Episode 18: Evaluating Chronic Groin Pain | Hernia Talk Live Q&A

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Speaker 1 (00:00:01):

All right everyone. We are live on Hernia Talk. It’s another Tuesday with Dr. Towfigh. As many of you know I am a general surgeon who really enjoys the evaluation treatment of hernias and hernia related complications. You could follow me at Hernia Doc on Twitter and Instagram. This is also live on Facebook currently, and you can follow me on my YouTube channel where I will post this at the end of the session. Today we have our amazing how do I explain this? I feel like he’s my partner on the other side of United States in New York. Dr. Mark Zoland. He works at Core Surgical in New York. You can follow him on Facebook at, oh, sorry at G L S N Y L L P, which I believe used to stand for general laparoscopic surgery of New York LLP. And without further ado, welcome Dr. Zoland.

Speaker 2 (00:01:03):

Great to be here and honored to be here.

Speaker 1 (00:01:08):

So for those you don’t know, we kind of talk a little bit beforehand. This is the first time I’ve actually met Dr. Zoland, but we have shared scores of patients mostly because they go to East Coast and West Coast looking for specialists and they see other doctors. But I’ve shared a lot of patients with Dr. Zoland and I know him. He stood out for me because of most of the surgeons that these patients go to visit. I agree with Dr. Zen’s assessment more than any of the other doctors. I feel like everything that I would say and interpret, like you would say or you have said when they’ve seen you. So it’s really an honor and pleasure to finally meet you, even though it’s virtual. And I can’t believe that we’re both in the same field that we’ve never physically met before after all these years. Yeah, I’m not young. I’ve been around for a while, so I don’t know why we haven’t met before.

Speaker 2 (00:02:07):

Yeah, no, we definitely overlap on quite a bit.

Speaker 1 (00:02:10):

Yes. So Dr. Zen’s practice is in New York. Are you in New York City actually? New York City,

Speaker 2 (00:02:17):

Yeah. I’m on the upper east side of New York City on 58th Street.

Speaker 1 (00:02:20):

That’s a nice place.

Speaker 2 (00:02:22):


Speaker 1 (00:02:23):

I mean, Beverly Hills is nice. It’s

Speaker 2 (00:02:25):

Been there for a long time.

Speaker 1 (00:02:26):

We’re twins in many ways. So Dr. Zoland, you were a board certified general surgeon, is that correct? You’re general certified? Certified training? Yeah, just like me. And then just briefly, how did you get involved in this niche or do you also do other general surgical procedures as part of your practice?

Speaker 2 (00:02:47):

Right. So I mean, I was a bread and butter general surgeon for a long time and I just found that the growing anatomy was wildly complicated and very poorly taught. And ultimately, I was tasked to teach the residents the groin anatomy. And we started working with cadavers and understanding it, and we started using MRI technology to really take a better look at it because I think from the radiology point of view and from the general surgical point of view it was just a very difficult area. Very probably the best way to describe it is just a poorly understood area. I don’t think we have a perfect understanding even now, but I do think we’re getting much, much better at it. And it just became a little bit of a passion, perhaps an obsession. And then I went into specifically groin pain, sports hernias, a cold hernias, pelvic floor pain because it just seemed like there was a need for it along with my obsession. So they went hand in hand.

Speaker 1 (00:04:02):

I think it takes a special person to get into this field because it is complicated, but at the same time, underappreciated. When you were a resident, did you want to be a hernia specialist?

Speaker 2 (00:04:15):

No, I wanted to be big cases, right, the big cases. But yeah, yeah, no, it destroys people’s lives. It makes people miserable and it’s just not very well received or understood. So it clearly was something that needed to be addressed. And I think it, it’s just certainly been fulfilling for me. It’s hard. It’s hard. I mean, I think you know, get a lot of success sometimes, but you also get failure. And for big head of general surgeons that we all are people don’t like failure and you have to keep going. And I definitely think that that’s a part of why so few people really delve into this so deeply.

Speaker 1 (00:05:09):

We had a couple of sessions in the past on Hernia Talk where we talked about the need for specialists in this field because there’s so many that have recurrences or chronic pain or undiagnosed groin pain that are kind of lost in the kind of general surgery world. And pain doctors don’t really understand what we do, and the gynecologists don’t really know much about groin pain outside of the ovaries and the uterus and some endometriosis. And so we overlap with urology and gynecology and orthopedic surgery, pain meds, pain management, physical therapy. We overlap with so many specialties, but in the typical residency does not expose you to any of that at the best you get to know how to do a Mesh based open or a laparoscopic repair. I mean, talking for myself, I for sure did not want to be a hernia specialist. That was, I think at my first job was at USC and they took me out to a lunch and they said, if you were to do one case for the rest of your life, what would that be? And I said, oh, I would do the Whipple. That’s like the god of all operations. And I was really good at it. I think I still hold the record at UCLA for the most number of Whipples done by graduating resident. So that was really cool. They said, yeah, you’re not going to be doing any of that.

Speaker 1 (00:06:42):

How about gallbladders and hernias? Do you think that’s something you would want to do for the rest of your life? Right. So I learned to love it. But yeah, I think we’re missing. Do you think we need more hernia specialists? Should that be something that should be, I mean, I’m sure your residents, and I know my residents enjoy it, but they still don’t go into it. My fellows do. Almost every fellow we’ve had in the past several years has come to our program because they want to do abdominal wall hernia, chronic pain. They’ve gone back to major institutions academic to start their own hernia center. So that’s been good. But I don’t know, I feel like other, there’s enough of us to teach.

Speaker 2 (00:07:31):

I think that it’s a little bit of a catch 22 very few practices would want somebody so specialized in this area alone because they need the general surgeons to cover the call and to cover the emergencies. So I don’t think necessarily that we need to produce more people that are so highly specialized. I do think we need to train them better. I do think we need to have a broader and better understanding of what the problems are so that the residents can start from the beginning understanding that this is more than just a first year level case and that the diagnostic component of this, which is eminently far more important than the actual surgical component. I mean, yes, we have to be good surgeons, there’s no question about that, but most of the surgeons that are being trained are good surgeons. So it’s really more about judgment.

Speaker 2 (00:08:29):

It’s about how you make the diagnosis, it’s about thinking about the algorithms. And for me, most importantly, it’s the relationship with people that are really interested in these difficult problems. I think pelvic floor physical therapists to me, are dear to my heart because they go deep with this. I think the pelvic floor physiatrists, I think my overlap with groin pain goes deep with the hip surgeons. So as long as you have this group of people around you that go as deep as you try to do, and then you need your specialists in terms of radiologists who care about this, who are not just looking to get through the read and spend as little time doing it and get to the next one and the next one and the next one, and they’re not really looking for the subtle abnormalities, you need to find those people that really care about getting it right. And quite frankly, I’m sure you do this too. You train them, you train them, you were trained, and you really work on finding yourself a group of people around you who see it the way you do.

Speaker 1 (00:09:40):

Yeah, I totally agree. We were talking earlier, and I hundred percent agree with your impression that even though we’re surgeons and everyone thinks all we do is operate, the history is absolutely what triggers like my algorithm for what diagnosis I’m going to go after and what the treatment protocol is. And I feel that a lot of what we do, if the patient had an obvious hernia, for example, on exam, then your average general surgeon would diagnose that and treat it. We don’t get that. But what we do get is a story that then will lead us towards either hernia or hip labral tear or pelvic floor dysfunction or endometriosis or something that explains the patient’s groin pain. How much of your practice is related to that gen like groin or hernia related?

Speaker 2 (00:10:41):

My whole practice, this is all hundred percent.

Speaker 1 (00:10:43):


Speaker 2 (00:10:44):

Me too. So it, it’s become busy enough and certainly the need for somebody who really goes deep in this is out there. And I do feel bad many times that I get calls from people in different states and they ask me, do I know somebody that would be able to take care of this like we do? And oftentimes I don’t have a name for them and they end up flying out to you or they fly into me, which stings because there should be somebody that does do this. And quite frankly, that doesn’t mean that there isn’t somebody. What I’ll often counsel patients to do in different states is really do their homework with the surgeons that are around them. And what I’ll even do sometimes is I’ll try to vet those surgeons for them to see which ones seem like they would be the type of surgeon that would go deep on the things that we’re talking about. Yeah,

Speaker 1 (00:11:38):


Speaker 2 (00:11:38):

Agree. But unfortunately, a lot of people do end up having to travel to come and see us, and I love to take care of these patients. I think it’s an honor and a privilege, but it would be nice to keep them at home, to get them to see the people.

Speaker 1 (00:11:53):

What do you offer the out-of-state patients? How does your office handle those?

Speaker 2 (00:11:59):

So oftentimes they’ll call and they’ll ask if there’s anybody near them. And if we don’t have somebody, we have them send the images if we can take a look for them. I wonder if you do that, do you take a look at just for people? Yeah, a lot. A lot, yeah. And I think that that’s the best that we can do. I, I think that if people, so my feeling and what I tell patients is if you think you have something going on, and this is really important, and you’ve seen many doctors who tell you that you don’t keep going to a different doctor, the simple fact is a lot of doctors don’t know the answers and we don’t know the answers. We don’t always sure know the answers. And most certainly, we’re not always right. And most certainly, we may find hernias that are not the source of your pain. So at the end of the day, we’re all just trying to find the truth. Nobody’s doing anything on purpose wrong, but if you almost feel like that you have something wrong in your body and you keep running into that wall, search outside the circle, expand the circle as he needs. And the internet has been fantastic for that. And I think that has also led us expand our ability to train people who are outside of our circles to look for these things a lot more than they had in the past.

Speaker 1 (00:13:30):

I what’s called a online consultation. So they basically, it’s purely by email and mail. So the patients send me all of their history reports, whatever they need. We have a questionnaire they fill out and they send me every single CD of their images, and I review that and I write up something for them, and they’re free to take that write up to their local doctor to see if they’re willing to get that care that I recommend closer to home, or they may choose to come see me afterwards because they haven’t been able to get anyone else to take over their care. But that’s been really helpful because there’s so many people that they’re willing to travel if they know they’re going to get help, but then it would suck if they come to me and I’ll be like, oh no, you have a hip problem. <laugh>, right? They can do that. They should be able to do some of that virtually. And now with COVID, virtual consultations have really uptick. So yeah, that’s been I think very helpful too for people out of state.

Speaker 2 (00:14:36):

And to that point, I really think that getting the imaging, looking at the imaging before dragging the patient out to see me is important because like you said, it would suck to have somebody come all the way out just to find out that either they don’t have a hernia or

Speaker 1 (00:14:56):

I would feel bad.

Speaker 2 (00:14:57):

Yeah, yeah, absolutely. Yeah. So I think you and I are very much on the same page though.

Speaker 1 (00:15:02):

So you bring up imaging as you know. That’s my thing. I love reviewing imaging. I find it like a puzzle solving. I really enjoy the process. I’m like an artist at heart. So I kind of like that 3D visual as well. And I’ve learned a lot. I believe you are the same. You’ve the patients that we’ve shared, I’ve noticed you have interpreted imaging similar to how I had interpreted it. You kind of validate me <laugh> in some ways. But you’ve also noticed how unfortunately the majority of imaging done for this subset of patients, small al hernias, et cetera, are misread. I think our study was something like three out of four misread. They either say there’s no hernia when there is one, or they don’t even mention whether there is or they just never looked for it. Yeah. So that’s like your pet peeve too, I think.

Speaker 2 (00:16:02):

Yeah, no question. And I think again, it it’s not because anybody’s trying to do anything on purpose or any particular radiologist is bad versus good it, it’s about their training, it’s about the definition. And in one of my lectures for the endometriosis summit one of the big points was that the definition of a hernia for radiologist might actually be different than the definition of a hernia for us. Yes radiologists are often trained that if you don’t see bowel or you don’t see a huge bit of fat going into the opening, that they’re not going to call a hernia. And yet, as I’m sure you’ve talked about this before, a small piece of fat going into the opening can actually cause more pain than a large one. So exactly. If they’re not going to call fat going into these openings, and the openings that we see most commonly of course are the inguinal femoral and obturator canal openings.

Speaker 2 (00:17:05):

You’re not going to get hernia diagnoses when indeed these are hernias. And what I try to explain to the radiologist is it’s not what is going into the opening is that the opening exists in and of itself because it doesn’t matter what goes into the opening, anything going into the opening can impinge upon the nerves and can cause pain. Yes. So at the end of the day, it becomes a definitional problem. And I’m sure you on your end and me on my own end are trying to change the definition. It’s hard. It’s swimming against the tide. Yes. And even earlier today, I was speaking to somebody who’s a terrific radiologist, but he was really having trouble agreeing with me that it was an actual hernia. So I said, listen, don’t say hernia, but say that something is abnormal. If you don’t abnormal,

Speaker 1 (00:17:53):

Explain when you

Speaker 2 (00:17:54):

See it, right? Mm-hmm. Exactly. Explain what you see, because if you don’t mention it, then people walk around with a piece of paper saying no hernia scene. And every single doctor after that who does not look at the imaging is going to say, well, you don’t have a hernia, obviously, move on to the next possibility when that was the possibility that was missed.

Speaker 1 (00:18:14):

So I had a recent one too, a couple weeks ago. I operated on a patient, very rare internal hernia. It’s not a abdominal wall hernia, but I like to solve mysteries. So sometimes they come to me with, why do you think I have this pain? And the imaging was pretty classic for exactly this perineal hernia. And I operated on the patient, he’s cured, but for five years, young guy, five years, he had this unrelenting pain starting to lose weight, et cetera. And I emailed the radiologist, I found their email, I emailed them and said, oh, just by the way, back in 2000 and something or other, when you read this email, I just want to let you know I operate on him. And the imaging is definitely consistent with that. And my hope is always, thank you so much. Oh, I really appreciate, you’re absolutely right.

Speaker 1 (00:19:07):

Or yeah, in retrospect you’re something, but more often it’s like, oh, well it’s based on your interpretation or these are hard to identify, and it’s a little bit defensive. And same with doctors. I’ve always thought that if I operate on a let’s say a recurrence or a meshoma or something and I saw something clearly wrong, I should reach out to the doctor. I did that early in my career and I didn’t have a single doctor that said thank you. It was mostly like pissy and I was a bad person and I was questioning something they did wrong, and so I stopped doing it, but I feel guilty that I’m not giving feedback to people to change their treatment. Do you feel that way?

Speaker 2 (00:20:03):


Speaker 1 (00:20:04):

Feel really bad about it,

Speaker 2 (00:20:05):

But I do.

Speaker 1 (00:20:06):

I keep getting hit back.

Speaker 2 (00:20:08):

I just keep going forward with it. I try not to take it personally. I try not to make it personal. I think for me it’s just about the accuracy and the truth of it. And if they get it wrong, I’d like them to know that they got it wrong. So hopefully they’re going to be the one out of three that actually takes it to heart and says, oh, I understand what you’re saying, but that’s the best we can do, I think. And it promotes a lot of anger with the patients if something was missed. But again, the patients also have to understand that it’s a definitional problem. It’s not any one personal radiologist. So going back to the point of your papers, I mean, that’s the start. Getting the papers out there, getting the permission out there learning as much about this as possible it’s the most that we can do. And training the residents, I think that’s a big deal. I think we both try to do that and it just has to widen a circle.

Speaker 1 (00:21:09):

Yeah, I agree. Okay, let’s get to some questions. We’ll start with a fun one. I don’t know if you’re an NBA fan, but what happened to LeBron James? Do we know which his groin injury,

Speaker 2 (00:21:24):

I don’t

Speaker 1 (00:21:24):

Know, kept him from so many games and he’s still hurting?

Speaker 2 (00:21:30):

I don’t know. And if I did know, I probably wouldn’t be saying here, but I do not know the answer to that one particular question.

Speaker 1 (00:21:40):

I mean, he’s part of my city. I just wanted to come over and at least get ruled out for Nicole hernia because that’s treatable growing. A true sports hernia or athletic pub biologist is very difficult to heal from, but a hernia you can just fix.

Speaker 2 (00:21:58):

Yeah. Well, the sports hernia can be fixed too. The issue with the sports hernia is that, I mean, first of all, it’s a misnomer. It’s a bad name, but yes it has under, its heading several different injury patterns that we see. And unfortunately sometimes, and this goes along with growing pain in general, sometimes what we see is the injury pattern isn’t the reason why the patient is having pain or the player is having pain. And then the other part of this is that the depth of the injury sometimes is misunderstood by the surgeon. And I’m not above this it, it’s happened to all of us that we might think it’s what we call an inguinal floor disruption or Gilmore’s Groin, but it ends up being more of an athletic pubalgia problem where you have an attachment to the pubic issue or it even goes deeper than that.

Speaker 2 (00:22:58):

That entire plate can be up and off the bone and you can actually have a fibrocartilage disruption of the abductor. So at the end of the day, what ends up being really important with the player is the history, the mechanism of injury, and the right type of MRI because this really, really helps at least me distinguish one injury from the other. And I think therein lies sometimes why you have some of the players healing and some of them not as well, because if you treat each of them as the same carbon copy problem, you know, don’t always end up with as good a result as you should. And I don’t want this to sound like I know more than all the other people. I do not. I just think we all need to be very careful when it comes to these neurotic play sports hernia, athletic pubalgia injuries. The imaging is critical. I do a lot of diagnostic testing but going back to the question, bringing it home, I do not know what happened to Levon James <laugh>.

Speaker 1 (00:24:09):

All right. Maybe we’ll find out soon. Okay. So based on that, can you just briefly go through your treatment algorithm? Because most of it, correct me if I’m wrong, most of it is non-surgical. The typical patient with a sports hernia, athletic pubalgia, aponeurotic plate disruption and the first line of treatment is non-surgical, correct?

Speaker 2 (00:24:32):

It depends on the timing. Got it. When we did a paper in 2014 we looked at 119 patients with the neurotic plate athletic pubalgia injury proven on MRI. And what we found was that there were two everything was based upon time frame. So if you get the injury within the first six months and it’s an acute injury, there is a greater than 50% chance or about a 50% chance that they are going to heal on their own. So if it’s within six months of the injury, we almost always have people rest. And the reason being that why do a surgery when half of those people are going to get better on their own anyway? Certainly nobody needs a surgery that they don’t need. However, we found that when the injury became more of a chronic injury and we used six months as an arbitrary line, but that seemed about right to us.

Speaker 2 (00:25:36):

If it’s somebody that’s had pain going beyond six months, they hit what I call the plateau, meaning they essentially get better to about 70%, 80%, and then they essentially live on that 70% plateau and every time they go out and play the sport that irritates it hurts and then they rest and it gets better to the point where they’re completely better until the next time they irritated. So when you find a patient like that, they’ve hit what I call the chronic stage and those patients do better getting the operation because ultimately they’ve essentially waited their time frame. But if you see somebody in the initial period of the erotic plate injury, you definitely want to have them rest and shut it down. The problem is, of course, a lot of these people are, all of us, we’re all a little obsessive and they don’t shut it down like they should and they don’t give themselves a chance to get better. Some people just don’t want to. The professional athlete is a different entity altogether because they have a season coming up and you have to, and the college athlete and the high level high school athlete, you may want to treat them a little bit differently because they’re not people that are going to want to wait three months or six months to find out if they still need an operation. So at the end of the day, it’s more about the timing than it is about all across the board.

Speaker 1 (00:27:03):

And is MRI your go-to or do you use ultrasound? Always. Always MRI. Yeah, I agree.

Speaker 2 (00:27:08):

I mean there are reports about sonograms, but I’m an MRI guy both for hernias and for athletic pubalgia. I think at the end of the day it gives me a huge amount of information. We do what we call a pubalgia protocol, which we wrote and we’ve been kind of dispersing it throughout the country both in papers and sort of individually. And I think that it really gives us a significant amount of information that we can go on.

Speaker 1 (00:27:37):

So we have three questions on MRIs for you. I think we have a budding radiologist in our

Speaker 2 (00:27:43):


Speaker 1 (00:27:43):

Hit me. So talking about looking at the MRI images, there’s, there’s like the bright and the gray to try and determine. So on this one’s just ask you the question, you can kind of phrase it however you wish. On t2, fat suppressed images, do gray intermediate singles signals suggest injury or only bright white high intensity signals? And also what’s the difference in appearance between acute and chronic injury on MRI? Maybe just make it as general as you can say, but definitely you can tell acute versus chronic and you can also look at the different image modalities with an MRI to determine where inflammation is versus like a tear.

Speaker 2 (00:28:29):

Right. So I mean, this is actually a really, really good question. The bright signal that you see suggests that it’s an acute injury. The intermediate signal suggests that it’s more going into the chronic phase or that it was an acute injury. At one point and way we think it happens and we don’t know for sure, but what we think happens is after the acute injury where fluid is deposited or leaks into the area, as time goes on, the body does dispense of the fluid and the intermediate signal we believe is the scarring effect. So this goes along very much with when you’re talking about t2, fat suppressed imaging. When we see somebody and their history, and again, this goes back to our point that history is incredibly important. They have two weeks of an injury and you do a scan and you see bright signal that they have the acute injury and that person only two weeks out, we have them sit it out and rest and hopefully that acute injury will just heal.

Speaker 2 (00:29:32):

And certainly there is most definitely a percentage of people that are going to heal on their own without an operation. When somebody who’s got eight months of pain and they don’t have any acute fluid signal, but they do indeed have intermediate signal that’s into the abductor, the abductor fibrocartilage underneath the app neurotic plate between the plate and the pubic periosteum you’re going to be thinking about that much more as a chronic injury. And that goes along with the history pattern. So that’s a really nice correlation that we see. And that’s a very good point that the question is making. What’s hard is when it’s completely inconsistent, when you have somebody with two years of pain and yet you continue to have an acute injury pattern, then you kind of wonder why does this patient keep injuring that spot and those patients you want to delve into a little bit more. Oftentimes diagnostic injections you want to question yourself. You always want to question yourself, am I missing it? Am I getting this right, am I getting this wrong? Does this go along with their story? I mean, all of this is really important.

Speaker 1 (00:30:41):

And do you do your own injections or do you it depends or do you have your pain doctor do? It

Speaker 2 (00:30:47):

Depends if the patient is easy when it comes to their anatomy and mm-hmm. What I mean by that is if it’s a 25 year old thin athletic man or woman, you can really feel the anatomy very well. And I’ll do it by field. If I have a patient who’s whatever, 55 and has packed on the 55 year old weight gain that we often see we included then it’s a little bit harder of an injection to do. And oftentimes those I’ll give to my interventional radiologist or my pain management person to do a sono guided injection. There are definitely times where I want to do the injection myself there. There’s something about the surgeon knowing where the anatomy is and doing the injection by and

Speaker 1 (00:31:38):

Getting that feedback as to how

Speaker 2 (00:31:40):

They feedback. Exactly. So I think that sometimes is a big component of it for me.

Speaker 1 (00:31:48):

What are these steroids? Do you use PRP? No. No. Is it

Speaker 2 (00:31:53):

Just local insulin? I’m a diagnostic injection kind of guy. I mean, and what I mean by that is I do Marcaine, which is bupivocaine, which gives me a three hour window when it comes to pubalgia. I very rarely want somebody to get a steroid injection. The concern anecdotally is that you can end up making the pain go away, but because you’re not repairing the injury, you’re setting somebody up for a worse injury. And we’ve seen this many times with some of the professional athletes where they ultimately tore off the entire plate because they just,

Speaker 1 (00:32:25):

They get a hundred milligrams or something of steroid, it’s crazy,

Speaker 2 (00:32:28):

And they try to get Tom playoffs and things like that or the adductor fibrocartilage becomes disrupted. So I’m very cautious about steroids. P r P stem cells, I believe that there’s a role for it. The truth is we don’t have good data one way or the other, so, so I’m never really too negative about it, but I also don’t do it myself, just not to muddy the waters at this point, but I think it’s a reasonable attempt to go after something if you have somebody that knows what they’re doing. But at the same time, we just don’t have data on that.

Speaker 1 (00:33:08):

And then also about injections, oh, hold on. What did I just do? Excuse me. What about Botox? Do you use Botox in your groin pain patients or your athletic psychology?

Speaker 2 (00:33:22):

I don’t, but I definitely have pain management people that I know do. And ultimately some of the stuff is very well received. I think that at the end of the day for me, where it’s been probably the best used is in the pelvic floor dysfunction patients who are just going the pelvic floor spasm.

Speaker 1 (00:33:48):

Yeah, those are really good.

Speaker 2 (00:33:50):

But for the pubalgia injuries, I just haven’t really seen that Botox as a big part of the equation.

Speaker 1 (00:33:58):

Question about, again, sport attorney is if it’s left untreated, have you seen it then on the other side? I mean is there a risk of bilateral issues or is it always a unilateral problem or most likely unilateral problem?

Speaker 2 (00:34:15):

Well, I would say 50% of the time I’m seeing bilateral. Oh, wow. Yeah, so I don’t think there’s any question that we see a fair amount of bilateral injury. Is it because one side is left untreated? The truth is, I don’t know. It’s actually a really, I, I’ve never even thought of it like that, but it’s a good point. So just a point of interest, what I’m looking at, there’s a slightly different pattern that has emerged. You can either have a unilateral injury, which is signified by what we call a clef sign on that one side you can have a bilateral injury where the clef sign seems to go right across the center. And then there’s something that’s a slightly different entity that I’ve been seeing over the last several years, which to me is a little bit distinct and it’s what I call central pubalgia, which is where the injury is really isolated to the very center. It’s not the synthesis itself, it’s anterior to the synthesis, but it has a slightly different pain pattern. This might be getting too deep, but it just interestingly that those are the different patterns that we do see on the MRI that do correlate fairly well with the clinicals.

Speaker 1 (00:35:31):

We have another question from Facebook live. So in people that have groin pain, whether it’s due to hernia or an athletic component or a tear, and people don’t want to go to doctors or hospitals or leave their house, what do you recommend for them to do to alleviate some of their symptoms?

Speaker 2 (00:35:57):

I don’t feel comfortable giving advice. I mean

Speaker 1 (00:36:02):

Ice packs, I like ice packs.

Speaker 2 (00:36:04):

Sure, ice packs are never going to hurt. But I do think that it’s really pathology dependent. I mean, at the end of the day, if somebody’s got an incarcerated hernia, all the ice packs in the world, they’re not going to help them. They need to go to the emergency room. If it’s athletic pubalgia and somebody knows that it’s athletic pubalgia, then sure ice packs, nonsteroidals, that type of thing. But it’s really hard to dispense advice until, and often patients come in and say, well, what are we going to do? What’s the answer to what we’re going to do? And at that point, we’re just starting the interview and part of it is, well, we haven’t come to a diagnosis yet, so we can’t really tell you what the next step is. Let’s just try and get to a diagnosis. So unfortunately, I get that COVID is an issue, but you don’t want to have people ignore something that might turn into something bad. So hard to give advice in that setting.

Speaker 1 (00:37:05):

Many questions about the bone, the periosteum one, I’ll give you a couple of the questions and you can answer them together. One is I have concerns about treating the muscle to the bone and periosteum, does that cause pain or is it at risk for causing pain? And there’s a similar question, do bone anchors cause less pain than sutures when placed in the periosteum? Also, is there again, another question about suturing in the periosteum. What are your thoughts about bone anchors, suturing chronic pain related to periosteal suturing or bone anchors and pubic, I guess is probably something they’re relating to,

Speaker 2 (00:37:50):

Right? Well, pubic is its entire own hernia talk live.

Speaker 2 (00:37:57):

So I don’t want to delve off into that, but when I first started doing the surgery, I was very concerned about periosteal sutures at the pubic. We definitely do use periosteal sutures when we do Lichtenstein repair and we put a suture into the pubic cubicle and in fact, we need to anchor that Mesh and that medial point. So I knew that that was okay. I didn’t know how it was to start moving immediately towards the pubic synthesis. But what was always interesting is that general surgeons have always been told, oh, don’t do that. Don’t do that. And yet orthopedic surgeons are doing that type of maneuver all the time, right? All the time. So there was such a disconnect for me that we as general surgeons are told one thing and yet orthopedic surgeons never think twice about periosteum. They never think twice about anything in regards to the bone and chronic pain syndromes.

Speaker 2 (00:38:53):

They’re putting place, they’re putting screws. Absolutely. So I think that was one element. And then the other was I had to develop an operation that I wouldn’t burn bridges and I could always undo is the way I felt about it when I first started because it was essentially starting with a new operation. So I created the periosteal sutures, not created, but I started using that method knowing that if it really started causing a chronic pain syndrome for somebody, I can always go and take them out. And I’m happy to say that 15 years later, it’s only a handful of times where the suture seems to be causing somebody a pain syndrome. I’m absolutely not saying that it can’t cause somebody a pain syndrome, but it really just doesn’t seem to happen all that much. As far as the anchors go, same thing the anchors have been extraordinarily helpful when we deal with the fibrocartilage injury where the abductor longest fibrocartilage comes off the periosteum and you can actually anchor it back up to the underside of the pubs.

Speaker 2 (00:40:07):

And we’ve had wildly successful results with that operation and we don’t end up with chronic pain syndromes from the anchors. And that goes along with any of the orthopedic literature that we’ve seen over the years that anchors are used extraordinarily regularly with orthopedic surgery. So I think that the surgeon, general surgeons fear of this has been a little overblown. I’m not sure why I’m not where it came from but quite frankly, I haven’t seen it as a problem. I think the question that somebody asked is a great one about do we think anchors may cause less pain or less irritation than sutures instinctively? My answer to that would be probably yes, because the sutures are holding down a wider swath of tissue. The reason why I don’t regularly use anchors though is exactly that reason. I need to get as much of the plate approximated to the bone as I can because that’s our problem.

Speaker 2 (00:41:18):

The plate is in some way coming off the bone and there’s where your injury exists. And my feeling about suture anchors or anchors in general was that it’s a single point of fixation, which is going to then bunch the erotic plate tissue up rather than having a broader catch of that tissue. So in my mind, there was always kind of this back and forth which one is a better maneuver? And then the second part is why drill into the bone if you don’t have to, I think is a reasonable issue or reasonable question to ask. And because I’ve had such good success with the surgery, and again, it’s not a perfect surgery, none of this is, there’s not a perfect equation here and I’m certainly not claiming that. But the results have been very, very good. And I think there have been times where I’ve done an initial operation the patient recurred quickly, maybe it’s due to their collagen, maybe it’s due to the fact that my sutures weren’t brought enough. I don’t know. But I have gone back and used anchors to treat those patients and that did pretty well. So that’s kind of a fallback position for me. I don’t know if I’m getting too technical here, but that was a very good question that somebody

Speaker 1 (00:42:32):

Asked. I get that question a lot because a lot of the patients that come to see me have been through so much and they’ve done so much research that they then come up with these really detailed questions, which my own resident probably would never be able to even think of but it’s really impressive that the patients can ask these questions. For the Lichtenstein hernia repair, which is the most considered the gold standard for open inguinal hernia repairs, Dr. Par recommended that to reduce the risk of chronic pain, the Mesh should be secured to the rectus fascia on top of the bone, not onto the pubic kind of periosteum itself. That was his thought. But you’re right, orthopedic doctors, so on periosteum all the time, I wonder if they go deeper into the bone and don’t catch just the periosteum alone if that makes a difference. I don’t know enough about the, yeah, I

Speaker 2 (00:43:31):

Mean orthopedics too. All I can tell you is for 15 years I’ve been doing periosteal sutures and I just don’t see it as a big issue.

Speaker 1 (00:43:39):

One thing that you mentioned with regard to pubalgia, the question that’s being posed, which is rel related to what you said, is the pain for athletic pubalgia because of these micro tears or is it the instability or the abnormal movement of the preop neurotic complex itself that causes the pain? Is it the tear or is it like the misalignment or,

Speaker 2 (00:44:06):

Well, I think they go hand in hand. I think the tears allow for micro movement and I think that instability is what people feel. And the reason why I think it has more to do with the instability than the tears causing the pain is because the pain goes from the pubic upwards along the lateral edge of the rectus most commonly, and it goes down along the adductor. So the fact that the pain goes along the two vector forces on the plate makes me feel like it’s about the movement of the plate in this kind of tug of war fashion. But I think you can’t have movement of the plate with pain if the plate is secure. So I think the tears and the micro terrorists all play a part of it. So the short answer, the vectors, we don’t the vectors, so we don’t forces answer but I think it’s a combination and the vector forces are what’s not letting it heal. So there

Speaker 1 (00:45:05):

Are surgeons, there are surgeons that claim if you broaden the muscle attachment to the plate, to the bone, right, that distributes the tension broader and changes of vectors. And we is one of the ways of treatment treat it. Do you agree with that?

Speaker 2 (00:45:21):

Yes. Yes I do. And I do that I will bring the conjunct tendon down to the shelving, the ligament to broaden and disperse load. I’m a big fan of logical mechanics to this whole thing. So phasix, so right, if you disperse the load, hopefully you’re not going to have so much tension on that one spot on the pubic and therefore you’re hopefully going to get a better result. Is it overkill? Maybe. But to me that seemed like the most logical way to do it, reattach what’s broken, disperse the load if it’s not too much of an anatomic rearrangement. And also I try to lengthen the abductor a little bit just to get that downward vector pole, which I believe is the dominant tug of war winner, so to speak just to lengthen that ad doctor so you’re not getting as much of a downward vector ball.

Speaker 1 (00:46:21):

We talked a lot about sports hernia and athletic pubalgia, but we didn’t answer a simple question. What’s the typical symptom of this process for this problem?

Speaker 2 (00:46:31):

So for somebody with athletic pubalgia sports semi injury?

Speaker 1 (00:46:36):

Yeah, yeah, sure. That’s been confirmed. What’s the typical symptom?

Speaker 2 (00:46:40):

Yeah, so the typical patient will come in and when you say to them, where do you feel your pain, they will point to their pubic tubercle. And for those of you that dunno where the pubic tubercle is, if you think of the pubic bone kind of right down at the center and you just go off to the right, probably about an inch to an inch and a half, depending on the size of your body there’s kind of a step off a little ridge that you can feel on the bone. And that’s where patients almost always point to as the epicenter I, I’ll always ask them, I understand that the pain radiates, but where is the epicenter of your pain? They will generally point to that spot and then when I will ask them and does it go down? Does it go up? Does it go lateral?

Speaker 2 (00:47:24):

Where does it go? They will point in two directions, they’ll bring their finger up along the lateral to the rectus and they’ll also bring their finger down along the abductor tendon. So that is your typical. Now sometimes you just have people with an upper plate injury who only feel upper pain. Sometimes you only have people with abductor pain but it usually emanates from that pubic cubicle. And the consolation of symptoms is usually activity induced, but interestingly it’s not always at the time of the activity. In fact, I get a lot of people who feel fine when they play, whether it’s soccer or hockey or cycling or whatever it is. And then it’s later that night or it is next morning. Next morning. One of the typical complaints is I was fine and then I went to sleep and then getting up out of the bed was really hard and then I’m shot for two days.

Speaker 2 (00:48:17):

And that’s a very, very classic sports hernia, athletic pubalgia type description to me. And that goes as very much along with the clinicals that we’re talking about when we see them in the office. And then the MRI often will, I think somebody did a great study where they looked at MRIs and they gave it to radiologists who were blinded to what the issue was and they simply ask if the issue is in the pelvis, look at the imaging and see which side you see the abnormality and tell which side you think the injury is going to be on. And it was like a 99% sensitivity that people were choosing the correct side of injury based upon some abnormalities they were seeing at the pubis. And what that told me was that there was a high correlation with what the MRI shows and what the injury pattern was. And in my practice over the last 15 to 20 years, that’s definitely been true for me.

Speaker 1 (00:49:11):

Let’s talk about laparoscopic surgery. This patient was offered laparoscopic repair with Mesh for their sport hernia. How does that end up repairing a muscle injury?

Speaker 2 (00:49:23):

I mean, I don’t want to sound grandiose, but I don’t think that it does. I think it never made sense to me. And remember I’m a laparoscopic surgeon. I mean I was trained in the time that laparoscopic surgery was really coming up and for inguinal and femoral and obturator hernias, I adore laparoscopic surgery. I think it’s fabulous. I think it’s the way to go. There is no other way. However I’ve looked at it every which way and for pubalgia, I just don’t see how you’re going to get to the front of the pubis laparoscopically in any effective fashion and be able to do all the things that we are doing when we do the pubalgia repair. So I don’t do pubalgia repairs laparoscopically and I don’t like to use Mesh in these high performance athletes in that level because I think that level is where there’s musculature that I really don’t want to create such a huge tissue reaction with the Mesh. And I’m also not really accomplishing anything with the Mesh if it’s at the neurotic plate where the injury is. So I know it’s a broad answer and a long answer, but simply I don’t think one can get to a good repair of a pubalgia case with the laparoscopic Mesh repair.

Speaker 1 (00:50:47):

I think a lot of times people use the term sports hernia because they don’t feel a big bulging hernia, which is your typical standard inguinal hernia and they use the, it’s a misnomer. In fact, I know surgeons that kind of prey on that. They say, oh, we’re fix. We’re fixing a sports hernia. They have this huge kind of camaraderie with the orthopedic surgeons. What they’re really doing is they’re just doing a laparoscopic hernia repair for a bonafide hernia. They’re just terming it that it sounds fancier, but that’s where we go into the whole occult hernia, hidden hernia. A lot of what I treat a lot of, and you treat a lot of, but it’s so important to determine the difference. The treatment’s totally different. The biology is different, the amount of inflammation and tissue injury is different and the recovery is different. Right,

Speaker 2 (00:51:41):

Absolutely. And to your point, the MRI to me is again the key to understanding the pathology. And the other thing to note is that in our paper there was a concomitant meaning at the same time hernia incidents as well as pubalgia injury about 30 to 35% of the time. So it’s not uncommon that people have a combination and I think they do go together because I think people with longstanding hernias who don’t really know that they have a hernia are very active or highly athletic. That hernia sitting there in the inguinal canal causes a different type of torque which ends up creating more vector force or torque on the pubic. So it good point, remain very logical to me when you think about it mechanically that inguinal hernia is quite possibly predisposed people and in the numbers it looks like they do predispose people to athletic pubalgia in many cases. So I think there’s definitely reports of people repairing veto pubalgia with laparoscopic hernia repair with Mesh, but it’s quite possible, like you said, that they’re fixing these inguinal hernias. It’s also possible that they are getting some secondary pain control from the hernia repair with Mesh. And I’m not saying that it doesn’t maybe stabilize the inguinal floor a little bit, but to me it it’s a very indirect way to try and fix what seems to me to be the problem at the front of the

Speaker 1 (00:53:14):

Pubs. Yeah, I think that’s where the history is really important because it’s a very different history, Anglo hernias usually than sports type injuries and then MRI. So one question is how do you find a hidden hernia if you don’t see it on ultrasound? So in our study ultrasound was great if it was positive a hundred percent of the time, pretty much almost no false positives, but it had a 50% false negative rates. So if you had a negative hernia ultrasound or ultrasound, it’s often not even correctly done. Then half the time you are missing a real hernia if it’s done for that reason and then we go straight to MRI. Is that your protocol? We go, if we have ultrasound that’s negative but the history and exam are consistent with or al hernia, then we jump to, I skip CT because it’s horrible numbers in terms of pelvic anatomy, so we go straight to MRI for those.

Speaker 2 (00:54:17):

Right. Well, I don’t, not a big fan of sonogram because for me that’s user dependent and I don’t do it myself. So then I’m depending upon somebody else’s interpretation of something, which I, I’ve learned over the years never to really do. I’ll always want the imaging, whether it’s a CT scan or the MRI. Personally, I will never get a CT scan if I don’t have to because of the radiation. Even though it’s a small amount and I don’t want to make it sound like adds up, nobody ever should get a CT scan. A feeling is quite frankly that for this specifically hernias a cold hernias and erotic plate injuries, MRI is going to show you everything you need to see. There’s definitely some things that cts need to be done for now, no question whatsoever. However, for this, I’ll always go straight to the MRI if I can. Insurances often try and block that pathway, but I just

Speaker 1 (00:55:12):

Find, yeah, I’m just doing my paper

Speaker 2 (00:55:14):

That, yeah, just give your paper.

Speaker 1 (00:55:15):

I just said them my paper and they don’t say anything.

Speaker 2 (00:55:18):

Oh, I dunno. Nobody listens to me with that, but at the end of the day, often knows we’ll have to get a sonogram just as a gateway to getting the the MRI. but I just find that the MRI is so incredibly helpful.

Speaker 1 (00:55:33):

That’s true. We have two questions on recovery from a sport hernia related operation. One is a patient who relapsed six months and was wondering what the causes of relapse are, and a second one is a live question, which is how long do you give postoperative pain to resolve before you would consider removing periosteal sutures?

Speaker 2 (00:56:02):

I mean, I like to wait it out as long as I can. And again, this isn’t a high frequency occurrence for me, so I don’t really have a set algorithm for it. I think it’s going to depend on how much pain the patient is in. I’ll almost always do a diagnostic injection for a suture to make sure that it is the source of pain because I think easy to say, oh, it’s the suture that’s causing pain. You go and you remove the suture and they still have pain and then you’ve done an unnecessary maneuver and taken out something that is securing the plate. That being said, if you do a diagnosing injection, and it certainly is the suture, you can still go with the steroid injection see if that works and if that doesn’t work, I would like to wait as long as I can before taking the suture out just because of its structural integrity helping with that like

Speaker 1 (00:56:54):

A year or six months, eight months.

Speaker 2 (00:56:56):

Yeah, so I would say six months would be a reasonable time frame. Yeah,

Speaker 1 (00:57:01):

Yeah, I agree. Okay. Let’s do one last question. We got some really great questions. Do you treat male and female growing pain differently and why? I see a lot of females, so

Speaker 2 (00:57:17):

Yeah, I definitely see a lot of females. I see a lot of overlap with pelvic or dysfunction. I don’t really think I treat males and females differently. I think I just go for the answer no matter what it is. Will the answers be female dominated in some directions and male dominated in other directions? Sure, the anatomy will dictate that. But I definitely think that I walk into a room seeing a patient with the exact same slate, blank slate in my mind for both patients or for both genders. And I don’t think that I look at them mechanically differently so much. I mean, there’s definitely differences in the female pelvis when it comes to growing pain and sports hernia type stuff. How I do the repair sometimes is slightly different because I can’t fit the same amount of sutures because of my landing zone is smaller, so to speak.

Speaker 2 (00:58:19):

But I don’t think there’s a whole lot of difference in approaching the patients because I think you still have to come up with your diagnostic algorithm. You still have to come up with the right answer. You don’t dismiss anything in one versus the other. I think you have to track down, like you said earlier, I think we’re detectives, we have to track down the leads. We have to try and disprove things that we think are wrong and prove the things that we think are right and we have to have an open mind. So I think you have to be as open as you can with all of this. I don’t know if that answers the question, but

Speaker 1 (00:58:55):

Yeah, I think it does. Of course, there’s certain things that women make have that men don’t and vice versa. But I think the important takeaway is that women can’t get a hernia just like men can have certain disease processes that are more common in women to have an open mind and be as kind of broad in your knowledge base and application of as possible. I have so many people that are told they no way they can have a hernia. They’re female. I’m like, but taught you that. But they teach that in medical school. I’ve actually been involved in medical school where they actually teach that and I have to tell them not to say that again.

Speaker 2 (00:59:43):


Speaker 1 (00:59:45):

Okay. So sorry, this will be the last question because I think it kind of falls into everything is how do I talk to my surgeon about a cold hernias when they don’t see them as a real cause of pain?

Speaker 2 (00:59:58):


Speaker 1 (00:59:59):

Sleep in that world.

Speaker 2 (01:00:01):

Yeah, I think carefully is the word here.

Speaker 1 (01:00:04):


Speaker 2 (01:00:05):

So I think you have to make a determination if the surgeon is going to be just closed off or not. If they’re closed off, my feeling is just find another surgeon. You don’t want to be the one convincing somebody to do a surgery on you that they don’t believe in. That’s a

Speaker 1 (01:00:20):

Very good point.

Speaker 2 (01:00:22):

On the other hand, honestly, if you have somebody, you can certainly show them the literature show them some of the YouTube videos that are out there in the world that, I mean, the two of us have been doing and others I believe have been doing in regards to a call turn is and if it’s a surgeon who’s a good solid surgeon and hopefully they have a good sense of hubris and brains, they’ll say, you know what? This is possible and I think you, and this is really important in our world. You have to look at every possibility and deem it as a possible issue because we don’t know everything. Most assured.

Speaker 1 (01:01:06):

Yes, I say that all the time. Yeah. Well, I’m glad you say that. You’re basically mimicking exactly what I say. I say it all the time. We don’t know everything. We’re still learning. That will be the same forever and whatever. For some searches to claim they know so much, it drives me nuts.

Speaker 2 (01:01:28):

Yep, agreed.

Speaker 1 (01:01:30):

All right, well on that note, I would like to say thank you. It’s our last kind of couple seconds on hernia talk. So Dr. Zoland, thank you so much. You’ve shared so much information. It’s been my pleasure and honor to at least be able to pick you out of a crowd now. I really, really, really respect everything you do. We will have this posted on YouTube pretty soon, and I’ll put all of our social media so you can link to it. Thank you, Dr. Zoland, for sharing your time and effort with me. Thanks everyone. Welcome. I’ll see you next Tuesday on Hernia Talk Tuesdays. Thank you very much and have a great evening. Bye.