition | Hernia Talk Live Q&A

You can listen to this episode by clicking here.

Speaker 1 (00:14):

Is that better? I kind of switched the microphone around. Let me know if that’s better. Okay. All right. We’re going to go away with a fancy microphone and go with the computer microphone. Okay. Basically everyone, I’m trying to teach you a little bit about sports groins and sports hernias because I was stressed out through most of World Cup because I was hoping that no one gets injured. I for sure saw so many people have injuries, mostly of the shin and the ankles in general. Soccer is really fun to watch, but I think it’s one of the worst for your bodies because you’re banging your head on the soccer ball so you’re, your head can get concussion. We saw multiple concussions and people being taken off the field and a couple were not allowed to play for a couple days. I think because the concussions were so bad.

Speaker 1 (01:12):

You are compressing your spine when you are doing these headbutts with the ball and then you’re running around a lot of lower abdominal strength is necessary. You do a lot of abduction kicking fast movements, moving forward backwards, a lot of kind of explosive movements and motions. And then man, the ankle, the amount of pressure and tension on those little ankles and knees. There were a couple A C L injuries. I think there was a hip injury and there were definitely some groin injuries and some actually male like kind of testicular injuries, mostly painful. No actual need for surgery for those. So I thought it’d be good to kind of review sports hernias given that there was so much talk and discussion about these sports injuries during the World Cup and help dispel some myths and rumors and so on. So in addition, many of you have submitted questions related to sport attorneys, which I’ll definitely review.

Speaker 1 (02:27):

We have about 12 or 15 questions, but in addition I have a couple questions that were submitted unrelated, so I’m happy to answer other questions while we’re here for the hour. So let’s just review what a sport hernia is. So by definition of sport, hernia is a, her hernia is an injury. It shouldn’t really be called sport hernia. It’s really called sport hernia because all the other medical terms are too medical. So people have just decided to call it sports hernia cause it’s easier to talk about sports unis. But it’s really a sports injury that’s related to the core muscles and your core includes your abdominal wall, your flank, your back muscles, your pelvic muscles, your muscles that hook up to your pelvis, which include your hip and your abductor muscles in the front and then your diaphragm and your chest wall. So injuries to all of those can occur and will have implications for someone like me who’s who does abdominal wall and pelvic wall surgery.

Speaker 1 (03:40):

Fortunately, most of these injuries do not need surgery, but they come with different names and the names are all related to where the interest is in terms of where her injury is. So for example, we call sports, what do you call sports injury or groin strain. I think if I use the term groin pull or groin strain, people understand that. I always talk about LeBron James because I’m a huge basketball fan. Our family are a huge family, is a huge Lakers fans. We literally have so much Lakers outfits to where every day. And so LeBron James is very dear to us as a current major player on the Lakers and he suffers from bad groin strain and it’s a recurring problem for him. So I prefer to call that groin strain than a sports hernia, although I haven’t personally examined him and I would love to.

Speaker 1 (04:35):

So if any of you know LeBron James out there, please tell him to call me so I can examine him and make sure there’s no missed hernia. But sounds like what he has is a groin strain. Other terms for these problems are sportsman’s hernias, groin plate disruption, groin disruption, gilmore’s hernia, micro tears, core muscle injury, abductor tendonitis, osteitis pubis, iliopsoas tendonitis, psoas syndrome. There’s all these different local areas where there’s injuries. The basic concept is there’s muscle and the muscle tears. Now it’s really hard to tear muscle first of all. So you should not just walk around and have a random muscle tear that doesn’t usually occur and usually it occurs in athletic muscles. And the reason why I say that, at least the ones that I’m dealing with and what doesn’t sound right, aren’t you an athlete, you have really strong muscles and then why would that tear?

Speaker 1 (05:52):

Well, the reason is your body is a pulley system. You may have heard this by other people before. So it’s like a pulley system and for every action there’s an equal and opposite reaction in terms of balancing this pulley. So for example, if you ever had a cramp in your leg, that’s a spasm of a muscle. Well your other, it’s really hard to walk actually because your other muscles are trying to compensate for the fact that you’re missing the ability to contract and use that cramped muscle. And the same is true for sports injuries. So as you know, muscles have to attach to something, right? And usually they attach to bones or ligaments and bones, muscle stretches. You can elongate muscles, you can stretch muscles. That’s how we stretch out. So on bone does not move. Bone is like rock cement, it doesn’t move. It is completely hard and not meant to stretch. So at the interface between where the muscle or ligament attaches which can stretch attaches two bone, which does not stretch that area is an area of tension. So what’s a good analogy for that?

Speaker 1 (07:11):

It’s like a purse. When you have a buckle and you attach a buckle to a strap of a purse, that area where the strap and the buckle kind of connect, that metal buckle will not tear, but the strap may tear. And you’ve seen people who have either luggage or purse that teared always tears an indirect intersection between something that doesn’t tear the metal buckle and the leather handle or something like that. So when you have, let’s take a hockey player. So the top sports injuries are soccer and hockey, football, American football, rugby. So those are the top. We don’t see swimmers or cyclists having these type of injuries a little bit in tennis as possible. You can have a growing strain and I’ll explain to you why we don’t see it as much, maybe a little bit of basketball and I’ll explain to you why certain athletes have it in basketball and others don’t.

Speaker 1 (08:19):

So part of the problem with soccer and football and hockey is you’re dealing with people with really, really huge super strong muscles. So they have these enormous muscles like a hockey player. If you’ve ever seen a hockey player, and I’ve treated many of them. These NHL players, their thighs are humongous when I put them on the operating room, their thighs are so huge. I mean it’s pretty amazing when you put them on these narrow operating rooms, their thighs are so huge that their legs can’t come close together because there’s so much muscle in between their legs and their legs are kind of split open a little bit and the thighs will be wider than the bed. That’s how thick some of these hockey players’ thighs are and they have to because of the type of sprints they do as part of their sports. Same with soccer, except with soccer they do a lot more cardio.

Speaker 1 (09:34):

So they tend to be a little bit slimmer than the hockey players because they’re constantly running around this really huge, they’re more like long distance runners, but they also sprint. So if you have these enormous muscles that are attached to bone, the bone doesn’t change size. If you’re a huge guy, your bone is the same size as when you didn’t have those muscles, those huge muscles. So the muscles overgrow and they remain attached in the same manner as when the muscles were normal. And that interface between the muscle and the bone is very sensitive. So one issue is the players are not stretching enough. The whole issue was stretching, like, oh, you should stretch so you don’t have any injuries, stretch, they don’t get an injury. Well that’s why if you stretch those muscles, you are elongating the muscles. You’re allowing to literally stretch, otherwise it becomes cramped and tight.

Speaker 1 (10:42):

If you’ve ever been in a long flight and you’ve been sitting down or you take an exam like a four hour exam, been sitting down and not moving, you can tell that when you want to get up to stretch, it’s a little tight, you’re a little tight and you’re trying to stretch things and bring them back towards normal. So the purpose of stretching before fully engaging in sports is to literally stretch and elongate those muscles and therefore the tension between the muscle and the bone in that interaction in that inter interface is reduced. So you’re making it so it’s not as tense and it’s it’s not as tense there. So then when you’re doing sports and you’re contracting those enormous muscles, they’re contracting without tearing off of where they’re attached. And that’s what a sports injury or sports hernia, sportsman’s hernia, gilmore’s hernia, core muscle injury, what all these are, it’s a tear usually between the muscle and where it attaches, which is the bone or a consequence of that tear.

Speaker 1 (11:55):

And these are usually micro tears. So it’s not a full on disruption of the muscle, it’s a micro tear. If I took an ax and I cut the guy’s leg off, that’s a full disruption. That’s not what happens. You don’t actually tear fully. It’s these micro tears within the fiber. So if you think of the muscle as clothing, like a knit sweater, this, it’s the fraying or if you think of it like a pair of jeans where you get the fraying, it’s like in style now, but the fraying of the fibers of genes are kind of what happens also to your muscle.

Speaker 1 (12:38):

You can also have tendon tears like Achilles tendon tears. You can have iliopsoas tendon tears. So it’s not always a muscle tear, but specifically for our purposes of discussion, we’re going to talk about the muscle tears. Otherwise it’s really, or an orthopedic issue when it’s a full tendon disruption or tendon tear. So the micro tears can cause pain. So if you have a micro tear of the muscle, it’s going to be painful every time you contract the muscle because it’s torn a little bit. And now you’re pulling on these torn frayed muscle edges. So that’s where you just got pain with activity. It’s not surgical, you just have to allow those micro tears to heal. That’s where we say, okay, rest rested, don’t overuse the muscle. Allow it to basically scar in that area and heal in the area for healing. So that’s where most of us say, yeah, you have a sports injury is groin strain cetera, no need for surgery. Now if you’re LeBron James or a playing in the World Cup and you have a groin strain, it’s going to affect your ability to perform at the level that you’re used to performing because if you’re in that much pain, you’re not going to be able to run as fast or jump as high and so on. And therefore for professional athletes, the treatment algorithm is very different than for the average athlete. Let’s say a high school college player or someone who plays on the weekends and so on and otherwise has a day job.

Speaker 1 (14:31):

So for people like professional athletes world Cup player, they are not told to rest because they can’t rest because they have a full game to play or the playoffs or the World Cup, et cetera. So they are artificially expedited in the healing stage. So the normal person, not professional, they just are told, rest it out, your body will heal these micro tears. It’ll go back to normal and in that process it will scar in a little bit and then you’ll do some physical therapy to break up some of that scar once it’s laid down and everything will heal itself and we’ll just work on reducing your risk of this happening again. However, for an athlete, they skip through all of that because they’re living is and their ability to function is based on their career and they are expedited straight to maximizing the healing of that rapidly, reducing the inflammation in that area.

Speaker 1 (15:45):

They often go straight to MRI the minute they get this snap or pain or whatever, they go straight to MRI to assess the problem. There’s a doctor back there that injects the area with steroids. Steroids a very strong local anti-inflammatory. They’re probably given some pills to take by mouth as well or a shot. Many of them get a shot of intramuscularly in their arm for example, of anti-inflammatories and they’re told to go right back in there and that temporarily gets rid of their pain and helps heal that area while they’re continuing to abuse and overuse that muscle. And the reason why a lot of these players get it, whether it’s soccer or football or basketball, is because many of them have inordinately large muscles and it’s not balanced with equally large muscles on the opposite side. So quads versus hamstrings, abductors versus adductors, the whole body, like I said, is a pulley system.

Speaker 1 (16:52):

So it’s very important that an athlete strengthens their muscles equally same way while your back and your front core, like I mentioned, includes your abdominal muscles and your back muscles. So if you have back issues, they will have you work on core abdominal muscle strengthening and have you do planks and sit-ups and different transverse abdominal muscle rectal rectus abdominus muscle exercises even though your issues with your back because a strong core in the front will support the back. The same is true for your thigh, strong hamstring support and balance, strong quad quadriceps tendons and vice versa. A strong abductors will help balance the abductor muscles. So if you overuse or overdevelop one part of your muscles to the detriment of the other, you’re at higher risk for injury, especially if you’re a professional athlete. And that’s sometimes what we see happens, which is why physical therapy is part of the prevention because physical therapists are well aware about this police system and this ability to this balance different muscle groups against each other.

Speaker 1 (18:13):

And in addition, physical therapists kick in once there is an injury to lengthen those muscles, work on strengthening the muscles because the stronger and more fit the patient, the faster their recovery. So that’s kind of like a general overview. The different muscles that mostly we talk about are in the groin. So they are attachments of muscles to the groin, fascia to the groin, adductor muscles to the groin, and the rectus muscles are six pack to the groin. There are other areas that where you can get sports injuries, but we tend to talk about sports injuries as like groin strains and groin holes. And one of the things that we call it commonly, it’s called athletic pubalgia, so athletic meaning of athletes and pubalgia means puba. Puba means like the pubis bone. Pubic bone means pain, so like pelvic pain, athletic pelvic pain. Oh, okay. First question, just go straight to treatment options. How do you treat a sports hernia via laparoscopic or open surgery? So first of all, most, and by most I mean more than 90% of patients who have true sports in sports hernias do not need surgery. So the first answer is I almost never have to do surgery on these patients.

Speaker 1 (19:48):

And then the question is, okay, do you do it laparoscopically or open? And I know there’s other questions coming up, so I’ll tell you, it depends. It depends the type of injury. So is it an anterior injury or posterior injury? Does it need anterior or posterior support? Does it need anterior posterior reconstruction? Are the nerves involved? And all of that will fall into the category of whether you should have an operation performed laparoscopically or bio open manner. This is a question, I’m going to come back to this question later because it’s unrelated to sports renewals. Okay, so here’s another question that was submitted with you all. Are there specific exercises that help athletes in general, especially those in high risk sports? So yes, phy, good physical. So then in general you may know that many athletes have returned to Pilates and yoga because they’ve understood that it’s not just important to build muscle, but it’s also important to elongate those muscles.

Speaker 1 (20:59):

Palates is a fantastic way to elongate muscles and reduce injury. When it goes to a physical therapist, much of what they do for you is based on Pilates type methods. Yoga is kind of more difficult I think to adopt for everyone. You need to a little bit more limber with yoga and if you’re not, you can injure yourself. So be careful with yoga. I’m not limber, which is why I, I’m a big fan of Pilates, but palates and physical therapy. So part of the preventative prevention of sports injuries, sports hernias is to strengthen muscles and prevent them to be at risk for tear. And then the other part is to help elongate it and then there’s a whole balance. So the strengthening is also strengthening of anterior and posterior muscles for example.

Speaker 1 (22:09):

Are there any kinds of exercises that can reduce lifetime risk of getting an ingal hernia? So this is specifically about inguinal hernia as opposed to sports hernias. So we believe that all exercises are good and help reduce risk of inguinal hernia and ventral hernias because it maintains your weight. We know obesity as we discussed last week, obesity is a high risk factor for any hernia. Exercise helps maintain your muscle strength and we know that the stronger and more fit the patient, the less likely that they will get injuries and if they do get injuries the faster they will recover. And we also know that in general, from an inguinal hernia standpoint, we don’t see athletes get hernias. If you look at patients who are regular exercises versus those who are not. All the studies show both in men and in women actually, that those who perform some sort of exercise on a daily basis are significantly less likely to have a hernia or present with a hernia than those that do not.

Speaker 1 (23:27):

So any type of muscle strengthening and exercise in general is considered healthy and safe for hernias and potentially protective of hernias. However, we do know from an old study, I think from 2000 and I want to say 2006, that where they took medical students and they measured their abdominal pressure as they were doing different exercises and they found that the exercise that we thought were bad were actually totally fine. So sit-ups, planks, weightlifting, deadlifts, overhead lifts, pull-ups, those all involved engagement of the abdominal muscles and did not increase abdominal pressure and therefore we felt they did not increase risk of any hernias, especially inguinal hernias. However, two specific exercises, one was jumping and the other one was squats. Those did cause a significant increase in abdominal pressure and usually when I talk to patients, especially if I feel like they will be doing jumping or squats or they like CrossFit, let’s say, I do tell them to look for different ways of doing similar exercises.

Speaker 1 (24:40):

So if you’re thinking of doing, let’s say squats because you’re looking on improving your kind of gluteal muscles, there are other ways of working on the glutes without doing squats, especially if you’re prone to hernias or you’re worried about hernias or you have hernia. So those, that’s where it is, I’m really excited. In the next year or two we should have new data, especially out of Europe where they have specifically gone through even wider range of exercises with much more detail and are measuring abdominal pressures and hopefully we’ll have a little bit more clarity as to what exercises are good and what are not in terms of prevention for hernias. So I hope that that was a kind of long, long answer for a short question, what physical activities should be limited if you want to minimize your risk of a sport hernia? Okay, so now we’re talking about sports hernia specifically not inguinal hernia.

Speaker 1 (25:41):

The activities that minimize rapid movements, twisting movements, kicking in particular, explosive motions, cutting, we often call it cutting. Those activities, put the most strain on the interaction between the muscle and the bone and therefore give you the highest risk of having some type of groin disruption. I would say that my recommendation is if you’re really wanting to prevent it, do low impact exercises that could include cycling or swimming. Those are really, really great and very, very low risk of having any growing disruption in terms of sports, at least given that sports hernias mostly current athletes who have good tissue quality, why do they not always heal on their own? Great question, especially with rest physical therapy and conservative Mesh me measures. Great question. So it alludes to the fact that a lot of these athletes with good tissue quality, first of all, no one knows that they actually have good tissue quality, they have strong, they have developed muscles, but one of the collagen within those tissues is normal.

Speaker 1 (27:08):

We don’t know that has to do with your family history. Some athletes are very, some athletes are very hyperflexible, that’s not really good for sports. You want to have very stable joints. So I assume maybe some of them actually don’t end up doing a lot of sports because they’re hyper flexible. Many are hyper flexible at the joints, which implies a collagen kind of mismatch and disruption disorder and once they they’re stronger, then they’re actually less flexible and that’s good because they’ll probably be normal. And I just had a patient last week, no this week, excuse me, so she was a marathon runner, but she said when she was younger she had very floppy hips and knees so she would sit down, I dunno how to explain it, but with the kind of knees in, but the legs out and the hips in inwardly rotated when she was a kid, but then she started running and that’s strength of the hip girdle and the muscles and joints and ligaments around the joints in her knee and she became less flexible. I would say less hyper flexible and more normal flexible.

Speaker 1 (28:28):

So that’s one thing. Live question. I have surgery last week. Oh you had surgery last week. Okay, great. Open surgery, right? Inguinal hernia. Great, can I come back in ball sports? So ball sports depends on the ball sport and depends on the surgeon you had. So obviously I would defer to your surgeon because you’re fresh after surgery because they know what kind of hernia you had and what type of repair that was performed and what your kind of lifestyle and risk factors are. However, in general, if you’ve had a laparoscopic repair, I usually don’t restrict any sports after surgery. I’ve had patients that cycle 50 miles the next day they travel, they run, they played volleyball, so I’m totally okay with that. Open repair with Mesh if it was not a huge hernia and you’re not worried that there may be a disruption and there’s like a less overlap of Mesh with tissues also most likely do not need to have any restrictions and can go ahead and start playing ball in the average risk.

Speaker 1 (29:45):

Patient tissue repair is different story with a tissue repair, you do not have the benefit of Mesh buttressing your tissue repair and you’re a hundred percent dependent on your tissue strength and quality and the surgeon’s technique to heal. Whereas with Mesh you kind of don’t. The Mesh takes over a lot of that. So you can have poor technique, poor tissues, and still do well with Mesh, not so with tissue repair. So if you’ve had a tissue repair with no Mesh, then in most of my patients I give you at least two weeks of just walking. You can cycle, but I would not do anything that has a risk of disrupting the groin or adding pressure in the area the same way. I don’t want you coughing and sneezing and so on. All right, here’s another question. Is numbness four months after an opening hernia pair with Mesh normal? Yes. My surgeon said it can last a while, yes, it can last over a year. I’m wondering if it will ever go away. It may or may not go away. Most early numbness after any hernia, any surgery I would say is related to the swelling in the area from the actual surgery. So if you have any swelling in that region compared to the rest of your body and your numb, much of the numbness is related directly to the swelling. If there was any nerve cut that would be a permanent numbing of the skin.

Speaker 1 (31:24):

And cutting the skin does cause numbness, right where you cut the skin. But those all go away after many years and you should kind of regain your sensation in the area from those specific ones. The surgery seems to have gone well otherwise great, and I’m exercising again and feeling better and losing some weight too. Perfect, which I need to do. Excellent. We talked about this last week. How important is to actually lose the weight before the surgery? Not after, but anything is good. The numbness is a few inches below the incision site right at the top of my groin, at the top of my leg and bottom of my groin. Yeah, that’s fine. That’s probably from swelling from the surgery because we are are, how should I explain this, upright human beings then any surgery you have will have swelling, but the swelling will be pulled down by gravity. So since you’re upright you’re going to have swelling a little bit lower than your incision just because any of the fluid eventually will gather down towards the groin area.

Speaker 1 (32:37):

All right, next question. Can you safely suture muscle as some surgeons do in their sport, turning operations going against surgical dogma? So the muscle that’s sewn is often the tendon part tendon is part of the muscle or it’s scarred muscle, so normal muscle is not easily sewn. You kind of need to either sew it because it’s scarred or you sew it in the tenderness portion of the muscle. You’re right, muscle itself does. It’s like filet mignon. It’s very delicate. Given how close the superficial ring is to the pubic bone, can the symptoms of sports hernia overlap with standard al hernia? Yes and no. Often no because the type of pain and the way it radiates and the fact that a hernia actually has a hole, whereas a sports hernia, hernia technically is not a hernia, does not have a hole. All of those make it so that sports hernias are often painful with engagement of the abdominal wall, twisting of the abdominal wall.

Speaker 1 (33:51):

Whereas inguinal hernias are not only painful with activity, but more so with any increase in abdominal pressure such as a cough or bending. So it’s actually the pubic one is not very close to the superficial internal to the, it is not close to the internal ring. That is not an accurate statement fairly far away. And so you should be able to differentiate in most patients the difference between an actual AL hernia and a sports hernia. All right. Hope that was well answered for you. Next question. Can four attorney be present with only subtle signs on the MRI i e not overt signs? So yes, it depends on the degree of injury. If you have a massive injury which is limiting you in the ability to function, that should be identifiable on MRI as swelling in the area, fluid collection edema and in the acute phase and the chronic phase of scarring in the region.

Speaker 1 (35:00):

However, in patients that just have a small strain where let’s say they were playing baseball or soccer because now it’s cool to play soccer because everyone’s watching World Cup, all right, I’m now 45 years old and I’m going to go play soccer and I haven’t been playing sports for a while and I’m not going to stretch. And you get a sport growing strain, something like that most likely will not show up on an MRI because it’s a much more lower grade strain. It’s truly a tear that’s not extensive. Your muscle’s probably not huge and therefore the distribution of the amount of injury will not be much and simple rest and anti-inflammatories alone should be adequate to address that without need for imaging. Can you describe the differences between Gilmore groin and athletic pubalgia? Okay, it’s basically the same thing. So Gilmore groin is very specifically, very specifically a disruption in the groin or inguinal floor. So as opposed to athletic pubalgia, which can be interpreted as many things and it can include Dr tendonitis and rectus abdominus tears as well as tears in the groin. My understanding is when people talk about Gilmore Groin A, they’re usually British. Dr. Jerry Gilmore was a British surgeon that figured this out in many soccer players at the time, I think in the 1980s. We don’t usually use the term Gilmore groin as much in the United States.

Speaker 1 (36:53):

And then usually when people are talking about Gilmore groin, they’re talking about the actual groin. So I think there’s going to be a question coming up which will help here it is, when do sport attorneys require surgery? So we talked about the algorithm, which is rest, anti-inflammatories, ice packs, Advil, ale, ibuprofen and so on. And then activity, which includes walking, low risk, low impact activities, things that don’t overdo the area because you don’t want the scar to then contract everything. And then if that works, great, if it doesn’t, then you’re going to need to do some injections into the area for pain control and to reduce swelling. If that doesn’t work, then you do more injections and consider adding what’s called P R P, which is a plasma ridge protein, which you basically take your own blood and spin it down into a rich concentration of proteins and then re-inject that into the space to encourage healing in the area.

Speaker 1 (38:04):

And then if that still doesn’t work and the patient’s debilitated, then they do surgery. And the surgery needs to be very, very specifically tailored to the patient’s need. So an Inguinal hernia pair is not going to fix a sport hernia because there’s no hernia adding Mesh isn’t necessarily going to address any sports tear because often Mesh adds more inflammation and there’s no need for that kind of support or addition of something that doesn’t stretch similar to the bone, unlike muscle and something that can potentially add injury. So the type of surgery has to be very specifically tailored to the need of the patient, the type of injury that was done. And then the more of the questions, I think it’s coming up, let’s see, or maybe I answered it already.

Speaker 1 (39:01):

Here it is. How do treatment options defer, defer, differ based on the type of injury? So let’s only talk about surgical options because I already reviewed the algorithm before surgery and I also mentioned to you over 90% of patients do not need surgery. So let’s say you down to the need for surgery, let’s figure out what the problem is. So if I do laparoscopic, if I think it’s a hernia, like an actual hernia that I do hernia surgery and that’s often done laparoscopically with Mesh for these big burly patients and they do very, very well. But if I had a ballerina or someone’s smaller build, I’m not going to do laparoscopic with Mesh, I would do a tissue repair. However, it’s possible that patients don’t have hernias or they have a, let’s say they do have a hernia because that’s common, but what they actually have is a tear and that tear is best addressed open and not laparoscopic.

Speaker 1 (40:04):

Why when you do laparoscopic surgery, you’re attacking everything from behind the muscle. You don’t see the nerves, you don’t see any tears, it’s behind the muscle, the tear and the nerves are all in front of the muscle where the fascia is. So that needs open surgery. So you cut right over the groin area, couple like a finger breath or tube above your groin crease and you examine the fascia and the fascia may have a tear in it and you have to close that tear. That does not need me Mesh, usually you just, it’s like a tear.

Speaker 1 (40:40):

Let’s see if you had a tear in your jacket or something, it’s just like a linear tear, like a fabric tear. So that can be part of the cause of the pain. You just close those with suture. There’s a nerve, the ilio inguinal nerve that runs right underneath that tear commonly. And many of these patients have nerve pain. I am not a fan of cutting that nerve. I know some people go in and just permanently cut that nerve because they feel that the nerve’s been injured over time and therefore kind of deserves to be just cut so that the patient is not left with chronic pain. I understand that me nerves can regenerate and in the right patient, I prefer not to cut the nerve but instead repair the tear above to prevent the nerve from getting caught in this tear and reproducing this nerve pain and leave the nerve alone.

Speaker 1 (41:39):

And I often put an anti-adhesive to reduce the risk of any scar tissue from involving the nerve further and may even inject some steroids in the area to help improve the health of the nerve as it’s trying to heal. And here’s a question. Can a patient have both a hernia and a sports? Yes. So this is the common scenario. It is much more common to have a true hernia, an Inguinal hernia than to have a sports injury or a sports hernia. Especially if you’re non-athlete, you’re not going to get a sports hernia. I have patients out there who you are, are definitely not athletes and they’ve been labeled as having a sports hernia and yet what they have is an actual hernia. But let’s say you are an athlete and you did truly have a sports injury, you can also have a hernia. So you get imaging let’s say, and they’re like, oh, here’s your hernia.

Speaker 1 (42:35):

Some surgeons will just be all focus on the hernia because that’s their, that’s easy for them to repair and forget that they need to actually address the patient’s symptoms which are not from the hernia but are from the sports injury. So the sports tear, so for example, I have seen people that have hernias, but they have a true tear, like I mentioned earlier, it’s the external oblique AP neurosis tear with the nerve exposed underneath it. That tear can only be addressed open, but they have a hernias, they’re like, oh, we’ll do this laparoscopically or nowadays robotically and they fixed a hernia and their symptoms are not better. Why? Because they miss the fact that there’s a sports injury and sports hernia that needs to be addressed. Are you curious what it looks like in there when you operate an athlete? I’ll tell you, I’ve operated on N F L, I’ve done N H L N B A now I’ve operated on several actual professional figure skaters.

Speaker 1 (43:41):

So these people are constantly pulling and tearing and damaging their body everywhere, all their joints, all their ligaments or other muscles they’re being, they’re falling, they’re jumping, they’re crashing into each other, they’re doing splits, they’re they’re cutting in and out, they’re inflamed and all that inflammation from their injury scars. So you go inside some of these patients laparoscopically and their tissue is not normal. There is so much scar tissue where there shouldn’t be right behind the muscles and involving so much stuff that I physically removed some of that scars as part of their surgically addressing their pelvic pain. And it helps a lot, but it is impressive how much scar tissue there is in the abdominal wall and the peritoneum in the interaction between those two and against the bone. Some of these athletes have such huge amount of muscles and they damage it so much. The muscle’s constantly pulling at its attachment to the bone and you get these pics of bone kind of like teeth that are growing and inflamed. It’s painful. It’s quite impressive I must say.

Speaker 1 (45:07):

Have you ever seen non-athlete develop sports hernia? No. From a gluteal bridge? No. And if you have had you treat it, it doesn’t happen. I just want to tell you that out there, it’s just not a thing. Let’s see. How much does your risk of getting a true al hernia increase if you’ve had a sportsman’s hernia? That’s a good question. I don’t know. I would have to do some research to see if anyone’s actually done a correlation of all the sports hernias they’ve seen and then how many of those patients also had ankle hernias. Because we do know that people who are athletic tend to are less likely to have natural hernias.

Speaker 1 (45:58):

But genetically, if you’re predisposed to it, you’re probably and you’re athletic, you’re probably delaying your presentation of a hernia. But as far as we know, those two are not related. Inguinal hernias are truly a collagen disorder. They’re genetic in nature. Sportsman hernias are due to trauma and tension and disparities in muscle strength and are not really related to collagen. So I’m going to say no, there is no risk of getting a true hernia, no increased risk of having had getting a hernia. If you’ve had a sports on hernia, I’m going to stand by that and if anyone has any that support, I would love to see it. How do you minimize the risk of recurrence when treating a sportsman’s hernia? Great question. So let’s see. The problem with a sportsman hernia is once you’ve torn it, you’re likely to tear it. Again. It’s the same with if you have a jacket that’s torn and you fix it, the chance of it falling apart at the right area, same area is the same with jeans.

Speaker 1 (47:13):

Wherever it tears, that’s the beginning of a tear, continue to tear at that area. So in order to minimize the risk of recurrence, you have to stretch a lot, do a lot of muscle lengthening procedures and really work with your therapist to balance out your muscles so that you don’t have disparities in pulling within that system, that pulley system. Have you ever had to remove sutures in the periosteum? Yes. Say from a lichtenstein repair that was attached to the pubic period? Yes. That’s part of the, if you need to do any type of Mesh removal or suture removal, yes. So we do that commonly as part of an open Mesh removal or suture removal procedure. How do you decide when to use Mesh and treating sports hernias? Good question. I almost never used Mesh for sports hernias. I don’t feel so lemme rephrase that. Synthetic Mesh every so often there are patients, I had a soccer player from, I think he was from Romania, he’s Romania, he had a true al hernia, but he also had a sportsman’s hernia.

Speaker 1 (48:38):

So I had to address both because he had a good, he needed a tissue tissue repair. But I didn’t want, let me rephrase this. I wanted to give him a tissue repair because he’s an athlete but because he was a soccer player, he was at risk of disrupting a tissue repair for the hernia part because he already had a sports injury in that area that needed to be closed. So I used kind of biologic Mesh in there. So he did get a tissue repair, but I used the biologic Mesh to buttress actually hybrid Mesh to buttress that repair for a year until he’s better healed. So that kind of helped. Okay. So let’s see. Any more questions? Can Mesh use affect an athlete’s long-term performance? Not necessarily. So I’ve operated on several N B A players because I love basketball, so I love my basketball players and I understand them and they’ve all had Mesh placed and the purpose of the Mesh was to allow them to get a very quick recovery, go back to playing and so on.

Speaker 1 (49:51):

And these are people that have won multiple B NBA the playoffs, they’re one of the NBA playoffs, so in all-star games and they’ve been in the Olympics. So it does not, if you do it correctly, you you’ve picked the right Mesh and the right procedure. It should not affect a typical high-end, high impact athlete for low impact like a ballerina. I do not use Mesh in them because they need to remain limber, whereas that limberness is not necessarily part of like let’s say a basketball football player’s world. That said, if you’ve read any news, there have been a handful of very prominent athletes whose careers have been ended because they had complications with Mesh placement in their groin. These patients all had, as far as I know, open repair with Mesh. I would not offer open repair with Mesh for to a professional athlete. I think the risk of exactly that happening is too high.

Speaker 1 (51:04):

Our are orthopedic surgeons ever involved in treating sports hernias? Yes, they are. Depends on your surgeons. So if you need an abductor tendon release or an Ilio psoas release or a psoaa lengthening procedure, any of these things that are in involving truly orthopedic operations, I usually operate with an orthopedic surgeon and I do not like to do those myself. There are certain surgeons that are not orthopedic surgeons that are okay dabbling in doing adductor tendon releases. I don’t do that because I feel the orthopedic surgeons know much more. They’re training about it than I do. There are certain institutes that are really, really good and are very involved. We’ve had at least one of the surgeons from the Vincera Institute, Dr. Alexander Poor, to go back to the prior sessions we had. We’ve had to listen to that where that’s almost all they do is related to growing disruptions and core muscle injuries and athletic pubalgia.

Speaker 1 (52:09):

And they do work with orthopedic surgeons, but a lot of the operations they do themselves as well. So it depends on the situation. I like to collaborate, I like to learn from orthopedic doctors, so I like to work with them together. Have you ever removed just a periosteal suture if it was identified as a cause of pain and not the Mesh following a latency and repair? So yes, I have done that and in some situations with the Lichtenstein hernia procedure, excuse me, with regard the Lichtenstein procedure, there are specifically a single knot or suture that’s causing the pain and you just go in there and just remove that one offending one and it can, the could be periosteal suture.

Speaker 1 (53:05):

When and why is the ileal nerve cut when repairing a sports hernia? So I don’t know why, actually maybe I do know why. I think the thought is if there’s Neuralgia and nerve pain then kind of the nerve will get rid of the nerve pain even if it’s not the nerve problem because a nerve is injured by being irritated by a, let’s say peritoneal, not peritoneal external oblique tear or something. I kind of discussed this earlier, but I think since nerves can self-repair over time, the more you can push them to self-repair, the better the option than to cut the nerve. So I’m not a big fan of cutting nerves, that’s just kind of my thing. Do you believe it’s sometimes necessary to at attach the pubic plate back to the pubic bone and if so, can it be done with sutures, with anchors? So it depends on the situation.

Speaker 1 (54:02):

If there truly is a disruption of the ligament to the pubic bone, yes you have to kind of bring that as part of reconstruction of the whole inguinal canal. But if this is a hernia repair, that’s a different story. And again, if you’re not an athlete, you’re not going to have athletic pubalgia. And that my friends, is the end of December, 2022. Oh my god. So everyone please take next week off, have a Merry Christmas. Those of you that start Hanukkah on Sunday, happy Hanukkah to all. You all have a very merry Christmas. I can’t wait to start 2023 with you all. It’s going to be a great, great new year. I love that you guys are so supportive of this platform, both on hernia talk.com and my weekly Hernia Talk Live sessions. I love you all. Have a great rest of your end of your year. Wishing everyone a much better 2023 than any all prior years. And please go to my YouTube channel at hernia doc to watch the rest of this and all future all prior sessions. I really, really appreciate you and will help to see you next year. Thanks everyone.