Episode 75: Orthopedic Causes of Groin Pain | Hernia Talk Live Q&A

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Speaker 1 (00:00:00):

Hey everyone, it’s Dr. Towfigh. Thank you for joining me. Today is Tuesday. We’re here for another Hernia Talk Live. Some of you are joining me via Zoom, others on Facebook as a Facebook live at Dr. Towfigh. Thanks to everyone who follows me on Instagram and Twitter at hernia doc. Many of you also sent me questions via hernia talk.com, which is the precursor to our Hernia Talk Live Q&A. You all know me as Dr. Shirin Towfigh. I am your hernia and laparoscopic surgery specialist. I’m very excited today because a surgeon that I completely admire so much, we’ll be joining us. His name is Dr. Guy Paiement. He’s French Canadian originally. He is one of the premier surgeons in orthopedic surgery at Cedar Sinai Medical Center, which if you have seen any of the reviews on US News and World Report notes, it’s one of the top centers for orthopedic surgery, both in my town Los Angeles, but also in the entire United States nation.

Speaker 1 (00:01:08):

And he leads the educational training for them. He’s a trauma surgeon, sports surgeon. You can follow him on Instagram at Guy Paiement or on Twitter at G Darius P. So he’s of course busy with patients, so he’ll be joining us shortly. I’m really excited to have him because the goal of today is to try and understand the orthopedic side of groin pain. So we’ve discussed this multiple times before. The groin is can, let me rephrase this. The groin is a very complicated space. You can have a lot of different problems that cause groin pain, it can be intestinal. We’ve had gastroenterologists come and talk to us about diverticulitis and appendicitis and Crohn’s disease. It can be gynecologic. And we’ve had gynecologists join us and talk about endometriosis, ovarian cyst, fibroids, adenomyosis, and other reasons for groin pain and often is just referred to as chronic pelvic pain.

Speaker 1 (00:02:12):

In women. We know obviously hernias can cause and it’s actually the most common cause for groin pain. We shall be having some spine surgeons coming so they can talk to us about how the spine can actually cause groin pain and how spine surgery can cause hernias. So that’s going to be really exciting coming up in the near future. And then today we’ll be focusing on orthopedic surgery as a different cause of hernia pain. So what is orthopedic surgeries? Basically surgery of the bones and in the pelvis there’s the pelvic bone and there’s also the hip. So the combination of the sacrum, the pelvis and the hip is what is part of the pelvis. And then groin pain can be referred pain from any of those areas where they may be disordered. It could be arthritis, a fracture, a tear, inflammation in the area and so on.

Speaker 1 (00:03:15):

So that’s what we’re going to be discussing with Dr. Paiement. I have a lot of questions. So many of you may know that I’ve written a book. It’s called the Sages Manual of Groin Pain. I’ve written it with two other of my esteemed hernia specialists, colleagues, Dr. David Chen and Dr. Bruce Ramshaw. It is I believe the premiere book on groin pain. And there is an intense chapter on just orthopedic causes of growing pain. And that’s important because it’s a very unique and important part. Dr. Paiement, who’s our guest today, was the author of that chapter. It is intense. He did such an amazing job of going through all the different diseases that can cause groin pain that are orthopedic and he has pictures of how to examine and all the different manipulations that doctors can do to help differentiate groin pain from other pain. So yes, we’re hoping to review all that with him.

Speaker 1 (00:04:19):

He is a surgeon that I often refer to, not because necessarily some of the stuff I refer to him as his specialty because he’s mostly, he does a lot of hip surgery and hip replacements, but he’s just a super intelligent surgeon. I feel that a lot of my success has to do with the success of having other specialists that I can rely on that like me are inquisitive and won’t kind of shy away from problems or complex patients and really know their kind of specialty well. And so I do have a great black book full of patients that, I’m sorry, surgeons and doctors that I rely on whether many of them are here on hernia talk and I bring them on. Many of them I share patients from across the United States and you’ve seen many of them from the east coast and the south and north and Midwest that have come on my show. So it’s really fantastic for me and for my patients to have access to these doctors so they can all kind of figure out some of these disorders with me. So we’re hoping that once he’s able to finish up patient care that he’ll join us for this. In the meantime, a lot of you have sent questions. It ranges from hip problems to spine problems to pregnancy related and labor related orthopedic issues, sports hernias.

Speaker 1 (00:05:56):

I’m really excited to review these with Dr. Paiement. And I’ll tell you, when I see a patient with a groin pain, I have a very open mind. In fact, some of them actually have hernias and I say, yeah, you have a hernia, but it’s not your problem. In fact, I sent him a patient I think last week. So the patient had groin pain and a very clear hernia, but the pain was ref… He takes like a C, makes his hand into a C and he puts it along his hip on the side and says, this is where my pain is. And that classically is a hip problem. Usually people who have groin pain due to a hernia have pain also encompassing focusing around the hernia itself. They may have testicular pain, but they often are better when they’re lying flat. Not true for hip disorders.

Speaker 1 (00:06:51):

This guy, he is not better when he’s lying flat. They often. They can have pain with certain activities that involve differential flexion of the hip- stairs and hills can be a problem and that’s not usually the situation for groin hernias. And then very importantly, when they’re lying flat, their pain does not go away and they have buttock pain, which is what this gentleman had. And you ask them, do you have a hip click in people that have labral tears or an impingement, they can have what’s called a hip click. And in having that hip click it, what it does is it actually is patho pneumonic for a hip disorder. Now not everyone that has a hip click has painful hip, but if you have a painful hip and you have a hip click, then those two diagnoses go well together. So those are little clues.

Speaker 1 (00:07:45):

So when I talk to a patient, I really don’t want to fix their hernia if that’s not going to help them. So I sent ’em to Dr. Paiement, for example. And we’ve also met Dr. Snibbe who was a actual hip specialist in town that I heavily rely on. In fact, I’m wearing his shoes. I think I showed you guys. Snibbs is like S N I B B S. You can find it online. They have, he makes comfortable shoes that are good for your hip and knees and pelvis and back. And I own a couple pairs and my mom lives by them. So I’m actually wearing snibbs shoes and you can watch my interview with Dr. Snibbe. I think it’s been a year cause we’ve been online on doing this for about a year and a half. So that’s the thing with a hip.

Speaker 1 (00:08:41):

So if they have a hip click pain that radiates to the buttock pain with hills or stairs pain, that’s not better when you’re laying flat and difficulties with either crossing your legs or being frog lagged, those are all more consistent with a hip problem. The other thing we’ll al I also am curious to talk about with Dr. Paiement is sports hernias. So sports hernias can be repaired surgically at times and that is a very tricky procedure because it’s often on athletes and you don’t want to mess up their career by doing an unnecessary or poorly healing operation. And so you really want to go to a specialist for those. We talked to a specialist in that early this year with Dr. Poor and we’re planning on having a future discussion with some other really world famous sports hernia surgeons both nationally and internationally. We also spoke with Dr.

Speaker 1 (00:09:40):

Aali Sheen in the past from Manchester in the UK. So the way that orthopedic surgeons approach sports hernias are very different in the way hernia doctors do. So I really want to hear how Dr. Paiement does it because that’s really clear. So if you guys want to send in your questions, I’d be happy to review them. I have a ton of questions for Dr. Paiement, which I will very gladly share with him the minute that he is done with his patient care and comes on over. I also am curious what other specialists you’d like to hear from. We have some really amazing for gut surgeons for hiatal hernias. It’s not something that I do, but it’s definitely in the world of hernias, diaphragmatic hernias, they’re all coming up. I’ve got a great session coming up on a hernia Mesh in all the different meshes, what’s been recalled, what hasn’t and what’s pros and cons for different meshes.

Speaker 1 (00:10:41):

And I recently had someone write to me asking to talk about insurance, which is a very US central type topic. I have a lot of people that come on and watch me internationally, so it may not be as relevant to talk about insurance to my international audience, but definitely something that can be done in the future. So if you think that’s a good topic then we’ll do that. Let me share a screen and kind of go through some of the questions that have been shared with you, by you. So one was I don’t have a tear and I don’t have a hernia. What other orthopedic problems can cause my groin pain? And when I see a patient like this, mostly it’s things that go into my mind are sacroiliitis, which is either an infection or inflammation of your sacro ileal joint or what we call the SI joint.

Speaker 1 (00:11:36):

And that can be either an autoimmune problem or a mechanical problem. There’s imaging for that. And you can also get injected to the SI joint. You can also have an autoimmune antibody that’s elevated H L A B 27 is a blood test that can be checked as that problem hip bursitis hip, anything of the hip joint can cause groin pain. So hip bursitis, hip labral tear, hip arthritis and hip impingement. So like a CAM type impingement. There’s also so as impingement, which is partially related to the whole hip bursitis kind of element. And of course you have a fracture that would be odd not to know if you’ve fractured your pelvis tumors theoretically of the pelvis can cause groin pain and then there’s a whole pubic synthesis issue. Let’s see, we got a question here in the chat. Can groin pain cause pains around the top of the legs and hips?

Speaker 1 (00:12:46):

Yes. So it’s very important to see where in the groin the pain is and how much of the hip and upper thigh is involved. So if it’s a hernia problem then hernia pain can radiate to the inner thigh and sometimes, but especially femoral hernias to the upper thigh, but often not the lateral or outer thigh. Spine problems can cause pain in the lateral outer thigh in kind of the lower front of your thigh. And then some people that had bad hip problems, they feel like there’s a tightness around their entire hip area, sorry, their entire upper thigh area, like someone put a band around their thigh and I’m not sure why that is. Dr. Paiement hopefully will help answer that, but definitely the area and the location of the thigh pain can be diagnostic of different types of hip problems versus hernia problems. Pain in the groin is in the center small joint.

Speaker 1 (00:13:57):

I’m not sure what that means. Maybe you can help me figure out what you mean by that. Next question, what type of pain exists with trochaic bursitis? Great question. So based on my experience, bursitis is there are different ranges of it. It can be very mild or very severe. The amount of pain in the bursa, which is the sac which carries the fluid space in the joint, the amount of inflammation there can be very, very painful. And typically it affects your gait, so how you walk. Whereas hernias should not cause you limping or any gait problems. Also sitting or crossing your legs can hurt also the pain can be at the groin but also at your upper buttock area immediately behind the groin. So that’s more diagnostic With bursitis you can even have that kind of C like pain where it’s like a pain if you put your hand on your waist and that’s where the pain is. So that could be from bursitis. X-rays and imaging are very diagnostic a bursitis, so it’s a fairly straightforward diagnosis with imaging. And then secondly, they tend to inject you. So there’s often no surgery for birth size, at least for the early stages.

Speaker 1 (00:15:20):

All right, let’s go to the next question because we got so many questions to go through. Dr. Paiement is still with patients, so I’m hoping that the minute he’s done, he can walk on over and help me answer these questions. Okay, that’s another live question. Let’s see. My left hip rotates forward constantly due to denervated abdominal wall and resulting poor posture. Yes, I’ve seen that my entire core aches and pt, we’ve been working on this but still struggling after almost two years. Any recommendations? Once your core is unstable, then that has a big difference. It’s like scoliosis. Once your spine is out of whack, then it can have a lot of other implications to things even like your heart and your lungs. So yes, when your core is unstable, that’s a problem. A surgery to help stabilize a core can sometimes realign the hip. I’m actually doing one, I think she wants a surgery in January. So a lady who does have deprivation injury of the abdominal wall and she actually, her husband’s like her posture is different and it’s true her, she kind of holds herself in a little bit of crooked way and the pelvis has kind of shifted, almost rotated and long-term not healthy. So we’re fixing her.

Speaker 1 (00:16:47):

Next question. What are the most sport associated injuries that can cause groin pain? Well, the most obvious one’s, the one that we’re struggling with in Los Angeles, which is LeBron James of the Lakers, one of the most talented, the greatest of all time LeBron James. And he has a debilitating sports associate injury. He’s a man that’s a large build, has humongous muscles of the rectus muscle and the adductors and his bone is just like everyone else’s bones. And so when he trains and plays professionally in basketball and our lovely Los Angeles Lakers that hopefully will win a game tonight against Golden State, we’ll see. He’s constantly those muscles are pulling off, tearing the bone apart. And he’s been dealing with this for over a year and it actually, yeah, for sure over a year and it’s been completely debilitating and he can’t play. It’s just, and the more you try and push through it, the worse it is.

Speaker 1 (00:18:00):

It’s kind of like a Chinese finger trick where the more you pull on it, it actually gets tighter. So the more he plays, the more he’s injuring himself and you really can’t, like rest is really, really important. But then how long can you rest when you are the head leader player? So yeah, that’s a problem. And there’s a question here about Osteitis pubis. So itis means inflammation. So osteitis pubis is inflammation of the pubis bone and that inflammation can be from something that LeBron James has, which is the pulling of the adductor muscle or the rectus muscle off of the bone and causing inflammation there. It can also be due to the infection though that’s uncommon, but it is a known cause of osteitis pubis. And so in the center that is not hernia pain and that is not hip pain, but pain can be due to like a sports hernia.

Speaker 1 (00:19:07):

We see that also in football players, again, large build males, a lot of really heavy muscles, thick, strong muscles that are pulling themselves off their insertion on the bone during practice or professional football games. And so we see it in football player, American football players, soccer players or European football players, rugby a lot of hockey and some basketball. So these are typically very strong people with really big muscles. They do a lot of this kind of hip abduction, which means like a lot of like splits type actions and running and jump jumping and so on and landing. And so what they see is you get the kind of muscle pull off and it’s very, very, very painful.

Speaker 1 (00:20:04):

All right, next question. Have you heard of groin pain after I V F? So that’s a really interesting question. I V F means in vitro fertilization, the whole process involves a lot of hormonal changes and hormonal kind of injections. And so patients can get groin pain after I V F for two reasons. One is of course these are women. So one is they can actually have exacerbation of their endometriosis. So they can have endometriosis in the groin region or the round ligament or in the pelvis. And the endometriosis is triggered by the in vitro fertilization because of the high hormonal injections and transfusions infusions. And so that’s one way where growing pain is worse during I V F. The second is in general hormonal surges, especially estrogen surges can increase your pain level. So all pain may be increased during I V F, potentially same way they could, that pain can get increased with someone during their menses.

Speaker 1 (00:21:14):

So if you have a small groin hernia, you may actually have more pain from the small groin hernia during your period, during your menses or during in vitro fertilization. It’s purely a hormonal thing. And then the question is about whether orthopedic causes can be worse during I V F. And that is really related to I think, hormonal changes in the laxity of the ligaments. And so I’d love to hear what Dr. Paiement’s answer would be to that. Next question is about traumatic separation of the pubic synthesis. Have you seen it during labor and what’s recommended for such injury? So if you’re a petite woman and you’re carrying a baby, it’s very possible that your body will undergo certain changes that are just horribly traumatic. For example, if you are a small body and the baby’s large or you’re a small body and your pelvis is narrow, more a male type pelvis than the more kind of wide female pelvis that all the hormones that go into your system that encourage your abdominal wall muscles to expand, also encourage your ligaments to be very lax.

Speaker 1 (00:22:41):

And in being lax it some people actually dislocate their joints. You can have discs that occur because of some of that laxity and then also your pubic bone can start separating from each other. That’s not even during labor, that’s during the act of being pregnant as the baby is growing, your pelvis also kind of disrupts and opens up the ligaments. Then there’s a question of traumatic separation of the pubic syphilis during labor. And that is really, I mean it sounds to me that occurs at the time of when the child is brought out of the vaginal canal and you can actually scrape that whole underlining area of the behind the pubic bone with instruments, with the baby’s shoulder, et cetera, and cause a lot of injuries. And I’ve seen people who do that, who have suffered from that. It’s just a horrible complication because there’s so much damage.

Speaker 1 (00:23:50):

Then you get scar tissue from that and then it’s kind of this bad cycle. Next question. This is a live question. I have a bladder Mesh injury. The obtuator internist was severely injured due to the sling being implanted in it. The rest of the didn’t come through. But basically the question is regarding the internist muscle being injured with the sling being implanted. As far as I know, there’s no surgery for that. It would have to be a combination of physical therapy and maybe even in injections. But the question is what recommendations are there for the obtuator internist muscle? So depending on how the bladder Mesh or the pelvic Mesh was placed, it maybe go through the internist through the obtuator canal and then also through the muscles with the different hooks. And because of that, the act of removing it may actually cause damage in that area.

Speaker 1 (00:24:52):

So it’s good to kind of see what can be done from an orthopedic standpoint. So we’re hopefully when Dr. Paiement is back from his patient care, we can get him on board and have him answer some of our questions here. Next is the question about pain from femoral hernia. It definitely increases during menses. Okay, so someone here is sharing their experience about how the femoral hernia pain severely increases with menses. She writes, when I had a hysterectomy for groin pain that I didn’t need, that increased my pain, my pain away, but the hernia pain was still there. Yes, so correct. The hysterectomy is almost never a treatment for groin pain. And I know that people are sometimes labeled as having fibroids or a myosis, but if the worsening pain with menses goes away because you don’t have menses anymore because you don’t have a uterus that doesn’t necessarily treat the problem, which is the actual hernia, which is the cause of the pain, which I think is what our viewer is trying to answer. Thank you for this platform. Oh, well thank you for always being my top fan.

Speaker 1 (00:26:23):

I really like that everyone joins me to this day. Still impressed, impressed that people join me to talk about hernias. I mean, I enjoy it, but I’m really impressed that you guys enjoy it because most people don’t go around showing interest in hernias unless they have one. Maybe y’all have one and that’s the impetus. I don’t know, but I’m, I’m very grateful that you joined me for an hour each week. I do do this in a way that I feel is hopefully helpful to you guys. Oh, we have a chat. Let’s see what the chat says. You make them interesting. Oh, that’s very nice of you. Yeah, definitely do not think hernias were interesting when I was in training, I’ll tell you that. But my residents, let me stop this a little bit. My residents actually find it interesting, which I love. When I was a resident, hernia’s not interesting.

Speaker 1 (00:27:24):

It was the most boring, straightforward, no interest, no, no interesting stories, no interesting surgeries. It was just like no one went into hernia surgery at all until I was much, until I finished my training. And then I started figuring out that wow, there’s a lot of hernia surgery that needs to be done. And I got to liking of Dr. Harvey’s amid and he’s just an amazing surgeon and he was the only one that made hernias interesting. So I started to kind of emulate him and try and be like him. And now all my residents think hernias are interesting. They seem to want to scrub in on all my operations because they have a choice. They have gastric bypass, they have a stomach cancer, a colon cancer, bowel obstruction or hernia, and they tend to choose the hernia surgery. So I don’t know if I’m interesting or the hernia’s interesting or the story is interesting or what the situation is, but I love that my residents enjoy hernias and almost every year or so I have someone among them that is very much interested in doing this as a career.

Speaker 1 (00:28:47):

So you got some really great surgeons coming up in the hernia world. Okay, next question. I’ll comment by you. You’re a blessing to those of us in need of help. You’re welcome. I do appreciate it. Next question. I’ve had this sling totally removed several nerve injuries running to the groin, inner thigh vaginal pain, but the groin and pubic pain is significant. I’ve had multiple blocks to the pelvis and general femoral nerve and injections to the obtuator. I don’t know if there was anything else C there was anything else I could do? Well, okay, so here’s the thing. You clearly had an issue that required some type of management because we’re having complications from the pelvic Mesh. The problem is the following, just because you had pelvic Mesh complication does not mean that that hasn’t caused other injuries or that you don’t have something that was missed.

Speaker 1 (00:29:46):

Orthopedic injuries could be one, an actual groin hernia could be another. It’s just so common to have hernias. It should be always considered as a part of the work workup of a groin groin pain. So in terms of management, I would start with an MRI pelvis to really understand where there’s inflammation, where there’s a hernia, is there retained form body that needs to be addressed? Is there scar tissue in the area? You can easily consider R neurography to see if there’s a neuroma that’s involved and then have someone carefully go through your physical examination and your story. So that’s kind of where we’re at and I’m very pleased to say that on that note, I believe Dr. Paiement is ready to join us and I know that you’ll love him as much as I love him because he is truly one of my favorite people and I may be too embarrassed to say it to him live, but you’ll see. You’ll see. He’s just such a thoughtful and caring and educated surgeon. So any minute now, we’re going to have him log on and let’s see how he does.

Speaker 1 (00:31:09):

We have all these questions for him and we only have half an hour. I may have to bring him back. What do you guys think? All right. I should practice my French with them. I’m always too embarrassed with the French people because I can speak French, but they’re accents so much better than mine. All right, here’s another comment. Yes, absolutely. Okay. Yeah, I think we will bring him back again because he is just a wealth of knowledge and that’s his payback for spending time with patients instead of with us. All right. Well I’m going to do is I’m going to scroll back to his introduction and hopefully we can get there with him. So some of the questions we’re going to review are the labor pains, the obtuator internist injury and the hip rotation with core instability. Let’s see where he is. All right. You know what? I will be continuing on with our session until he comes on because there’s a lot of questions. So one interesting question is regarding the interaction between hernias and orthopedic problems like actual separately, I have some patients that have a hernia and they have an orthopedic problem. So one question they ask me is, can a large hernia cause orthopedic problems? Usually not. They’re two separate problems. So orthopedic issues usually do not cause hernias and or hernias do not usually cause orthopedic problems. There he is.

Speaker 2 (00:33:20):


Speaker 1 (00:33:21):

Hi. Hi.

Speaker 2 (00:33:23):

I’m sorry the clinic was heavy.

Speaker 1 (00:33:29):

I’m going to have to come and break up your clinic. Everyone wants to bring you back. So you just committed yourself to another session in the future.

Speaker 2 (00:33:39):

Oh, no problem. This time I will cancel the afternoon, the whole afternoon.

Speaker 1 (00:33:47):

So welcome. This is Guy Paiement. You don’t hear me, but I just raved about you and

Speaker 2 (00:33:52):

Oh, thank you.

Speaker 1 (00:33:53):

You are such a blessing to my patients and sometimes I don’t even know if you’re mad at me for sending me, sending many of my complicated patients, but I trust your judgment, so that’s why. Thank you. So

Speaker 2 (00:34:08):

We answer questions. Are you asking me questions or

Speaker 1 (00:34:11):

Yes, we have a lot of live questions. I’m hoping to get through some of those and we have tons of questions that were presented before. So I will kind of go some of through some of those. But one question here, I’ll show you this, I’ll share screen with you here. So one question which I’d love to know your thoughts on, has to do with traumatic separation of the pubic synthesis during labor. Have you seen that?

Speaker 2 (00:34:42):

I’ve seen that many times actually. When I was at C S F, it’s a largely OB G Y N department, almost as large as Cedars. You’re talking about five, 6,000 deliveries per year.

Speaker 1 (00:34:57):

Yeah, I think cedar,

Speaker 2 (00:34:59):

We will see that quite often In most cases the separation will correct itself and the synthesis will go back to its original position.

Speaker 1 (00:35:15):

Oh really?

Speaker 2 (00:35:16):

Yeah. The cases with that I’ve seen that required surgery were usually women who had two or three pregnancies very close to each other and between each pregnancies, the synthesis pubis would not have time to close back. And I remember the first person that I had to do surgery, she was the wife of an internist at U C S F and she had four babies in six years and she was a grammar school teacher and she had so much pain that she couldn’t work, mean she couldn’t even take care of these poor kids. So I went and put double plates across the synthesis pubis and she did fine, but it’s extremely rare. I’m must have done maybe I take 11 or 12 and 30 years.

Speaker 1 (00:36:16):

So if it happens, this is traumatic, this is at the time of labor or this is because of pregnancy and the lax

Speaker 2 (00:36:23):

Actually, as you know in the third trimester there is a hormone called relaxin that starts being released and it affects the synthesis pubic, but also the sac joint in the back. They become more flexible. And of course if you are carrying twins or triplets, the synthesis opens even more. And if it’s a big baby or if it’s a difficult deliveries, it can open more. But generally speaking of all the cases that I’ve seen, I would say we less than 1% would require surgery to put the synthesis back in

Speaker 1 (00:37:07):

Place. And is there certain types of binding or physical therapy that

Speaker 2 (00:37:11):

They take? No, the physical, it’s time essentially. Yeah.

Speaker 1 (00:37:16):

Yeah. Okay. Okay. Really

Speaker 2 (00:37:18):

Interesting. But I would say especially if it’s a relatively young woman, let’s say under age 40, usually the synthesis will close back.

Speaker 1 (00:37:29):

Okay, very interesting. Next question has to do with the obturator internus. So this lady had a bladder Mesh injury, the obturator internus was severely injured due to the sling being implanted in it. Are there any recommendations for the obturator internus injury I’ve had? Yeah, she said I’ve had the sling totally removed. There’s several nerve injuries running down the groin and inner thigh vaginal pain, groin and pubic pain is very significant. I’ve had multiple blocks to the pelvis and femoral nerve, obturator nerve kind of at a loss. But my recommendation was a MRI pelvis to look for inflammation, injury, any disruption or actually a hernia that may be missed. And sometimes you can have neuromas from these bad injuries,

Speaker 2 (00:38:20):

But I don’t know what exactly what she’s referring to. But if she’s referring to the obturator internus muscle, you’re absolutely right. I think an MRI will determine if that muscle is inflamed or the other short external rotators in the neighborhood because they originate from inside of the pelvis very close to where they would’ve put that Mesh. Yeah, you’re right. I think the best thing to do is to have a good quality pelvic MRI like a three tesla and basically tell the radiologist that exactly what she’s looking for. Because as you know with pelvic MRI, they have different sequences, either soft tissues or muscular. She needed a soft tissue sequence.

Speaker 1 (00:39:18):

Yes, absolutely. Okay. Next question had to do with rotation of the pelvis as it relates to the core. So I have a patient that I’m operating on who had denervation of her abdominal wall from spine surgery and actually not spine surgery. She had a nephrectomy, they did a T 12 injury. So she has degradation of her abdominal lot and this has become a growing mass on one side, like a little baby. And her hip pelvis is rotating as a result of it. And there’s another lady that’s on this. And so far we’ve had a lot of female questions, but I do have male questions too. Similar situation. She also has degradation of her abdominal wall from multiple kind of hernia pairs that have gone wrong. Sounds like she says. My left hip rotates forward constantly due to denervation abdominal wall and results in poor posture. My entire core aches in pt. We’ve been working on this but still struggling for almost two years. Do you have any recommendations?

Speaker 2 (00:40:23):

I presume this is a asymmetrical denervation of abdominal, I mean one Yeah, one side is normal. The other side is, am I correct about that?

Speaker 1 (00:40:34):

That’s correct.

Speaker 2 (00:40:36):

Really this is a big problem. Yeah,

Speaker 1 (00:40:43):

And that makes sense if your core is imbalance. So yeah, for that I actually do, I kind of try and return them to a more normal abdominal wall. It doesn’t add function, but there’s more stability. So I plicate the abdominal wall with a very wide Onlay Mesh and that seems to help these patients that are clearly denied.

Speaker 2 (00:41:06):

It definitely helps. The problem is that you, because of the denervation, you lose the dynamic stabilization of the core muscle on that side. Yeah, I’m not sure there is a magical solution for that.

Speaker 1 (00:41:28):

Yeah, that’s a tough problem. So here’s some more questions that have been submitted. This was interesting one, have you ever heard of groin pain after I V F in vitro fertilization? Yes. Okay. Tell me, because I gave them my theory, but what is your theory, I mean, or what is your reasoning for groin pain? After I V F?

Speaker 2 (00:41:50):

The case that I’ve seen, the patient had multiple attempt at I V F and it was the last attempt. The procedure took a long time and it was positional at the time of the procedure. Oh, I don’t know what your theory is, but I think that’s something that the OB G Y N should be aware of that and I V F, it’s not a minor procedure.

Speaker 1 (00:42:29):

So you’re saying at the time of egg retrieval? Yes. The way that they do, well it goes, they go transvaginal,

Speaker 2 (00:42:38):

But they had put the patient in too much abduction for her leg. It took a long time. It was usually, it’s a fast thing, but took a long time. And that lady had a couple of court harvesting procedure had not worked and that was really, in that case, a positional problem. And eventually she got better and then the pain went away.

Speaker 1 (00:43:07):

So we know that when women undergo certain gynecologic operations, the longer ones, if they’re often put in lithotomy, so the legs are in stirrups and if that’s done incorrectly where there’s too much abduction, so too much hip flexion and external rotation and it’s not like the hips aren’t aligned, then you’re like, are you impinging at the joint?

Speaker 2 (00:43:35):

What happened? Usually you end up with a adductor sprains that you see on people slipping on ice. You see that on ice skater hockey player and it takes really a long time to heal.

Speaker 1 (00:43:52):

Okay. Do they

Speaker 2 (00:43:53):

Get this muscle? These muscles are used all the time when we walk in daily life. Yeah, these patients will complain that they say growing pain, but it’s a little bit more toward the midline. It’s more if you allow me to see that it’s more crutch pain than growing pain.

Speaker 1 (00:44:14):

And then what about labral tears? Can’t they get labral tears from that positioning or no?

Speaker 2 (00:44:21):

No. Okay. No.

Speaker 1 (00:44:23):

Okay. There’s another question regarding sports associate injuries. What are the most commonly seen sports associate injuries that can cause growing pain?

Speaker 2 (00:44:41):

Definitely the labeled tear.

Speaker 1 (00:44:43):


Speaker 2 (00:44:44):

The, there’s a surprisingly large percentage of the population that have a CAM deformity. And the most common explanation, the most accepted explanation for the origin of a cam deformity is that when you’re a teenager, you’re 12, 13, 14, during your growth spur you do a lot of sports. And because you’re growing so fast, the growth plate becomes really thick but also weak and you have a little slip. It’s not the classic slip capital femoral epiphysis where the femoral had completely slips from the net, but just a little slip. So the head goes backward and a little bit sideward and then the growth ends. And usually it’s people who are very, very active and they end up with a cam deformity. And these people, they are very active when they are teenager in their twenties, in their thirties, and then they get a label tear.

Speaker 1 (00:45:58):

And can you explain what a labral tear is?

Speaker 2 (00:46:01):

Okay. The hip joint, it’s a ball and socket joint. So the socket is a hemisphere, the ball, it’s a sphere. They are together a little bit like a ball-bearing joint. And the labrum is essentially a rubber gasket around the joint. So if for people who are mechanically inclined, so I mean you’ve seen rubber gasket that they break or the tear, the joint becomes a little bit loose if you want. And painful, I would say 10, 15 years ago in teenager, people in their twenties, people would do anoscopy, remove the labrum. These days if all is possible, you repair the labrum, you would repair a meniscus in a, let’s say a 22 year old person. And in some cases you can even reconstruct the labrum with a semiosis or a standard.

Speaker 1 (00:47:13):

Wow. Okay. Here’s a next question also related to the labral tear. By the way, my audience is very, very intelligent. The questions they ask is so beyond I learned their questions. So the question is this is the pain in the groin region due to a labral tear? An example of radiating pain remote from the pain generator. And if the pain is associated with a labral tear and it’s due to radiating pain, then does palpating over the groin not recreate that pain or palpate over certain areas to recreate the pain?

Speaker 2 (00:48:00):

If I understand the patient, the question correctly, as you know the hip joint, it’s pretty deep.

Speaker 1 (00:48:12):


Speaker 2 (00:48:12):

In the groin, the last structure, there’s a lot of other structure on top of the hip joint. And I agree in people who are thin and athletic, you can palpate the groin area and push hard enough to induce pain if there is a labral tear. But diagnosis of labral tear is essentially made by, you bend your hip, you move your knee toward the midline and the foot toward the outside and could this causes the pain. It’s very likely a labral tear.

Speaker 1 (00:48:54):

Yeah. I told ’em they should go to, you wrote the most amazing chapter in our book, the

Speaker 2 (00:49:00):


Speaker 1 (00:49:01):


Speaker 2 (00:49:02):

This is a pretty reliable sign, Shirin.

Speaker 1 (00:49:05):

Yeah. Yes, very much. And the other thing also as part of their, where their pain is labral tear also give buttock pain, whereas you don’t get that with hernia pain.

Speaker 2 (00:49:15):

Yeah. They labral tear can give you what people call a C sign. They’re going to take their hand and yeah, they’re going to put, let’s say the thumb in the front and then they’re going to tell you that they have pain also in the buttock.

Speaker 1 (00:49:29):

Yes. What is the pain associated with trochanteric bursitis or hip bursitis? How is that different?

Speaker 2 (00:49:38):

The pain associated with trochanteric bursitis, it’s completely on the side. It’s completely lateral. Usually if you palpate the most prominent part of your hip, I can use that word, you’re going to trigger very, very exquisite pain. Another thing that be needs to remember with trochanteric bursitis, if you are standing without moving, it doesn’t hurt. If you take really, really short step, it doesn’t hurt. If you start walking faster, longer step, you bend your hip more, it hurts. Yeah. Ultimately stairs are very difficult. Getting up from a chair is very difficult.

Speaker 1 (00:50:23):

Yeah. Curious about what you know about implant illness. As you know, there’s something called breast implant illness. I’m starting to see more and more people with what we’re now calling Mesh implant illness. So they have a systemic reaction to the Mesh implant groin or belly or wherever. The Mesh is fine, but they start getting hair loss and weird rashes and joint pains and swelling and chronic fatigue and brain fog, memory problems, no weird tingling sensations in their hands and feet. And you take out the Mesh and all that goes away. So do you see implant illness or systemic reaction to any orthopedic implants?

Speaker 2 (00:51:14):

Yes. Oh, I think the most notorious example is what they called I would say about 10 years ago. There are a few implants that came on the market. There were metal on metal,

Speaker 2 (00:51:30):

There was a metal cup and a metal head without ceramic or polyethylene in between. And that metal usually is chrome cobalt and these patients with C elevation of their chromium level, cobalt level, nickel level. And that can give you some local problems with pain, inflammation there is cause there’s something called a pseudo pseudo tumor. It’s not really a tumor, but it’s a lymphocytic reaction to the metal irons that are liberated. And also that can give you kidney problems. Yes. Neurological problem. Fortunately you don’t see that with titanium implant hasn’t been ever been described with titanium implant. Really with chrome cobalt implant. And these implants, they also contain nickel. Yes. A lot of people have nickel allergy. If you’re allergic to silver jewelry, you’re probably allergic to nickel at the same times because there’s a little bit of nickel in the silver jewelry.

Speaker 1 (00:52:45):

If you wear cheap earrings, which I don’t. Yeah,

Speaker 2 (00:52:48):

Sometimes just

Speaker 1 (00:52:51):

The nickel nickel in them. I have a nickel allergy actually. Okay. And so we also see it in people that have gallbladder surgery and they get clips and depending on the manufacturer of the vascular clip, there may be nickel in it and I’ve had to remove it. In some patients it’s a pretty amazing reaction they get.

Speaker 2 (00:53:13):

Although now I think most of these clips must be titanium. Yes,

Speaker 1 (00:53:17):

They are

Speaker 2 (00:53:19):

In males. I think what you need to look at if you have a watch in the back of the face of the watch is stainless steel. There’s always a little bit of stainless of a nickel in stainless steel and the person will have a rash or a it, it’s going to hitch under their watch and they stop wearing their watch essentially.

Speaker 1 (00:53:43):


Speaker 2 (00:53:44):

Unless you have something really fancy at hundred thousand dollars.

Speaker 1 (00:53:51):

No, it falls into the surgical field. So it’s not worth that.

Speaker 2 (00:53:56):

Something like Patek Philippe or something like

Speaker 1 (00:53:59):

That. Yes, that’s correct. What is psoas impingement syndrome and how does that

Speaker 2 (00:54:05):

Present? Okay, so if you talk about the hip people call talk about snapping hip. So there are two types of snapping hips. The most common one, it’s what people call the external snapping hips. It’s essentially the IT band rubbing over the greater trochanter and it’s going to cause a bursitis. And some patients, especially young women, are very flexible. They can snap their hip for you. More unusual is the internal snapping, which is essentially a SOS impingement syndrome. And it’s when you bend your hip first, let’s explain the, the sous tendon essentially is coming from the iliacs and the sous muscle. The muscle mass is inside of the pelvis. They have a common tendon that comes out of the pelvis and go and attaches on the top of the femur and allows you to bend your hip. It’s the primary flexor or bender of the hip. So when the sore tendon comes out of the pelvis to attach on the femur, it can get caught in piece of bone. If you’ve had a pelvic fracture in the past and hasn’t knee perfectly, but these days the number one cause SOS impingement syndrome is someone who’s had a hip replacement, the cup was not perfectly positioned and

Speaker 1 (00:55:46):


Speaker 2 (00:55:46):

Lead is sticking out. So tendon rubs on the metal of the cup and it’s very painful.

Speaker 1 (00:55:55):

And then staying on the topic of so as muscle, what is so as lengthening surgery, because I have some people that come in, they always told I need so as lengthening or they had groin pain and they’ve had so as lengthening usually at some major institution that does a lot of these fancy operations. But it never got rid of my groin pain. Of course it wasn’t related to that. So what is psoas lengthening surgery?

Speaker 2 (00:56:20):

Well, psoas lengthening, it’s like any other tendon length lengthening. You cut the patient, the tendon in half, you go down and you cut the other half and you reattach the tendon in a longer position so that the length of the tendon increases. But the psoas impingement syndrome can be a difficult diagnosis and it’s definitely needs to be proven before thinking about any kind of surgery. And the way to prove it is to ask the radiologist to do an injection of the psoas tendon sheath with yes, Xylocaine or mark. If the pain goes away for a few hours, then you prove the diagnosis, then you can go for a psoas tendon lengthening. In my experience, the failure of psoas in lengthening procedures are essentially failure of diagnosis. The problem was not the psoas impingement syndrome.

Speaker 1 (00:57:30):

That’s what I’ve noticed. And I don’t even see that many of those. But every single one that’s come to me, that was not their problem. And they had a very complicated orthopedic operation.

Speaker 2 (00:57:42):

And that’s why I think it’s important to establish a diagnosis without any doubt. And then you can proceed.

Speaker 1 (00:57:51):

And we have great radiologists at Cedar Sinai. Yes, thanks to you. I’ve made great friends with them. They’re all my speed dial too. But they’re so helpful because I just feel, I’m very grateful that we have radiologists that you can speak to and actually have a very close relationship with. And you can coordinate care for a specific patient. Oftentimes it’s a very kind of distant relationship. You write an order in a computer and it spits out the other side and the radiologist may or may not do exactly what was necessary for the patient. But to have radiologists that are actual clinicians that are interested in the patient care is really, really cool.

Speaker 2 (00:58:32):

I’m going to tell you something that we have four musculoskeletal radiologists that sees Yeah. And believe it or not, had never seen that before. Sometimes they go and they examine the patient before doing the MRI or the procedure and all that. Yeah, they are really, they’re not really physician, they are not like x-ray readers.

Speaker 1 (00:59:00):


Speaker 2 (00:59:00):

Absolutely. I have the greatest respect for them.

Speaker 1 (00:59:04):

I had one lady, I said, you know what, I think she has a gen femoral nerve injury from her lateral spine approach. And I said, the only way I can prove that is I, so I can have pain inject her back. Her back is a mess. She’s got so much hardware there and I can’t inject it in the front because that’s not where her injury is. It’s in the, so as where the general femoral nerve is coming out and I basically work with them, we figure it out exactly on imaging where this general fibro nerve would be within the psoas muscle where it’s coming out. And via imaging guidance literally went exactly there and the lady is cured. And for a radiologist to cure a patient, it’s not common, but he examined the patient and did everything before and then followed through afterwards. And it was the most satisfying thing that he was able to kind of understand my thought process, but make it happen cause I can’t do it and cure the lady.

Speaker 2 (01:00:18):

Yeah. I’m going to say something very controversial. I think most radiologists are overpaid for what they do, but our four musculoskeletal radiologists at Cedars are underpaid for what they do.

Speaker 1 (01:00:36):

Yes. I would say I would. That’s very true. I’m very grateful. I learned MRIs by sitting next to roller and just having her read my images and I would ask questions because we don’t learn. I mean you in your specialty, MRI is very important in general surgery. It’s not, it’s CT scans and x-rays. So MRI is very foreign to us. So I had to learn it and she was very, very, she’s so good at it and I was like, I don’t even call her anymore. I read all my own imaging because I was able to learn from her. So I agree. A lot of the radiology overpaid because I read my own, I don’t even read the report, I don’t even need the report. Just read it myself. It’s usually incorrect. Anyway.

Speaker 2 (01:01:24):


Speaker 1 (01:01:25):

We actually published two papers on that about how incorrect. It’s like three out of four. Three out of four incorrect. Can you believe that?

Speaker 2 (01:01:33):


Speaker 1 (01:01:33):

Yeah. Horrible. Horrible. Well you’ve had a long day. I really appreciate the time. My pleasure with us. But I won’t let you go too far. I know where you live and I know how to reach you. Okay, so actually I dunno where you live, if I know where you live during the day. Okay. So I will make sure that in 2022 we’ll bring you back and Okay. Ask more questions because we have more.

Speaker 2 (01:02:01):

I’m going to be on time next

Speaker 1 (01:02:02):


Speaker 2 (01:02:03):


Speaker 1 (01:02:04):

I appreciate any time you give us. And thanks everyone. Thanks for joining us on Hernia Talk Live. I’m signing out. Dr. Towfigh, thank you to Dr. Guy Paiement. We will bring him back, I promise next year. We’re pretty much booked this year. We’ve got some other great specialists to talk with as well. Thanks to everyone who submitted your questions ahead of time, everyone who is here live and I’ll make sure that you have access to this session on YouTube so you can like and share with others. And I will see you all next week. Thank you, Guy. Bye bye-Bye.