Hockey and Hernias, Part V: Pelvic Floors and Physiqz

(continued from Part IV)

In 2010, I shared my experience with the so-called sports hernia. I had no idea then that so many people would find that story or the subsequent posts on the same topic.

Long after I thought I was done writing about this subject and figured my posts were buried on the Internet, Jon Chambers found my story. Jon is the content editor at Physiquz.com, a site dedicated to physical therapy and powerlifting. He has written many pieces about sports hernias, including the guest post that follows.

 Image provided by Physiqz

by Jon Chambers

The complex sports hernia injury is largely misunderstood. In fact, the name ‘sports hernia’ is a misnomer as there is no true herniation present. On the contrary, it is actually a structural weakness that develops in the deep abdominal wall and exterior obliques. This damaged soft tissue lays the groundwork for the injury’s worst symptom: chronic groin pain that doesn’t seem to respond to traditional physical therapy methods.

Effective treatment methods are largely unknown to general practitioners, leading to difficulties in receiving an accurate, positive diagnosis. For this reason, the professional advice of an expert should become a top priority for those injured. With that said, medical understanding of the problem has expanded dramatically since first mentions made their way into research journals in the 1980s. Using these studies as a roadmap, an effective roadmap to recovery has been born.

Increasingly, evidence points to muscular imbalances as the primary culprit in developing the injury. As the adductor muscles of the inner thigh become stronger, the core is unable to compensate—resulting in tears as the abdomen is forced far beyond its limits. “One-sided” athletic activities that are repetitive in nature, such as the kick of a soccer ball or the hitting of a hockey puck, are a main contributor to this uneven development.

The solution to resolving pain lies in working to restore balance. By utilizing a full-core rehabilitation approach, those afflicted are able to restore symmetry to the muscles of the hip and groin. As the athlete regains proper movement patterns, pressure is then lifted from the area allowing for relief.

Conservative treatment should be prescribed for 6 weeks. If substantial progress is not made in that time towards lowering pain levels, however, moving forward with surgery should not be feared. At surgical success rates of 95% and higher, taking the time to find a doctor specifically trained in the treatment of sports hernias is well worth the effort.

(Jim Dwyer here again, with an update on my situation and comments on Jon's post. I'd say that I'm in the 5% category. Hard to say what may have gone wrong with the surgery or subsequent physical therapy because there are so many suspects—bones, ligaments, nerves, fascia and tendons—that reside in the pelvic floor.

Before even finding a surgeon, I recommend finding a pelvic floor therapist, someone who has performed a manual exam on hockey or soccer players.

If you're like me and learning about pelvic floor therapy after surgery, you too can benefit. After four or five visits with the pros at The Pelvic Health and Rehabilitation Center (Lexington, MA), the pain has decreased in frequency and duration. There is no magic fix for it, but there is relief. Even with the mysterious and maddening flare-ups, I'm hopeful that I can enjoy life more.

I don't expect to ever play organized hockey again and powerlifting is not my thing. Maybe a pick-up game or power walking. If I can do those activities with less pain, I'll consider that a victory. 

Thanks to all of you have visited the site and to the people like Jon who are doing their best to help those who seek help with pelvic floor pain.)

Hockey and Hernias, Part II: Clarification and Recommendations

(Continued from Part I)

“Groin injuries are like a box of chocolates: You never know what you’re gonna get.” -Forrest Ghimp ("h" is for hockey and hernia)

Many a hockey player—whether you’re a professional like Andrew Ference or an amateur like me—has done the hockey hobble. Most of us are familiar with groin injuries, incurred or witnessed, but far fewer are unfamiliar with or confused by terms such as sports hernia, athletic pubalgia, and Gilmore’s Groin. These conditions are discussed on the Web, but the data can be overwhelming, and in some cases conflicting, so my purpose here is to condense and categorize, to sift and to simplify. Coupling what I’ve learned from my experience with this kind of injury with the comprehensive Internet research, I hope to help those who are hindered by groin injuries.

Let’s start, then, with the general terms and drill down to the more specific:

Groin: For purposes of these posts, I’ll distinguish between lower groin (below the crease formed by the leg and abdomen; the femoral region) and upper groin (region between the abdomen and the aforementioned crease; the inguinal region). I can’t speak to lower groin injuries as my injuries were upper groin problems—except to say that abdominal muscles and corresponding nerves are connected to the lower span the two regions.

Hernia: This condition is most often caused by a weakening in the wall of a muscle. Hernias are more common in men than in women, can occur at a variety of locations, and vary in origin and cause.

Inguinal hernia: The abdominal wall was weak at birth (a.k.a. congenital hernia) or weakened later on in life (a.k.a. hernia), the latter sometimes a result of repeated pressure in sports like hockey and soccer. Two types of inguinal hernias are the direct and indirect.

Indirect hernia (a.k.a. congenital hernia, true hernia): This is the most common hernia, where the protrusion or bulge of intestines has breached the abdominal wall.

Direct hernia (a.k.a. acquired hernia): This one can often go undetected by MRIs and/or x-rays and thus is more difficult to diagnose. The fascial tissue (more on that in a future post) of the inguinal floor and/or abdominal wall is weakened. The destabilized abdominal wall may not break, however, and thus not become an indirect hernia.

The definitions above are widely accepted in the medical community, but terms such as sports hernia, Gilmore’s groin, slapshot gut, and athletic pubalgia are sometimes used interchangeably even though some believe sports hernia and athletic pubalgia, for example, are different injuries.

Despite the disagreement on definitions, the doctors who diagnose and treat these injuries have come to the same conclusion: Time does not tend to heal hernias; in most, if not all, cases no amount of rest, ice, heat, elevation or Ibuprofen will fix these conditions. Surgery is often the only solution.

The remaining question, then, is which procedure to perform. Here again, as with the symptoms and diagnoses, surgeons don’t agree on a standard procedure. A common consideration is whether or not to use mesh: Is laparoscopic (a minimally invasive procedure) surgery the solution or is a deeper trip down the inguinal canal required? And when does removing mesh make sense?

As I suggested in the disclaimer, I don’t have all the answers and can only focus on my own experience. The most important thing, for me, was to find a doctor that would understand the complexities of the diagnosis and treatment. Thus, I needed someone familiar with my symptoms and who has treated other adult hockey players.

Although my doctors, Brian Busconi and Demetrius Litwin were right for me for a variety of reasons—they both have played hockey, are well-regarded in treating groin injuries (yet perform different procedures), and they collaborated before deciding which surgery was best for me—they may not be right for you. If you’re not in New England, for example, you might want to consider other doctors. With than in mind, I suggest you at least consider the following professionals, even though a thorough Internet suggest of  each may reveal unhappy clients:

California
Dr. William Brown: I’ve never contacted his office, but Dr. Brown’s client list includes the San Jose Sharks.

Georgia
Dr. Jeffrey Hoadley: I’ve never contacted his office, but Dr. Brown’s client list includes the Atlanta Thrashers.

Massachusetts
Dr. Brian Busconi and Dr. Demetrius Litwin: Busconi is a pioneer in this field, and his initial studies more than ten years ago were met with incredulity and criticism from those who are now believers. Litwin, who hails from Saskatchewan, sports an impressive resume and has a terrific bedside manner. That the two collaborate should quell any qualms about inflated egos.

Dr. Scott Martin: Direct and decisive, he recommended my arthrogram, a procedure that fixed the first injury. He’s also a consultant to the NHL.

Dr. John Stevenson: He’s not a surgeon, but his specialty is his unique commitment to spending as much time as necessary finding the right surgeon, as he did for me.

Dr. David Berger: I’ve never talked to him, but he has treated NHL players such as Penguin defenseman Brooks Orpik and Bruin defenseman Andrew Ference

Pennsylvania
Dr. William Meyers: I’ve never spoken to anyone in his office, but Dr. Meyers, who works on Hahnemann University Hospital staff, has treated professionals and amateurs in many sports. Philadelphia magazine also listed him as one of the region’s Top Doctors.

Germany
Dr. Ulrike Muschaweck: I’ve never contacted her office, but she founded the Munich Hernia Center and gets rave reviews from professional and amateur athletes.

Helpful links: A short list of sites I’ve visited

http://www.aafp.org/afp/2001/1015/p1405.html
http://www.sportsmd.com/SportsMD_Articles/id/287.aspx
http://sportsherniablog.blogspot.com/2008/03/sports-hernia-surgeons.html
http://www.sportshernia.com/sports-hernia-approach/sports-hernia-options.php
http://www.thegroinpaincenter.blogspot.com/
http://sports-hernia.net/
http://www.lloydrelease.com/

Stay tuned for my findings on stretching and nutrition as a means for injury prevention. See Part III.

Hockey and Hernias, Part I: Disquietude and the Disclaimer

The purpose for this post is to help hockey players (and other athletes, as well as those who live with them) who are enduring or susceptible to incurring a common, yet confusing condition: the hernia.

The first in a series, which will include topics such as treatments, nutrition, and prevention, this piece is related strictly to the symptoms and diagnosis.

Disclaimer: I am not a doctor and in no way suggest that you should take any of the information below as the truth for your situation. I can only relay what I’ve learned from my own experience:

In September 2008, during an AMHL game, I was skating backward. I didn’t step on a puck or stick, and I don’t recall over-extending my left leg—when piercing pain in my left groin felled me. I couldn’t rise or skate toward the locker room on my own power, but half an hour later I could walk out of the arena, hefting my hockey bag on my shoulder. Within three or four days, blood had drained down the length of my inner thigh, all the way to my knee. The picture reminded me of a map of Argentina. I was able to ride the stationary bike (not a wise move) without much discomfort, but I quit doing that when my primary care physician told me that I had torn a groin muscle and then recommended rest followed by physical therapy.

Six weeks later, I was back on the ice, only for a few laps of light skating. No pain—at least when I was on the ice. But three days later, the pain returned for no apparent reason.

So, two rounds of PT, an MRI, a pick-up game, seven doctors, one arthrogram, one doozy of a sneeze, and one surgery later, here I am.

Courtesy of Physiqz

I believe I incurred two injuries, which is not unique for those of us who repeatedly and forcefully stride, to the groin: The first was what one orthopedic specialist termed, after analyzing the MRI, a grade one tear that also likely entailed a minor stress fracture as muscle pulled muscle away from the pubic bone. This type of injury, he said, only needed time to heal. But I still had inexplicable onset (delayed) pain, so another orthopedic specialist recommended an x-ray arthrogram, which revealed no major damage, and cortisone, which alleviated the first injury but not the second. The more formidable irritant, what Doctor Number Six (with an assist from Doctor Number Seven) would diagnose as something akin to a direct hernia, required surgery to repair what he would say was “a very large hole” in the inguinal floor (more on that later).

I’m immersed in physical therapy and hopefully on my way to returning to playing hockey. I’m behind schedule yet realize not every patient is on the same recovery timeline. So that gets me back to the crux of the disclaimer: The information below is culled from what I’ve learned in conversations with doctors, comprehensive Internet research, and the day-to-day disquietude of recovery.

If you’re a hockey player or enthusiast, you’re likely familiar with general terms such as groin and hernia. Perhaps, however, you (like me, when I first sought diagnosis and subsequent treatment) are confused by words like athletic pubalgia, inguinal canal, and sports hernia. The information on the Internet can be overwhelming, and in some cases conflicting. Feel free to research these terms on your own, or wait until the next segment, where I’ll post my research results.