Episode 33: Pelvic Floor Therapy & Hernias | Hernia Talk Live Q&A

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Speaker 1 (00:00:00):

Hello everyone, this is Dr. Towfigh. Welcome to Hernia Talk Live, yet another Tuesday, what we call Hernia Talk Tuesdays, where we answer your questions about hernia related topics. This is simulcast on Zoom and Facebook Live. You can also follow me with this screening on YouTube afterwards, and you can follow me on hi Twitter and Instagram at hernia doc. Today’s esteemed guest is a new friend of mine we met on social media. Her name is Tracy Sher. She’s a pelvic floor physical therapist and really a specialist in pelvic disorders. You’ll get to know her, you can follow her at Pelvic Guru, and hopefully we can actually share our current webinar on her platform as well. And as we do that, let me stop sharing my screen and say hi to Tracy.

Speaker 2 (00:00:57):

Hello there. Thank you for having me on. And I actually was so excited I got to wear my gut hernia and I don’t even think I showed you this yet, but I’m wearing, I’ve got my pelvic pelvis earrings too. It

Speaker 1 (00:01:10):

Out. So cool. I wonder I can,

Speaker 2 (00:01:13):

So I’m ready.

Speaker 1 (00:01:15):

I wonder if I can get hernia earrings. That would be a little weird though.

Speaker 2 (00:01:20):


Speaker 1 (00:01:20):

Mean, I have to think of a nice way of making hernia jewelry.

Speaker 2 (00:01:26):

I mean, I could think of some strange ones. Yeah, I don’t, yeah, we’ll have to think about that.

Speaker 1 (00:01:30):

I know. In fact, I have these earrings, they’re like dangles with little balls at the end and my mom’s like, you can’t wear those. You’re a hernia surgeon. It’s too much testicles. So it’s

Speaker 2 (00:01:44):

Triggering for some, maybe it’s

Speaker 1 (00:01:46):

Triggering something

Speaker 2 (00:01:47):

Hanging down.

Speaker 1 (00:01:49):

So for those of you who don’t know Tracy, I’ve had the honor to meet her because I’ve seen a lot of her work on social media, mostly educational through the Pelvic Guru, that’s your name on most of your social media platforms. And you also have, so you have educational platforms for patients and you also have them for professionals, physical therapists and people that deal with pelvic floor disorders. Is that right?

Speaker 2 (00:02:23):

Yeah, we’ve actually focused overall on some broad education for community members. And then we have professional education courses and we have a professional membership. So for those, anything in pelvic health, if you’re a professional, we have a membership, and actually just this year in January, we are rolling out two platforms. We have one that’s specifically for education for professionals, and we’re going to be rolling out a full platform for community members. So I’m so excited and hundreds of courses on it, and it’s the first time we’re really stepping out and doing a lot more education and offering a lot more things to the community. So it’s been a big goal of mine to do that.

Speaker 1 (00:03:01):

That’s really fantastic because there’s not enough out there really. There’s not enough on hernias, there’s not enough on pelvic floor. We have a lot of overlap in our specialties. So yes, your education is, you got trained in physical therapy and then did you do extra training after that or how did you get involved in pelvic floor?

Speaker 2 (00:03:23):

Yeah, so the way, typically what happens, there’s not a lot of specific specialized training in pelvic floor or pelvic health in any of the doctorate programs for physical therapy now. So what happens is they may have a semester or some sort of course on women’s health or pelvic health, just maybe a few weeks or so on it. But in my case, I took a women’s health type course and I was like, this is interesting. I’ll learn about prolapse and some basic things. And I had my heart set on doing either neuro stuff, something to do with strokes and spinal cord injury or orthopedics. I had no intentions of getting into pelvic health. And then what happened is I had a clinical rotation that was in orthopedics and they said, oh, you’ll be doing women’s health as well. And I show up my first day of this clinical rotation and my instructor says, go ahead and put some gloves on first patient first moment there, get some gloves on, you’re going to be doing a vaginal exam. And it was like, okay, what did I sign up for here? I wasn’t sure what. Yeah. And really the story that I tell about this because of this experience, it was so powerful for me that from then on that moment on, after working in that clinical environment, I realize there was such a huge need for this.

Speaker 1 (00:04:35):


Speaker 2 (00:04:36):

I can’t tell you as a student how many patients, and this is still true, and what we can talk about tonight as well, which is someone would say, I’ve had this low back pain for years and no one can figure it out. And I would go internally and I would touch on the obtuator internist muscle, and I was just learning to palpate where I was going there. And they would say, I don’t know what you’re doing, but that’s the pain I’ve had for 10 years. Oh wow. No one has ever been able to figure out what that is. What are you on? And it was like, wait a second. I’m just a student here. I didn’t really even know how powerful it was. Yes, we’re having back surgeries, going to chiropractors, having so many different surgeries when real actually was potentially this muscular problem that in the pelvis that was just being missed.

Speaker 2 (00:05:17):

So it was a aha moment for me that we are simply missing a lot of these pelvic health cases. And so from that point forward, I went to my next rotation in stroke rehab and I set up a full continence program, continence program for stroke patients. I mean, I was so passionate about it and then went on where I just basically became so specialized, I took extra courses. So to answer your question, you then really need a lot of extra postgrad continuing education courses. Correct. So things like pelvic floor, 1, 2, 3, pregnancy, postpartum pelvic pain courses, it goes on and on. So I’ve taken over 20 years of doing this. I’ve taken, I don’t know, I can’t even tell you how many courses you end up taking to really get specialty training in pelvic health.

Speaker 1 (00:05:59):

I’ve mentioned this comment in previous hernia talks is that what I’ve learned is that as doctors, a lot of times we’ve lost the tactile kind of palpation and physical exam, the ways of little tidbits of a physical exam, how much information they can give you. We ordered CAT scans and MRIs and blood tests, and oftentimes we just need to lay hands on patients. And I see so many patients that have been to multiple doctors and they say, the doctor never examined me. They never touched me. And that’s very odd to me. But what I have noticed is that physical therapists, that’s what they do and they do a lot of it. And I get a lot of referrals from physical therapists, and they’re the ones that really feel the difference between a muscle that is spasming versus a muscle that’s relaxed, an area that’s tight and an area that’s not trigger points. Doctors just like, oh, there’s no bulge, no hernia, or they don’t really necessarily spend a lot of their time, unfortunately, at least in the United States, maybe better outside the us. But I feel that you guys and your specialty and physical therapy and even more in pelvic floor, the tactile sensation, the difference between normal and abnormal is very much more appreciated than we do in western medicine.

Speaker 2 (00:07:26):

And even just to go onto that, it, it’s not even just the feel, because sometimes that can be truly subjective. Someone can, that’s the hardest part about our job is that someone can say it’s tight, but is it really tight to what’s the inter-rater reliability versus in intra-rater reliability? But one of the biggest things I think we are really good at and what we teach a lot is testing and retesting. So for example, if I touch someone somewhere and they say, wow, that’s my exact pain understanding, okay, they’re having a reproduction of symptoms that this exact location. Got it. But imagine going to seven different physicians or other kinds of health professionals and no one’s ever even identified the pain. Yes. And so let’s say the pain is down here, it’s actually on their abdominal wall somewhere. And I immediately reproduce that. You just touch it and they say that’s their pain, but they told they had pudendal neuralgia because no one ever touched them or they just said they had pain was sitting and that was it.

Speaker 1 (00:08:20):

And the work

Speaker 2 (00:08:20):

Know if I’m touching them there and they’re saying, this is not pudendal neuralgia, then okay, so then let’s figure out, let’s test retest. I’m going to have you move your body back and I’m going to test, does that make it better or worse? Now I’m going to have you stand now I’m going to have you sit different positions. So we’re looking at not only just the palpation in touch, we’re looking in relation to movements to what makes it better, what makes it worse. Can I do something and can I test and retest that and go, oh, wow, that’s better. Whatever you did that helps. Or whatever I’m doing at home now we know that helps. And I think that gets me missed sometimes in medicine it’s this quick idea of, oh, it’s this nerve or this muscle, but we’re not really testing and retesting and touching things. So your point is really

Speaker 1 (00:09:01):

Yeah, so true. So true. We have so many live questions already. Oh my goodness. So if you’re okay, we’ll dive into them. I have some other ones that were submitted online, so we’ll go through those two. But in deference to those that took the time to log in and join us, we’ll do an easy one first, tell me about some opportunities in looking online, or maybe it’s your website for good pelvic floor exercises. What are some good online resources for pelvic floor exercises? And maybe before we jump into that, maybe just briefly overview, where is the pelvic floor and what does it mean if you have pelvic floor problems or pelvic floor disorder?

Speaker 2 (00:09:45):

I’ve been waiting for this moment. Let’s

Speaker 1 (00:09:48):


Speaker 2 (00:09:49):

I’m ready to teach. This is what I love to do more than anything. It’s really just do a lot of education on pelvic health and pelvic floor. Yes. It’s really misunderstood. So when you asked, if you said, if asked me to do this, I jumped on. I’m like, yes, absolutely. I would love to do this and share.

Speaker 1 (00:10:03):

Thank you.

Speaker 2 (00:10:04):

So what I’m going to do is because some people that are watching this may not even know we talk about pelvic floor, but it’s not just one muscle. And a lot of times people think it’s just one muscle or one thing when really it’s a whole area. So what don’t you

Speaker 1 (00:10:17):

Do is in general surgery, they don’t teach it to you during residency?

Speaker 2 (00:10:21):

Yes. In fact, you know how I went through periods years where we would actually train residents and they’re still friends of mine to this day, many of the residents that went through our program where we would teach them palpation, understanding the pelvic floor, and they said they just never got any of it. And so it was really a big

Speaker 1 (00:10:37):

Deal. It’s very complicated too. Yeah,

Speaker 2 (00:10:39):

It is. Because it’s all inside. Sometimes they refer to it as it’s orthopedics and a cave because everything you’re trying to touch or look at, it’s doing it much more in a blind sort of state. So what I’m going to do is, and by the way, for any type of anatomy for whether whatever gender, you have a pelvic floor. So it’s not specific. Some people think it’s only female anatomy and with a vagina, and that’s not true. Every single person has a pelvic floor.

Speaker 1 (00:11:09):


Speaker 2 (00:11:10):

So we’re going to focus here just on this, but I want to show you the different layers here. Let me show you

Speaker 1 (00:11:20):

By the way,

Speaker 2 (00:11:21):

Thank you. This has been one of the other missions is to create these educational materials so that we can really get good information out to people. And so there are actually three layers that make up the pelvic floor. And so if we look at this, this is actually the first layer. People don’t even realize these muscles are actually part of the pelvic floor muscles. So if you look at the pelvis in general, pelvic floor muscles support provides support to these structures here as well as they support organs and help in function. There’s a lot of different functions for them. But if we look at the first layer of the pelvic floor, you’ve got that transverses. The external area here is a superficial transfers perineum. And this is sometimes when you hear about episiotomies, that sort of thing, it happens here. You’ve had this one muscle that comes wraps around on both sides called the bulbocavernous or bulbospongiosis muscle. And then you have smaller ones issue caver. And then the external anal sphincter, believe it or not, is the first layer of the pelvic floor. So before we even talk about going deep, there are people that have a lot of pelvic pain and problems that are just on the superficial layer. So sometimes that gets missed because they immediately think they need to go deeper or look at other things when really it’s sitting right here.

Speaker 1 (00:12:39):

So your pelvic floor, I explained it to a salad bowl and it has three holes in it, one’s to pee, one’s the vagina, and women men don’t have that. And then the third is the rectum,

Speaker 2 (00:12:51):

Right? And each of these sections has sphincteric support from the pelvic floor. Got it. So that basically wraps around. So then actually this is a good segue because then if we look at the next layer, this is one of my favorite images. This is actually the second floor layer of the pelvic floor. And these are the compressor, urethra and these other muscles that surround the urethra itself. And then it’s also the deeper transverse perineum. So it’s the inside part inside. So that’s second layer, which can be a problem. And actually for a lot of people with pudendal neuralgia and pelvic pain, they actually have an issue at this deep perineal body or deep transverse muscle, and it gets missed regularly. When you palpate on that, they’ll say, that’s, that’s my pain. Why is everyone telling me it’s just the nerve when it’s actually this muscle itself.

Speaker 2 (00:13:38):

So that’s important too. And then third, we get really fancy. Let’s see here, we can get into, this is what a lot of people think of the pelvic floor, and this is all the deeper muscles here. So this is when you’ll hear something like levator ani group of muscles. And so we’re looking at, there’s just group of them that make it up here. So Iliococcygeus, pubococcygeus okay. So there’s different muscles that make it up. And then we have obtuator internists that’s on deep as well. On the inside it’s basically hip. They move the hips and there’s stabilizers on the side. And then we have all sorts of other muscles coxes, and you can see some pure forms in the back too. But basically there’s a bunch of deep muscles as well. So there’s three layers. And so when we talk about pelvic floor, it’s the entire support system that helps this pelvis get support, but also supports organs as well, and also acts as a variety of functions for the sexual function as well. So pelvic floor encompasses all of that? Yeah.

Speaker 1 (00:14:40):

So your urinary function, your sexual function and your bowel movement function are all supported by all these muscles working in tandem. And you have disorders of the muscles, weakness of the muscles. It can be too tight or too weak. It can have a hole in it like a hernia or any combination of that can give various problems. Or you can have, in my specialty as a hernia specialist, I actually see people that either have hernias in the pelvic floor, which can be repaired or they have spasm because of a regular hernia, like a routine or a groin hernia can cause spasm of this area. Then people have bladder issues and they go, instead of going straight, they get pulled into this whole urologic workup, whereas the bladder issue is secondary to their hernia. So there’s very complicated, and so many of us specialists don’t, over our knowledge, doesn’t overlap with other specialties. So colorectal gyn, yes, urology, physical therapy. And it’s quite nice to work with people like you that have a little bit more of a broad knowledge, but a lot of our patients don’t get to see specialists that understand everything that goes on in the pelvic floor.

Speaker 2 (00:16:07):

And one of the things that I think has been key point in my career and why patients are coming with really complex cases to see me from all over is simply because you need someone or a team of people that can look at all the different differentials. You need to be able to say, okay, in this case, does it make sense that it is urological? Does it make sense that it is in fact maybe a hernia or yeah, is it a hernia with secondary pelvic floor? Right. Correct. And we don’t see that. We get a lot of, well, it must be it’s IC or it must only be a hernia or it gets very myopic sometimes. And so the more that we can consider all the differentials, and what I tell patients often is, this is my working theory. I’m now going to connect you with who I think would be the right people for you. And this is my working theory. Now we may go through tests and realize that’s not in fact what’s happening, but let’s at least go in what seems to be the right direction.

Speaker 1 (00:17:01):

Yeah, totally agree.

Speaker 2 (00:17:02):

It leaves it open for a discussion. So

Speaker 1 (00:17:04):

Can you explain what are pelvic floor exercises doing when you’re told to do pelvic floor exercises?

Speaker 2 (00:17:13):

Yeah, so this is another whole, I wouldn’t say controversy, but really complicated topic actually because pelvic floor, so I’m going to actually, let’s see. Well, I’ll leave it here for a moment and then I’ll take the screen off, but sure. Essentially the pelvic floor has three primary ranges of motion, or it’s actually one full range, but it has three types of functions. One is it’s contracting, so it contracts and lifts, it relaxes. So when we’re walking around, we have a little bit of a bounce to our pelvic floor contracting, a little relaxing, a little contracting, a little relaxing a little, right? So you’ve got this kind of play with that range. But when you sit down and if you really want to have a nice bowel movement or you really want to let everything out your urine out properly, your pelvic floor actually has to gently relax and open more. And people who have weak streams sometimes or pelvic floor spasms and can’t relax enough, may have constipation issues, don’t, they’re not able to fully relax their pelvic floor. So the muscles stay a little bit in that relaxed or tense state, but they don’t actually fully relax. So when we’re looking at someone’s pelvic floor function, I’m trying to figure out can they fully contract? Can they relax? Can they actually do a gentle bulge different than straining? You’re not straining or pushing. Yeah, it’s very,

Speaker 1 (00:18:31):

Straining is not good.

Speaker 2 (00:18:32):

Straining is not good pretty much. And at the same time, we don’t want to shame someone if they did. It’s like, it’s okay, you didn’t do any damage, but don’t keep doing it. Yes. So when you ask about exercises, this is why it gets so tricky because every single person has a different function of what’s going on with them. So typically if we’re just looking at a general spectrum, if someone has had babies and they’ve noticed, oh, I have leaking now, and they feel like everything’s sagging down, they maybe have a prolapse. We would usually say they potentially have a weak pelvic floor. And again, this is very generalized, so we would work on the whole range, but focusing on strengthening. If someone came in with significant hernia history or pelvic pain history, that sort of thing, and we go to palpate and everything’s really tight and even the sphincters feel tight, that’s a person we don’t want to give exercises that keep contracting and contracting.

Speaker 2 (00:19:21):

So that would not, a keel type exercise would not be something I give them. It would be maybe down the line, but first we want to think of giving them things that relax everything. So we have specific exercises that are for relaxation of the pelvic floor. Then there’s people who just want general pelvic floor health, and that would be the full range. So to answer your question about how do you get this help, that’s exactly what we’re working on is creating these programs that people can say, okay, I have this kind of issue. Ideally they get checked by someone like us pelvic floor specialists who really understand and can individualize programs. But we also know across the world, not everyone has access to it. So the more that we can do general information,

Speaker 1 (00:20:01):

The question is what are some good online resources for pelvic floor exercises?

Speaker 2 (00:20:07):

Yeah, I’ll have to share. That’s exactly what we’re putting together. There are some individual programs that I would have to maybe share in the comments after I can give some specific websites and things. Great, because there’s a variety of people within our organization, the membership that are really working on this as well. So they have different sites up, but there are YouTube channels as well that are excellent, and I can go that route and share that. So for example, Shelly Proco and Dusty and Miller, yes, both have things on YouTube or on their websites that are all about using yoga and relaxation of the pelvic floor. And it’s all really safe stuff that you can do. So it depends on what they’re looking for. And then we have a lot of postpartum types of exercise programs out there for those that really want to get stronger. So something like what’s called MUTU system teaches all about activation of the pelvic floor more. So there are lots of different programs out there, and those are just a few that I can name now, but there’s so many, I mean I’m in touch with hundreds and hundreds of people that have these kinds of programs.

Speaker 1 (00:21:08):

Our next question has to do with hernia surgery. This patient had laparoscopic inguinal hernia repair with Mesh. The patient has soreness on both sides for a year and a half. It gets worse with movement, but fine with resting and all the imaging is normal, their surgery recommended a pelvic floor specialist. Would this be something that pelvic floor therapy could help with? And if so, why isn’t otherwise fit in normal weight person?

Speaker 2 (00:21:38):

Yeah, that’s exactly what we want to try and figure out. This is for anyone that’s a pelvic floor special at pelvic physio, this is exactly what we love to do is figure out what is it? Is it something that I can touch that when I palpate there, they say, oh wow, that’s my discomfort. And if I have them raise their leg, they immediately say, oh, that takes it away. Or is it something that’s more, we want to look for patterns in their history. So I would have a lot more questions to ask. Got it. But it sounds like it makes sense that that would be a definitely there’s sometimes I would say it just doesn’t make sense to see a pelvic physio at this point. But in this particular case, particularly with movements, that’s exactly what we’re assessing is what movements are creating this problem for you and can we touch it at the same time? Can we affect it by doing different things? And then we create a program around that to see if we can get that better over time together. If its, they say, oh wow, I’ve noticed this last week. I haven’t had it every day now I’ve only had it two days a week or so. That’s what we’re looking for. So yes, we absolutely work with that.

Speaker 1 (00:22:37):

So the inguinal hernia repair with Mesh done laparoscopically, you’re actually putting Mesh in the pelvic floor In some patients, especially if you put the Mesh too low, it can interf, the Mesh interfere with the normal contraction of the muscles and the flexibility of the muscles. Everyone’s a little bit different, but you can have some dysfunction by too low placed Mesh, which will interfere with normal flexibility and contraction of the muscles. So I agree, a pelvic floor specialists can help examine, see if there’s any tightness or the pelvic floor or any other abnormalities they can find and then determine if their therapies can improve it. If they can, great. But if they can’t, sometimes you have to go back to your surgeon and say, okay, I’m actually getting more pain with pelvic floor PT and maybe there’s something more mechanical that my surgeon can address. That’s my take on it. Do you agree?

Speaker 2 (00:23:35):

I think that’s exactly it is. Sometimes it is a referral back for sure to the surgeon or to who. And sometimes I can say get a second opinion because sometimes it makes someone else looking at it that understands the surgery but isn’t necessarily the same surgeon as well. And yes, and then it’s really just figuring out is it, I know right away I usually quite quickly on if I’m touching something around that area, if it even makes sense for me to keep going there and having them do the movements or is this something that’s more of a red flag that needs to be escalated to say, you know what? I really think you should go back to the surgeon. Yeah, it just makes sense.

Speaker 1 (00:24:06):

Right, yeah. But you’re definitely a very important part of the team for some of the reasons we explained earlier. Okay, this one’s more about, this question is more about abdominal muscles. My lower abdominal muscles don’t seem to be engaging at all. Are nerve conduction tests run to verify normal activity in this region? Do you want to take a crack at that?

Speaker 2 (00:24:29):

Yeah, I think the hard part is I really, I think nerve conduction tests are in most cases can be relatively inaccurate because you have to know which nerve are you testing, at what level are you testing is. It could even be a spinal chew and it may not even be a peripheral nerve. And then also it’s sometimes, how do I say the word, my abdominals or my glutes aren’t working sometimes gets used, but it just turns out that the person may benefit from having someone teach them an exercise or teach them a few types of things. And that may have them start to feel like they’re activating it more. So I don’t necessarily jump to, you immediately need to get a nerve test or I’m concerned that we need to get nerve tests because often they really are inaccurate or it’s not the right testing of them. So it’s almost like you start to chase things. So for me personally, I’m not suggesting don’t ever do those things. I just don’t think it’d be the first thing I would look at or

Speaker 1 (00:25:23):

Consider. Some people are not very clued in as to how to engage their core. That’s it. Or they have a diastasis or something else that throws their core out off balance. And just to clarify core, the core includes not just your abdominal muscles, but your pelvic floor is part of your core, your diaphragm is part of your core, your flank and your back muscles. So whenever there’s any imbalance or disorder affecting any of those, you can have core imbalance. And if you’re really athletic, especially you can tell a difference between, I mean I have athletes that have little umbilical hernias and they’re like, I can’t engage my core. I’m like, really? But they’re so in tune with their body, whereas maybe someone like me wouldn’t even notice. It’s a little bit different, but it’s based on your core, right? A

Speaker 2 (00:26:16):

Little bit. Yeah. And it’s really about, you said it earlier, it’s about motor coordination and awareness. So there are times when just having someone cue queuing them a different way and saying, Hey, why don’t you do this or move that way. And I’ll say, oh, I finally feel this, or that makes sense now. So it’s a lot to do with more with coordination and even sometimes touching and there’s been studies that have shown that even just touching or palpating on a muscle window to activate it can increase that by 30% their activation. So I look at it as this is what we love to do is figure out how can we get them to be more aware of it or how can we get them to move better. And sometimes they may actually be activating it, not just aware of it. So it really, it’s that I go that route much more than expecting that they, yeah,

Speaker 1 (00:27:01):

It’s super uncommon to have a denervation of the abdominal wall and usually that results in a relaxation or a bulging and not a difficulty in engaging. We have a chat from one of our colleagues, so she’s a physical therapist as my most difficult pelvic floor patients have symptoms that are intermittent. They can be great for three days and then terrible again, might this be a symptom of a hernia? Can it present with fluctuating symptoms? Have you seen that?

Speaker 2 (00:27:31):

Oh yeah, I definitely, I think it’s too, and this is where I would defer to you as well on this, but to me it seems like usually there’s a mechanism. So did they lift? Maybe they didn’t lift or do anything heavy or do much activity for three days. So they did feel better. Yes. So I’d like to know what their activity is because if you really look at the pattern, and sometimes I have them write down, well what did you do for that week? And you’ll notice that for three days they really just were more sedentary. Well then actually when they’re more active, that could indicate in fact that when they have symptoms, this is indicative of a hernia. So I think there’s a place for that, but I think I would love to hear your answer to what you say.

Speaker 1 (00:28:10):

So hernia, well, the short answer is we don’t really know. There’s no science that can prove this specific activity or pressure will always give you symptoms. Everyone’s a little bit different, but in general, there are situations where maybe you’re constipated and you’re straining and that’s adding additional abdominal pressure. Maybe the type of activity you had during that day is different or the way that you cared yourself and type of clothing you wore. All of those can affect whether a hernia will have symptoms that are exacerbated. I mean there are people that run around in the same exact hernia that have no symptoms, others that have severe symptoms. And then there’s the people in between that are intermittent. So it’s very related to whether an intestine is stuck or not. Hernias are mobile, so things that go in can come out. That’s why we like to do dynamic studies, dynamic imaging. It’s ultrasound or MRI, sometimes CT to look at hernias because just as it’s not a static problem and things can move in and out and all those can affect it, it doesn’t mean you do or do not have a hernia though it’s not predictive in any way. Yeah. So thank you for that question. Okay, next question has to do with athletic pubalgia. What are types of specific physical therapy for patients with known athletic pubalgia?

Speaker 2 (00:29:36):

Yeah, these are interesting and tricky questions to answer.

Speaker 1 (00:29:39):

I know

Speaker 2 (00:29:42):

Some things that are much more specific. We always do this or this is what we consider with that. It really is symptom driven a lot. It’s when they get exacerbated and it’s similar to a lot of these movement dysfunctions I was talking about. The goal with that is first of all, is it really that pubalgia there? That’s the first thing you want to rule in, rule out, make sure that that’s what it actually is. As you were saying, sometimes things are getting missed. Is it actually a different, is it a hernia there? Is it a pelvic floor dysfunction functioning that way? Right. But let’s say that it is something like that. When patients have had that, we look at, again, the pelvic floor, we treat everything around it as well. But I also do a lot of movement changes. So for example, if they consistently have problems every time they’re walking certain amount of mileage or they’re running or those things, we don’t say you won’t ever be able to do that again.

Speaker 2 (00:30:33):

But we take everything away that’s really exacerbating those symptoms and we start to scale them back slowly. Sometimes manual tissue mobilization around the area can help, but not for the reason people think. It’s not because you’re doing some magical with their tissue. It’s actually again, just a way to input into the nervous system there. It can help sometimes with any kind of thing that you would do for inflammation, that sort of thing. But really it’s more modification of symptoms and scaling back so they get stronger around that area. But first taking away things that continue to really affect that area if it’s specifically if everything else has been ruled out.

Speaker 1 (00:31:10):

So what we are taught for athletic pubalgia is acute. So just happened. And I athletic pubalgia is basically a strain or sports hernia or there’s all different terms for it, but it’s basically a tear or really bad strain of a muscle usually against a bone or ligament. The initial treatment of that is anti-inflammatories and rest. Does that mean they should not do physical therapy during that early phase because you have to rest or no?

Speaker 2 (00:31:43):

Well, I think it depends, and this is the other thing that comes up, physical therapy, the tricky part is it’s not really a modality, it’s more of the professional who’s handling it. So there, if you say, hey, do physical therapy, you may have one physical therapist that’s really aggressive that’s doing a lot of stuff that may aggravate it and you may have someone else that understands that pr, that idea that, hey, this is an acute phase, so what I’m going to do is support the tissue. I may do things to actually decompress or take pressure off that tissue. I may give them some gentle exercises that aren’t going to increase symptoms that they can still move. So I think it still can be done in the acute phase. It’s just a matter of really scaling it down. And then of course once they’ve gotten past that stage, there’s a lot more we can start to do for them.

Speaker 1 (00:32:25):

Also, you have other technologies like ultrasound and red light therapy and ways to reduce inflammation or accelerate the reduction inflammation and area, right?

Speaker 2 (00:32:37):

Yeah, it depends. Ultrasound has not been found to be, we are not really using ultrasound that much anymore. It’s kind of one of those over time research has kind of thrown that out. But there are some that are doing more of this infrared or cold laser and having some success. I think the verdict’s still out on that fully. Got it. But it’s definitely, I think if anything, the take home with all of this is the idea of scaling everything. So if someone says, I simply am not able to do this or this, pubalgia is just so bad, it’s figuring out, well what can they do? Where can we back them away and slowly get them into movements they can do. Because if you’re not active in those muscles at all, that’s also can be a problem. So we want to make sure that we’re doing things to actually get them to be more mobile but not actually create more irritation of that area.

Speaker 2 (00:33:23):

And by the way, there are times when people actually have pubic synthesis separation that gets called pubalgia and you can actually put your finger, you’ll go to the central part of their pubic area and they’ll jump and they’ll say, whoa, that’s, and you’ll, they’ll actually have more of a separation that’s being missed as well. So again, it’s really making sure we’re looking at the whole pelvis and everything around there. And I’ve actually caught some pubic ramus fractures as well that were actually being said to be actually pubalgia or more just an irritation or inflammation. And they had, I could just tell from the bone with so tender there that we went and had them get another x-ray and it did show up as a missed.

Speaker 1 (00:34:02):

Wow. So just to clarify, you treat both males and females, correct?

Speaker 2 (00:34:09):


Speaker 1 (00:34:10):

Yes. Cause we all have pelvic floors.

Speaker 2 (00:34:13):

We all do. And actually I would say that you also, if you’re looking for someone that specializes in pelvic floor, you do want to ask those questions. So depending on what body parts you have, I think it’s important to say how much experience do you have? Do you feel comfortable treating someone that has penile pain or that has pain with ejaculation? Those kinds of things. Because if someone primarily only specializes in postpartum care, yes, they be fantastic at what they do, but they may just not have the experience to work with someone that has a penis that has prostate or that has any kind of hernia there that it just may not be their specialty. So I think that’s important to ask those questions.

Speaker 1 (00:34:52):

On that note, there is a penile question. Can you injure the RQ at pubic ligament or suspensory ligament of the penis during core training perhaps done with poor form? That’s a tough one.

Speaker 2 (00:35:06):

I don’t know. Yeah, I know these questions

Speaker 1 (00:35:12):

Stumped me. I’m not sure

Speaker 2 (00:35:14):

I’d say anything is possible, but if you look at statistics and if you look at, I would think there could be a lot of other things to consider instead of thinking it’s immediately that, yeah, I don’t know. I haven’t seen that injury enough to say personally I’m not. Yeah,

Speaker 1 (00:35:32):

That seems like an odd one. With regard to that question though, are there a lot of, or are there any male pelvic floor specialists?

Speaker 2 (00:35:42):

Yes, there are actually. We’ve trained a variety of them and there’s some all over the us There’s not a lot. If you look at ratio, it’s very much more female dominated in terms of specialists there. But we do have a variety of male practitioners that are in the US as well as across the world, yes. Right, perfect. And actually one or two of them that I know they actually had an experience with significant pelvic pain and wanted to go into that specifically because they thought that they could help so many more people with it. So that was really, it’s inspiring to hear some of their stories.

Speaker 1 (00:36:15):

Got it. What are some exercises that can cause injuries to the abdominal muscles and their insertions? Are there exercises that can actually injure the pelvic floor or the abdominal wall?

Speaker 2 (00:36:27):

Not some of these questions, they’re great, but they’re actually pretty resilient and we’re actually quite strong. So even if someone says, what would it be, something that would cause a hernia immediately, you can’t even pinpoint it to say there’s no, oh, if you do this, you’ll always get a hernia. Yeah, it’s the same thing with this. There’s not really an exercise I can think of that if you immediately, or if you repetitively do this, you will injure the abdominal muscles. In fact, I’ll go as far as to say, even when we talk about pregnancy and postpartum, there used to be this idea that don’t do any crunches because you’ll make your the diastasis recti worse. The linear elbow will separate more and we just haven’t seen this in research to be true that just doing a lot of crunches or a lot of planks increases insertion issues or abdominal muscle tears or problems. Got it. Now we do know, I guess in people that are smokers or already have some weakness of the abdominal wall, you could have potentially have them do things that are beyond the tissue integrity. I’m sure there are cases like that, but I can’t think of one exercise that I would say don’t ever do because you will.

Speaker 1 (00:37:35):

I agree. Exercise are not intended to cause injury. There are certain extreme sports where you could injure yourself, but true exercise. Yeah. Same with this next question. What exercise can injure the adductor muscles if you’re doing, yeah, even if you do the splits, you shouldn’t injure your adductor muscle.

Speaker 2 (00:37:57):

And it’s all about preparation and the movement too, because one of the things I say actually, I tell patients there’s that exercise at the gym, there’s the machines where you push your leg in. Yes. You strap your legs onto that contraption and you move your legs in like that. Yes. I usually say for most of the patients I, I’m very clear, I don’t like to say don’t ever do any particular exercise, but that if I were to pick a few that I would say I would not recommend. Yes. I don’t love that exercise. The lever arm is in a strange place where it’s actually, it sits the most of the weight is going to be distributed in a strange area, but then when someone pulls their legs in against weight, they’re actually having to contract a lot of the pelvic floor. It’s actually got a lot of contraction there and around the pubic.

Speaker 2 (00:38:47):

So if someone, when I have seen abductor injuries, believe it or not, I have seen it from that machine. They put too much weight and they’re heavily just trying to go too fast or too hard with it. And so when we have seen some injuries there, it’s sometimes been some sort of shearing force or problem with that type of exercise. Again, very rare and I wouldn’t say don’t ever do that, but very rare. And then of course we see a lot of athletic injuries with adductors and hamstrings, so just more pivot movements, that kind of thing, but an actual exercise, not necessarily.

Speaker 1 (00:39:21):

What about gluteal bridges? That’s become like a fad. You injured, injured with gluteal bridges? You know what I’m talking about? They put, they’re basically,

Speaker 2 (00:39:32):


Speaker 1 (00:39:33):

Body is somewhat horizontal but not supported by anything, and then there’s weights that’s put on just a lower pelvis and you do these pushups with your pelvis.

Speaker 2 (00:39:44):

Right. So Brett Contreras became famous for this, the gluteal thrust maneuvers where you’re basically one of the, if you look at again, the research in terms of activating glutes, it’s one of the highest in terms of actually getting glute activation isolated there. Okay. Is it as functional because you’re not walking around doing it? No, but it is actually for true gluteal intensity, it can. So the question is can abdominal muscles or tennis insertions to the pubic bone be injured? Yeah. Again, if you’re using relatively decent form and you’re not overdoing anything, usually no. It’s not something that you would immediately think you’re going to have a pubic bone injury. Now, if someone came to me and said they think they injured themselves that way, we could certainly look back and figure out does this make sense in their particular case? Yeah. I think maybe what this person’s asking in this particular case, it may have been that they did this, but is this a typical injury we see for gluteal bridges? No.

Speaker 1 (00:40:40):

Yeah, I agree. All right.

Speaker 2 (00:40:44):

Yeah, we we’re having some interesting questions here.

Speaker 1 (00:40:47):

I know. Oh, this is a good one. It’s about pelvic pain, but it is a known cause of pelvic pain is pelvic congestion. This is a patient with chronic pelvic pain and then CT scan shows pelvic congestion syndrome. And for those of you that don’t know what that is, which is probably most people, because I didn’t even know what it was until I got into the specialty pelvic congestion syndrome is exactly what it sounds like. You have congestion of the veins, almost like a extra pressure of veins. So I call it varicose veins of the pelvis. And so it acts just like varicose veins of the leg when you’re upright and walking around, it pulls more and you get more pelvic pain and the treatment is deal with, it’s a vascular problem. But is there anything that physical therapists can do about congestion?

Speaker 2 (00:41:42):

This is kind of an interesting crossover too, because if the primary issue is vascular in nature, and so some of the things I look for and who I refer to for vascular is if they tell me they constantly have a heaviness, yes, they feel like by the end of the day everything’s super heavy, they just notice they’re having a lot more complications with it. It just feels heavy and we’ve ruled out probably not prolapse issues. Then we’re looking at do they have local labial? Is it more of a local issue where it’s just really more around the labial area? Is there, or do they complain about a heavy congestion all around the abdominal area as well?

Speaker 1 (00:42:23):

Yeah, the labral we see with pregnant women,

Speaker 2 (00:42:25):

Yeah, for sure. And you see this, I’ve seen this in smokers and other people too. It’s just a change in their vascular system and they’ll have that heaviness there. So I like to look at is it peripheral? Is it more like, hey, this may be a deeper thing. Sometimes we’ve caught some patients where we sent them off and they’ve had nut crack nutcracker syndrome, which is a specific vascular issue, and then we have them do like venograms and things, and it could be CTs but venograms as well to really map out. So a medical issue, I always wanted to make sure they get that help first, but what do we do? There are those of us that, and I’m not an expert in this particular area, but I’ve been trained, we do more of lymphatic type of work where there are lymphatic specialists that also specialize in the pelvic area and so Got it. They may have that person wear special garments around the pelvic area, abdominal area, as well as do some really nice specific lymphatic work around the pelvis. So there are people who really do specialize in lymphatic and congestion issues. But again, if you are just doing the congestion lymphatic part of it, but the underlying problem isn’t treated, they may continue to have these symptoms and problems because the underlying vascular problem.

Speaker 1 (00:43:36):

Yeah, very true. Very cool. Yeah. Okay, so this is a hernia surgery question about chronic nerve pain. How can you help? So if there’s nerve entrapment from an operation, are there physical therapy modalities that can help release that?

Speaker 2 (00:44:00):

Also tricky thing if it’s, I mean if it’s true, true entrapment, I would be concerned. It’s more about what we teach a lot. So when I teach my pudendal nueralgia on the pelvic complex pelvic pain course, it’s the heavy word. The heavy word or wording around all this is neuromodulation. So it’s more about if someone has specific pain, that’s it. It’s just in this one area and it specifically seems like it potentially a nerve or region a neuralgia in that area. It’s a lot of can I, and I sound sometimes like I’m repeating, but this is really important, this idea that can I do anything? Can I lift up the tissue there? And they say, oh wow, that feels really good. I really want you to stay there that don’t move your hand. To me, that’s a form of neuromodulation. It’s a way to tell them, Hey, there is something we can do that does make it better.

Speaker 2 (00:44:47):

What can we do to have you do at home to have that continued effect? And so sometimes just by doing neuromodulation, by changing the way they move or changing the tissue, you can actually get, it’s this whole connection with the brain that you can in fact get it to modulate to the fact where they say, wow, it’s really not as bad anymore. But if it’s a true entrapment, then I get concerned that telling them, oh, we just touch you and everything’s better. We really want to make sure that we’re looking again at is it true en treatment that needs some type of intervention, surgical or other. But from a neuromodulation, we do this all the time and our education’s really heavy now on the brain and pain connection and working on neuromodulation as a big part of

Speaker 1 (00:45:26):

This. That’s fantastic. And are most physical therapists in tune with that or is that hyper specialized?

Speaker 2 (00:45:33):

Yeah, so this is what happened. It’s really been interesting to watch. I’ve been teaching all over the world for probably 10 years now, and when I used to teach, I would go to wherever it was Israel or wherever I was going, and I would go there and I would say, raise your hands if you’re familiar with Laura Moseley’s work or Brain Pain connection and all this neuromodulation, and it would usually be only one or two people in the whole room. And then it’s gotten to the point over the years now where I’d say probably 50 50, there’s probably 50% of the room is more aware of it and we’re growing with in terms of that education. And so I think that it’s, the pain research is so clear now that this has to be mentioned that I think almost every course really we should be Tela teaching this and this should be the way we’re addressing pain. If anyone has pain, we really need to be understanding of that.

Speaker 1 (00:46:19):

Yeah, very cool.

Speaker 2 (00:46:20):

So I’m hoping to continue to get it to be higher. I think it’s getting higher now, but it was fascinating how it’s changed over the years. Thank goodness.

Speaker 1 (00:46:27):

So this is a great question. I have an answer to it, but it’s mostly because of you and your colleagues. What type of exercises should be used early after hernia or athletic pubalgia surgery and how soon should they begin?

Speaker 2 (00:46:44):

Well, I do have some answers, but now I’m curious to know what you were going to say.

Speaker 1 (00:46:48):

What do you think? Well, we have our recently past president of the America’s Hernia Society is Dr. Ben Poulose. He was one of our guests on hernia talk and he’s currently practicing, he’s chairing at the Ohio State University. So his love is to not just focus on hernias and hernia repairs, but also abdominal core health. That’s his thing. And in doing so, he’s done a lot of research on the core and how hernia repairs may improve that, but also the rehabilitation of it. And so if you actually go on the American, sorry, abdominal core Health Webs website, which is achqc dot com, there’s a patient section and you can download exercises that he’s found to be helpful immediately after surgery so you can share it with your doctors while you’re in the hospital with your physical therapist. There’s a whole handout to share, which is mostly physical therapy friendly. And there’s another handout for patients. So that’s, that’s been posted on our website before on Instagram. I have a link to it. So that’s what we know. I don’t really know much more about what’s been scientifically proven to be helpful. Everyone says, well, if I get my knee replaced, I’m a very specific physical therapy regimen to undergo. Why isn’t there one from my abdominal wall? And I don’t have a good answer for that, but maybe you do.

Speaker 2 (00:48:25):

Yeah, so the answer is that some of it’s just that no one ever really, like you said, no one’s really put it together, but it’s so great to know that there is something out there now like you’re saying, because we just haven’t put something together for each specific surgery. We just know usually that for this particular type of surgery, we know usually six to eight weeks of really nice recovery in most surgeries. So for the most part you’re doing really small movements. There’s not one specific exercise that’s good for every single single surgery. It’s more about getting movement in all areas, particularly lower extremities and just getting them moving and making sure that you’re not exacerbating pain too much or making the person feel worse, especially around the surgical area. But really it’s usually always you actually, if you look at the knee surgeries and you look at what you probably have in the, I’ve seen the hernia one at that one time, they look actually somewhat similar actually.

Speaker 2 (00:49:16):

They’re very general movements. It’s usually getting your leg to be moving gently lifting up. It’s a lot of things that we would give for someone with basic just getting their legs moving and their arms moving, and then we just scale it from there to the point where we do want them ultimately after that six to eight weeks doing a lot more squat type movements and all that, and the research continues to show, and this is the biggest point, I can say that there’s not one good specific exercise that’s the best, even if they have low back pain, if they have abdominal pain, it’s what does a patient like to do? What are they going to be the most excited to do out of all their exercises and also the thing that helps them move. So we usually say some form of walking because that’s great for movement, but then also what are pick four exercises that you love to do and that’s great, at least something that’s more upper body, something that’s maybe more lower body, and you’re probably going to get around the mid area as well, the whole core that we’ve been talking about.

Speaker 2 (00:50:10):

So it’s usually more what they like to do. There’s been no, every study that’s come out has said there’s not, for example, someone had back pain you we think of exercises, okay, you’re going to have them plank or you’re going to have them squat or something. Those are good exercises, but it doesn’t necessarily mean they’re the only ones that person can do.

Speaker 1 (00:50:27):

Yeah, no, I totally agree. And then how early after surgery you think it’s appropriate to do that?

Speaker 2 (00:50:33):

Well, it depends what you’re doing, but I think for anything that’s in the first three, two weeks, it’s really more gentle movement. Yeah, I would keep it so that if you think about it, even when someone’s even two weeks postpartum post, not postpartum post-surgery, they’re still moving around. They’re lifting things and things. So I think it depends on also what the surgeon recommends. So are you recommending them not lifting that much during that time? What’s your recommendation?

Speaker 1 (00:50:59):

So it used to be that everything was six weeks. You no lifting for six weeks, no exercise for six weeks. I don’t know where that number came from, but it’s pretty much been debunked by most of us specialists. You really should have a hernia repair performed so that you can just go back to normal activities as soon as you wish. And I do not recommend, and the international kind of hernia specialists do not recommend the guidelines, any type of activity restriction. That said, if there’s a situation where it’s like their seventh operation, really horrible tissue, you may want to be careful because there are patients that will not do well. But I believe just like the orthopedics where you want to get that joint moving and then strengthen the muscles around it as part of your physical therapy and it won’t destroy whatever operation they did. The same is probably true for the abdominal wall. What’s good about this AHSQC dot com website and they’re linked to all these handouts besides the fact that it’s free, is that it does kind of break it down into within the first week after surgery and then the first three weeks and then months later. So it does kind of guide you a little bit as to how you go through. But I mean, I do hernia repairs. I’ve had cyclists go and cycle fi 50 miles the next day.

Speaker 2 (00:52:28):

Oh wow.

Speaker 1 (00:52:29):

See, I’m totally okay with that.

Speaker 2 (00:52:31):

I still am a big believer in scaling things. I still think, because we work with a lot of, I’ve worked with professional athletes and triathletes and they always want to get back into it. And even in those cases it’s like, okay, prove to me first in a cordial, fun way, but let’s see first what you can do at the scale down version. If you pass that test and you’re not having to pain discomfort and you’ve also really been healed from, I mean some of these surgeries, you really do need time to heal, but I want them to first pass that and then we scale it. I would not recommend 50 miles cycling personally right away,

Speaker 1 (00:53:05):

But they’ve perfectly

Speaker 2 (00:53:07):

Fine. They’re going to do it, but I think everything’s scaling it. So within the first few weeks everything were gentle. And then I do think that within that six to eight weeks you can start to really ramp them up. They’re already moving around and getting out of bed and doing things anyway, so

Speaker 1 (00:53:20):

That’s right. Also, my other thing too is if you have a lot of pain, that is not normal either. The surgery, at least for hernia surgery should not be done tight. It should be done to bring back function and not necessarily make you super tight. Same way when you buy clothing, it’s to be a functional outfit, not for it to be super tight because you’re just going to tear through it. So a lot of people have so much pain and really horrible recovery after surgery. And even though everyone’s a little bit different, sometimes that’s indication that the repair was done too tightly or it wasn’t as gentle for your body as it could have been. Right. Another question about sports hernia is a lot of sports questions, is it common to have pelvic pain with a sports hernia?

Speaker 2 (00:54:09):

Yeah, I mean, I would love to hear your answer on this because I think sometimes we don’t know we’re, we’re not sure that they have necessarily, when we’re doing our exams, we can’t always say, aha, it’s definitely a sports hernia, so it’s harder for us to know this. So we are doing our differentials and again, treating them from what we’re finding their symptoms are. Yes. But it’s tricky to say that specifically. Oh, it’s definitely a hernia, a sports hernia. So I’d be curious to know how you would answer that.

Speaker 1 (00:54:35):

Yeah. Sports hernias are definitely poorly studied and poorly understood. It’s often in an athletic person, the term is thrown around by anyone who has, usually males that have pelvic pain that they can’t feel a hernia and there’s no other reason for it. You got a sports hernia, which means I can’t feel it. You have pain the groin, but I can’t feel it often. Those are just hernias and yeah, hernias can cause chronic pelvic pain. It’s a well-known cause of it. Mostly it’s diagnosed poorly diagnosed in women, but in men that don’t have the traditional big bulge from the hernia, that can definitely cause pelvic pain. And we don’t usually use a term chronic pelvic pain as much in men, but there’s definitely a subset of patients that have undiagnosed what we call occult or hidden hernias that contribute to their pelvic pain.

Speaker 2 (00:55:29):

Totally, absolutely. And that’s where I was going to go too with it is say that if someone really does have pelvic pain and it, it’s a male that has pelvic pain, so many other things I’d be considering than thinking, oh, it must be a sports hernia. That’s the first thing I go to. We do want to look at pelvic floor, abdominal wall in general. All these things you’re talking about isn’t a cult hernia, those things in general.

Speaker 1 (00:55:49):

So the short answer is no. A true sports hernia should not cause pelvic pain in a true sense of the term. But if you’re labeled with sports hernia and it’s caused by something else that can be contributing to your pelvic pain, then that can be true. I have one last one that we’re going to finish up with. It’s complicated, so I’m going to read it for you. Hopefully we can answer it. So this patient says she has abdominal hip groin pain on the right side. She’s had multiple operations in the past, endometriosis two C-sections, hysterectomy, right angle hernia pair. She has known disc disease of her hip of back. She has known thin cartilage of her right hip socket. She’s told she needs a hip replacement in the future, so she doesn’t know where to start. Physical therapists would want to go, would not go internally in the past because she was considered to be too tight and it was too painful. But she does have a hardness of pain going horizontally across her lower abdomen towards her right hip, but her pains are abdominal, hip and groin. I think that may just be your hip.

Speaker 2 (00:57:05):

Yeah, I think the larger question, so one of the things I ask patients, and this seems to be a really nice way to do it, is if I had a magic wand and I could put it on you and make something better for you, what’s the number one priority? And then we go one, two, and three, what is it preventing you from doing? And so sometimes people want to do pelvic floor, for example, an exam, but that’s actually not even, that’s say, well, I have difficulty having intercourse, but it turns out that that’s number seven on their list. So I actually like to know for that particular person, she said about having discomfort along abdominal wall, hips, that sort of thing back, but what is it preventing them from do? What are you having trouble doing? Good point. And what’s the priority? So if the answer is, oh wow, I’m not walking anymore because of abdominal pain, that would be where I would focus first. So it really depends on what the symptoms are and what, instead of thinking, oh, we have to always go to the hip or the back, I like to know first what’s their priority. That really helps tremendously to at least start uncovering some of this stuff.

Speaker 1 (00:58:08):

Does a hip problem like a labral tear or something, does that cause pelvic floor problems, spasm or pain? It

Speaker 2 (00:58:16):

Can. And there’s this tricky situation where you can have an, you can, and we talked about this before too, and it gets really complicated. Someone can have a labral tear similar to someone can have a herniated disc in their back and have back pain, but that doesn’t mean that the herniated disc is causing their back pain. Correct. Similar way, someone can have a labral tear that’s found either incidentally or if they’re looking for it on an MRI or an arthro arthrogram. And what’ll happen is they’ll get labeled as, that must be your hip pain or that must be your pelvic floor problem. Yeah. When actually it was more of an incidental finding. So we need to really make sure, does the other hip testing that we do, we do some really nice manual tests too. Does that also correlate with their symptoms they’re having? And we can really rule out and screen a lot for the hip as well, hands-on those of us that are trained to do that specifically.

Speaker 2 (00:59:04):

So I really like to corroborate that and say, does that make sense as a hip makes sense in this case. So simply having a labral tear, are there people that have labral tears that then have pelvic floor disorders? Absolutely. Okay. Are there people who have pelvic floor disorders and then also happen to have a hip problem but their pelvic floor may not ever get better fully? Well, I shouldn’t say ever. It may not get better if we don’t address the pelvic floor itself. Awesome. So it’s always, there’s always this, well, maybe it depends, and I know that’s tough to hear sometimes, but I think it’s actually liberating because it gives us a lot of opportunities to try different things instead of saying, well, if the labral tear doesn’t, the surgery doesn’t work, there’s nothing more we can offer. There’s so many things to look at.

Speaker 1 (00:59:46):

Yeah. Yeah. It’s very complicated though, I must admit. And there are very few specialists, very few people that choose to go into this specialty, I would say, and those that Do you love it? Yes. Just the way I love my hernias and I really appreciate that you wore my got hernia. Yes. For this webcast. I really do. I love it. Thank you so much.

Speaker 2 (01:00:11):

I appreciate your

Speaker 1 (01:00:12):

Shirt. We’re like mutually excellent fans of each other.

Speaker 2 (01:00:16):

Yes, exactly.

Speaker 1 (01:00:18):

For you do have the Global Pelvic Health Alliance and I was very lucky to be able to, we did a whole two hour session together on that one. I really enjoyed it. And that is available to be watched free of charge on my Instagram link. So if anyone’s interested in that, I thought that was really, really well done. So thank you for that. Yes. Great. That’s pretty much it. I feel like we covered a lot of sports questions, but also a fair number of pelvic floor questions, males versus females. I definitely learned a lot.

Speaker 2 (01:00:59):

And I think that if I could say to encapsulate a final thought is just the idea that it is sometimes challenging with pelvic floor, with pelvic health. And I tell this, there’s so much hope for those that are dealing with this that I would say give up. So just like we’re talking about, there are people that really are specialists in this that have dedicated their lives, lives to doing this, that really are passionate about it. So if you go to five people and they say, ah, I don’t want any, I don’t know anything about that, or just take this medicine and they’re not giving you a lot of time. No. There’s someone out there, yes. Who it may take a team of three people, but there are people out there that will connect with you. And now we have telehealth, we have all sorts of ways of doing this across. And you do consultations as well. Yeah. All across the world. So there are people who are passionate that can help you. So don’t give up and think that you’re doomed to have this issue. It’s just a matter of sometimes trial and error with it.

Speaker 1 (01:01:51):

I totally agree. And on that, no, we’re going to say goodbye to our audience. I will make sure that you have this available for you to watch and share on YouTube. It’s also available on my Facebook page at Dr. Towfigh And I’ll share all those links with you on my social media platforms at Hernia Doc on Twitter and Instagram. Thank you, Tracy. I really appreciate your time. I know it’s later at night that it is here in Los Angeles, so you’re in Florida. Hope you enjoy the rest of your evening. Thank you for volunteering your time and thank you. Thank you for everyone. I know that we went through a lot of great questions and I do appreciate it and hope you have a good night. All right. Thank you. Thank you. Bye-bye. Bye.