181. Consulting a Physiatrist for Groin Pain

This week, the topic of discussion was: 

• Sports Hernias
• Physical Therapy
• Physical Medicine and Rehabilitation
• Adductor Tendonitis
• Groin Pain
• Muscle Spasm

Guest: Dr. James Wyss, Physiatrist (Physical Medicine & Rehabilitation Specialist), Hospital of Special Surgery, New York  

Welcome to HerniaTalk LIVE, a Q&A hosted by Dr. Shirin Towfigh, hernia and laparoscopic surgery specialist who practices at the Beverly Hills Hernia Center. This is the only Q&A of its kind, aimed at educating and empowering patients about all things related to hernias and hernia-related complications. For a personal consultation with Dr. Towfigh, call +1-310-358-5020 or email info@beverlyhillsherniacenter.com.

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Transcript

Dr. Towfigh (00:00:10):

Hey everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live. I am your host, Dr. Shirin Towfigh, your hernia and laparoscopic surgery specialist. Thanks for everyone for joining me. We are live as a Facebook Live and also on Zoom. You can find me on Facebook at Dr. Towfigh. And for those of you that would like to follow me on the other social media platforms, we’ve got Instagram and X at hernia doc. As always, this episode and all prior episodes are, we’re getting close to 200, so that’s really cool. They will all be available to you. Are all available to you on my YouTube channel at Hernia Doc. And if you like podcasts like I do where I listen to podcasts when I’m driving. We’re also a podcast, so you can find me as a Hernia, Talk Live, wherever you listen to podcasts. So I’m super excited today because I get to meet and you all to meet Dr. James Wyss. He is a physical medicine and rehabilitation specialist. You will learn all about what that means and how that can help you. He works at the hospital for special surgery. We’ll learn more about this very special hospital in New York and I’d like you to welcome Dr. James Wyss. He can find him on Instagram at Dr. James Wyss. Hi,

Dr. James Wyss (00:01:32):

How are you? Thanks for having me.

Dr. Towfigh (00:01:34):

I’m good, thank you. Are you at work still?

Dr. James Wyss (00:01:38):

I am.

Dr. Towfigh (00:01:39):

Oh my lord.

Dr. James Wyss (00:01:41):

I have a new puppy at home and that’s our third dog and the house is full as is, so it

Dr. Towfigh (00:01:48):

Oh, okay.

Dr. James Wyss (00:01:49):

Did not have work, so I purposely planned it this way.

Dr. Towfigh (00:01:52):

Thank you. Because of the podcast needs you staying at work just for me. Just

Dr. James Wyss (00:01:57):

For you. Absolutely.

Dr. Towfigh (00:01:58):

It’s seven 30 at night.

Dr. James Wyss (00:02:00):

Yeah, I’m sorry. I know that’s right. I’ll head home after this. And the last name’s pronounced Weiss, by the way.

Dr. Towfigh (00:02:06):

Weiss, I apologize.

Dr. James Wyss (00:02:07):

It should be WIS or Vice, but it’s pronounced Weiss.

Dr. Towfigh (00:02:11):

You’re mispronouncing your own last name

Dr. James Wyss (00:02:12):

The whole family has been mispronouncing it for a long time.

Dr. Towfigh (00:02:16):

Well, it’s a pleasure to meet you. We share patience and that’s why I got to meet you and that’s why I reached out to you because I have a lot of friends and colleagues who work in New York that do similar practice than I do hernia surgery almost exclusively. They’re a handful in New York. They’re all really, really good. They’ve all been past guests of mine and I said, I need someone who can help me with X, Y, and Z. And your name came up, so I appreciate you accepting to be a guest on the show.

Dr. James Wyss (00:02:50):

You got it. I think it was Dr. Mark Zoland who, and Mark’s been wonderful learning from him and sharing patients with him. So happy to be here.

Dr. Towfigh (00:03:00):

Thank you very much. And he was a great guest a couple years ago. I think he was. So thank you. So my very good friend from high school is my physical medicine and rehab specialist, and I don’t even know how he knew to be PM & R or physiatrist. I was never exposed to that specialty in medical school. So maybe you can explain a little bit for our audience, which is mostly patients, how did you even learn about PM & R and what do you do?

Dr. James Wyss (00:03:37):

And to add confusion internationally it’s PRM, which is physical and rehabilitative medicine, which actually probably makes more sense, but Okay.

Dr. Towfigh (00:03:45):

Well we have a very international audience actually, so thanks for clarifying.

Dr. James Wyss (00:03:48):

Wonderful. And there is a strong international presence in my specialty. So this is my second career. I was a physical therapist first and so I was one of the rare, and I sort out a job towards the end of my career as a PT working with a physiatrist, which is their name for a physical medicine and rehabilitation doc. And so I had on the job training and an opportunity to see if that might be what I want my career to look like. And so yeah, I was one of the rare people, probably the only one in my class who went into medical school pursuing this career. I almost deviated from it because one of my loves is sports medicine and I loved the idea of family practice, but I kind of stuck with the plan and here I’m today. So you

Dr. Towfigh (00:04:41):

Went to college, finished medical school and then applied for the PM&R residency. And how long is that?

Dr. James Wyss (00:04:50):

So we typically do an internship one year in medicine. Some do an intern year in surgery, but most do a year in medicine. And then there’s three years of residency for PM&R. The first year is heavy in a lot of inpatient rehabilitation care. So a lot of more neuro rehabilitation, some multi-trauma, but a lot of spinal cord injury, brain injury, that’s a big part of the roots of the care we provide. And so having a year in medicine is really helpful for that. You kind of feel at first like an intern in a rehabilitation hospital and then the next two years dive a little more into the specialty, which is pretty broad, which can be very

Dr. Towfigh (00:05:38):

Broad.

Dr. James Wyss (00:05:39):

Right. Which can be rotations in burn care, outpatient orthopedic type care air can be more electrodiagnostic work. So a lot of our field overlaps with a lot of the other medical specialties with time it does for all of us.

Dr. Towfigh (00:05:59):

And some of you work more on the orthopedic side, others more on the spine side, right? Correct. Some do pain management.

Dr. James Wyss (00:06:07):

Yeah, my practice is a little blend because I take care of a lot of athletes with spine conditions and then I do a lot of what lots of people refer to as sports and musculoskeletal care. So it’s a lot of work on the extremities, also a lot of knee and shoulder and hip care and further down on the extremities. And then some people just kind of fall into a path of more pain management and interventional spine care and they may not do a lot of sports or peripheral extremity work. And then there’s a whole other side of my specialty, which some might call more rehabilitative medicine and physical medicine, which is really a lot of that kind of inpatient care that I referred to as well. And the post-recovery from life-changing injuries and events like a spinal cord injury.

Dr. Towfigh (00:07:05):

So when would someone come to you as opposed to your prior career, which was being a physical therapist.

Dr. James Wyss (00:07:12):

And there’s a lot of overlap there in certain states when there’s direct access to physical therapy, a lot of the problems that people might seek me out for, they may see a physical therapist first. They’re experiencing low back pain, they injured their knee but they don’t think it’s too serious shoulder injury. So a lot of those problems do go direct access to physical therapy and I think it’s kind of rules within the state, but it’s also patient preference and I think patients are still seeking out more if they can physician directed care at first.

Dr. Towfigh (00:07:49):

Sure. Because you can prescribe certain things that a physical therapist can’t prescribe. Right.

Dr. James Wyss (00:07:57):

Ordering tests, there’s limitations on the PT license. That’s a whole snipper topic. I can talk on both sides of it.

Dr. Towfigh (00:08:05):

It’s a lot of overlap and I guess PMRs focus because there’s so much overlap, they kind of end up focusing on something. And then if someone doesn’t need surgery, when would they choose you as opposed to an orthopedic surgeon?

Dr. James Wyss (00:08:22):

So in a hospital like hospital for special surgery, ideally the pathway we’d like to guide patients on is to be evaluated by a non-operative or non-surgical specialist first. And then if it’s severe enough or there’s a clear surgical indication, the referral goes from me or one of my colleagues in physiatry or primary sports medicine and then goes on to orthopedic surgery, that would be the ideal model. But often there’s not enough of us on the front line. So some of it is a little random I think. Yeah,

Dr. Towfigh (00:09:03):

There’s really not

Dr. James Wyss (00:09:03):

Much connections that you have and who you know get referred to.

Dr. Towfigh (00:09:08):

Yeah, there’s really not that much. There aren’t that many and your names are weird PM & R because it’s hard to say physical medicine but then physiatrists, I don’t know when that term came about. That threw me for loop because it sounds like physicist. Yeah, psychiatrist. I mean I’m sure you do all of that anyway

Dr. James Wyss (00:09:32):

And there have been debates about is it physiatrist with an I or a physi with two E’s in terms of how you would genetically pronounce it. But yeah, no, I mean I basically tell my patients, first of all I’m appreciative if they do a little homework and have taken the time to understand my specialty, not just me and my career but my specialty in general. But if not, I just take a moment to explain it to them and let them know it’s not a household name and I don’t know if we will ever be, but certainly you kind of alluded to it, we fill gaps in different areas,

Dr. Towfigh (00:10:14):

So

Dr. James Wyss (00:10:14):

Much of medicine and in the surgical realms as well.

Dr. Towfigh (00:10:18):

Well my physiatrist, I mean he is very intelligent and I think the beauty of your specialty is you really understand the body so much and how everything interacts. Orthopedics kind has their own, they’re like joints and bones and muscles, but I mean I guess they should be into function, but it’s very much more a mechanical thing. And then you’ve got the physical therapists who are excellent by the way. I’m sure Mark has told you what I keep saying, which is I actually get quite a number of referrals from physical therapists, so good. And actually hand on patient feeling where it’s abnormal, where it’s not, where their spasm, where there’s not bringing it down to muscle groups. People come for example with groin pain, which we’ll discuss more in detail and they’ve had endoscopy colonoscopy and I’m like how is that causing groin pain? They see GI doc abdominal pain, which really the groin and they get pushed and then they get pushed into this other urology gynecology as the physical therapist that says, I think this may be a hernia. Because they’re really the ones that do a really good exam and their fingers are really sensitive to know what’s wrong.

Dr. James Wyss (00:11:41):

I always tell my patients or other colleagues that I did not learn my physical examination skills in medical school. Unfortunately good mentors along the way who showed me things right in the clinic, but I really trained my hands as a physical therapist. I mean not just the evaluation, but a lot of the treatments you provide are hands-on and observation with a little hand on that body part and it just trains your hands in ways that we don’t get in medical school.

Dr. Towfigh (00:12:11):

So interesting.

Dr. James Wyss (00:12:12):

I didn’t go down a surgical path. I do a lot of interventions but that using needles and fluoroscopy and ultrasound did not train my hands the way that I think learning palpatory skills in physical therapy school.

Dr. Towfigh (00:12:30):

Plus I think in the United States we don’t stress physical exam as much. We have a lot of get a CAT scan, get an injection. It’s a lot of studies and tests as opposed to physically putting your hand and being like, yep, based on this exam, this is what you have. Very yeah,

Dr. James Wyss (00:12:48):

That’s time with our patients, right?

Dr. Towfigh (00:12:51):

Yeah, so true.

Dr. James Wyss (00:12:52):

So true. Quicker sometimes order a test but not as helpful. I always say, Hey, we’re treating you not your pictures or your report or anything like that. Yeah, that’s hard.

Dr. Towfigh (00:13:03):

A lot of patients that I see, the doctor never touched me, never examined me, and it’s saying you clearly have the hernia. No

Dr. James Wyss (00:13:11):

One never examine. I was shocked the few times I heard that at first and then I just realized, okay, this is part of what’s going on out there in practice.

Dr. Towfigh (00:13:20):

Yeah, yeah, it’s a thing. Do you work out exclusively at the hospital?

Dr. James Wyss (00:13:25):

I do. So currently I’m in our Long Island office. We have a big satellite in Nassau County on Long Island. We have satellite locations in Connecticut, Westchester, New Jersey, Florida as well. So we’ve grown a bit Initially a lot of my work was on the main campus and now I spend more of it because family reasons and different things on Long Island

Dr. Towfigh (00:13:52):

And hospital for special surgery. It’s a very elite hospital, very highly specialized. Can you explain what a patient would expect to get their treatment in there?

Dr. James Wyss (00:14:03):

I mean most people compare it because our neighbor is Memorial Sloan Kettering, so they kind of understand they’ve maybe had themselves or a loved one or a friend has had some care at that hospital and so they often relate it like, oh this is a specialty hospital, they specialize in cancer there. You guys specialize in orthopedics there. And long history, I think over 150 years, I’m hoping I’m not misquoting anything that really has grown into a really leader in orthopedic care and education and really with time I think has grown in a way where we’re looking to provide a continuum of care in musculoskeletal care, not just that referral for complicated orthopedic surgeries that maybe failed elsewhere and coming there. That may have been some of the roots I was built on, but now it’s being built into a continuum of musculoskeletal care, which fits why I even went to medical school and why I remain at the hospital

Dr. Towfigh (00:15:18):

Sounds like a perfect fit. So as you may know, this is a live show and therefore we encourage our audience to turn in questions either before or during. So there may be questions that are coming in. I have a couple of questions already that have been posted to me by some of our international viewers. They can’t watch live hours. A little bit wrong to which will be nice. We’ll get through those. But one of the main reasons I want to talk to you because you have the physical therapy orthopedic and a little bit of general surgery kind of bent to your practice. Groin pain is complicated. So in men it’s a little bit easier in women you add the whole gynecologic reasons for growing pain. But people who come to my office, I have to figure out even if they have a hernia, some of them have hernias, one of the problems I see are people that have hernias, but the hernia is not the cause of their pain.

(00:16:25):

So they get their hernia fixed and not only did it not affect treat their underlying cause now they have a complication from the hernia repair that they never really needed. So the patients are at a loss and the surgeons that I did a perfectly good hernia repair and as general surgeons we’re not really well taught about all the different pelvic anomalies that can happen. So my role is often to figure out is it gynecologic, urologic, orthopedic nerve related, could it be a muscle tear or something and so on. So do you have any good ways of figuring out what are key questions or key activities that can help differentiate all these different reason for groin pain?

Dr. James Wyss (00:17:23):

I immediately, which is the opposite of what I do, I immediately kind of think about my physical examination. I spend most of my time every day, you probably do listening to my patient and a lot comes out of that. But when it’s someone who is, and like you mentioned the case of someone who had a surgery done that didn’t fix the problem, even if they didn’t have a complication, there’s an added layer of frustration and now there’s added issues of chronicity there and that just makes it harder to treat. So many times with this I do really have to depend on my physical exam and fortunately for my work it’s kind of straightforward because patients should be able to localize their symptoms to some extent. So we often say, can you point with one finger to the epicenter of this all and then you can show me if it radiates or spreads out or however.

(00:18:25):

But can you localize where you think that’s starting from? And then I should be able to either put a stress with some sort of passive stretch on that tissue or that bony attachment. I should be able to ask them to try to perform maneuver that contracts that muscle and then I should be able to palpate that. I personally say palpation for the end because I find if I go palpating around during the early part of my physical examination, I may have aggravated everything and now every test I do after that seems symptomatic. So I listen enough to take me down a certain path of what I think I’m going to find. And then that issue, for example, if I think they have a misdiagnosed proximal hamstring tendinopathy or a partial tear or the high, not hamstring, I’m sorry auc, I might strength test into a deduction and passive stretch the hip into AB deduction last and then palpate that structure last just so that I throw off the exam. So I have to mechanically find the source and that makes some of what I do a little more straightforward than probably the dilemma you are often faced with.

Dr. Towfigh (00:19:48):

So that falls into the realm of sports injuries and we use the term sports hernia, which it’s not a hernia but it’s a sports injury which includes, correct me if I’m wrong, the way I explain to my patients is the rectus muscle inserts on the bone, you can tear that the adductor muscle which allows you to walk and go upstairs and push the thigh in a kick, a soccer ball or whatever that also inserts on the bone. You can tear that, you can have a tear of your fascia in the groin area of the external oblique, you can actually tear that. Sometimes you tear it right over the nerve and then the nerve gets irritate because it keeps getting pushed into this tear. So you can have nerve type pain from that and then you can kind of shear or shred some of the deeper muscles in the groin, hernia, whatever. Those are not hernias, but they can all cause what people call groin pain and a lot of times the tears in the muscles, some of them you can see on imaging, but what’s the frequency that radiology will help you with some of the

(00:21:11):

To moderate problems?

Dr. James Wyss (00:21:12):

Yeah, I mean I think that’s improved a lot and Mark Oland’s been a big part of that even though he’s not HSS now, he has a strong affiliation I think as privileges at our hospital. But some of our work with him I think has been very helpful to put together an athletic pubalgia protocol for the MRI because lots of times you were just doing a typical coronal MRI and it was not lined up for the pubic bone or the attachment. And so I used to see a lot early in my practice and I’ve been at the hospital since 2010, so that doesn’t go way, way back, but I would get a lot more cases that were called osteous pubis because she sure on the fat suppress images you again that the pubic bones were all lit up, but then when you got the right images you saw that there were anatomical reasons for it.

(00:22:12):

This wasn’t a stress fracture, this wasn’t related to maybe metabolic issues. There was an anatomical problem, an injury either with those muscle attachments you described or what some people refer to as the AP neurotic plate on top of the pubic bone. And so we started to see that better and once we did, then I started integrating ultrasound at the bedside a little into my practice. Sometimes you just sore the bone, looked a little more irregular on the side of the symptoms and that went along with the exam and the MRI and everything started to come together better with time. So

Dr. Towfigh (00:22:53):

Is that because the bone, when the muscle attach or the fascia attaches onto the bone every time it’s like NFL football players I’ve seen they have horrendous bones because it seems like over time the muscles constantly pulling, these humongous muscles are pulling off of the bone and kind of like it’s like pulling your hair out, right? It’s bone and you get these spicules whereas it should be like a smooth bone. You have these areas where the bone keeps getting lifted off of its natural position. Is that

Dr. James Wyss (00:23:26):

What it’s Right. And absolutely we call those cortico irregularities. If you’re looking on neur ultrasound and it looks like that. It goes from it being a smooth bone to spicules and rough areas of it. And it does many times correlate well as long as your exam again is going along with it. And fortunately that’s the same thing we see for all the other muscle attachment problems. So all the tendon issues we see the same changes at the heel bone on the calcaneus. When someone has a bad achilles tendonitis we speak, I pick any tendon and you see those, the rotator cuff on the greater tube, we see these changes the longer some sort of tendon related problem is happening and it’s not a bone problem, it’s a soft tissue attachment problem.

Dr. Towfigh (00:24:20):

Got it. So if it’s a true hernia, they can have pain at the groin and then it can radiate some patients it radiates around to their lower back. Some people radiate to the inner thigh, even to the testicle. Can you see that with sports type or athletic prebi or sports or groin pain?

Dr. James Wyss (00:24:45):

I think you can, but usually when I, it’s rare that I find a pretty clear cut case of sports hernia and I also see a large symptomatic hernia. It seems like we many times see these small hernias that the radiologist points out to me a little fat trap somewhere. So see those a lot. But yeah, I think and I might be seeing a subset of the population where it’s almost been weeded out by the time they get to me that this is more likely orthopedic in nature. I don’t get as much confusion with that.

Dr. Towfigh (00:25:30):

So hip disorders also give groin pain and the way I explain to the patients is if you actually look at an anatomy skeleton, the true hip joint is not where people point to it outside, here’s my hip. It’s actually further in which more aligns with where the groin is just in a deeper plane. How do you help differentiate from the history, let’s say a hip disorder versus a groin or hernia

Dr. James Wyss (00:26:01):

Disorder? Yeah, yeah. No, that’s a great question. It’s easier in someone typically over 50 who’s developing some osteoarthritis of the hip joint because they’ll notice a change in their walking or sometimes it’s a friend or a partner spouse who will notice he walks different over the past couple of

Dr. Towfigh (00:26:22):

Years and that’s not normal for hernias. Hernias don’t affect your gait.

Dr. James Wyss (00:26:26):

Right. From what I understand, that’s a hundred percent true I think. Yeah. And then they’ll also talk about difficulty with shoes and socks. They’re doing some creative things to get their socks on, whereas they used to be able to put their foot up on the other leg and just throw whether they were standing or sitting, they could just throw that sock on, throw that shoe on, and now they’re talking about, oh, I put the other one on first and then I do this. And so that’s pretty classic difficulty with shoes and socks getting in and out of a car or public transportation. It’s that transition when people get stuck. I often tell my patients, they say, why does the problem if they know it’s their hip joint feel better if I’ve been moving for a while rather than when I get up, I say, well, motion’s kind of lotion for the joint.

(00:27:17):

And we say, I’ll move that. That’s good. The best time, the best time I look for hip problems or an altered walk is after they’ve been sitting waiting for me to see them a little bit. We’ll go through our history and I’ll say the first thing I want you to do is take a few steps out into the hall and they’ll have an abnormal walk and then it corrects a bit as they’re in the hall. So these are kind of classic hip joint problems and again, easier to identify in the crowd. That’s kind of over 50. It’s the pre arthritic conditions in 2030 year olds. I work with a lot of college athletes, so I’m a medical director at St. John’s University and that group’s harder to figure out the hip joint pain because sometimes they’re fine with all their everyday activities, really only sporting activities that then produce it, which that’s more challenging.

Dr. Towfigh (00:28:11):

Got it. Yeah, I feel like they tend to wear, they like softer shoes if they got hip problems and when they sleep they like to put their pillow under their knee. Whereas for hernias, people don’t necessarily need to have a tabletop position for their, that makes sense. If they have an FAI like a femoral acetabular impingement or something

Dr. James Wyss (00:28:37):

Also. And I do think the physical exam is really helpful in that group as well because if I have somebody completely well supported on the table and now I support their thigh and guide them through some motions where I’m really trying to just isolate movements of the hip and that aggravates it, it shouldn’t be anything else. It shouldn’t be a hernia that you might often see. It shouldn’t even be a sports hernia because it’s just passive movements of the hip joint that’s actually reproducing their same pain that should be ball and socket pain.

Dr. Towfigh (00:29:13):

Got it. And lying flat shouldn’t make your hip pain go away, whereas lying flat usually makes the hernia pain better.

Dr. James Wyss (00:29:21):

Interesting,

Dr. Towfigh (00:29:23):

Okay. The other thing I noticed is people with hip disorders have a buttock pain as in addition to their groin pain, but you don’t get buttock pain with groin

Dr. James Wyss (00:29:34):

Makes sense.

Dr. Towfigh (00:29:34):

Hip pain due to hernias.

Dr. James Wyss (00:29:36):

And I think a lot of that buttock pain because back of the hip pain is the least location of pain when it’s in the hip joint it can happen. But what also commonly happens is if the hip’s not functioning well, the back gets thrown off a bit. If your walking’s not right for a certain period of time or your sporting movements have changed to compensate for hip joint pain, you’re going to move different through the rest of the pelvis and the lower spine. And so that butt pain sometimes is the development of some secondary lower back or posterior pelvic pain.

Dr. Towfigh (00:30:11):

Got it. Here’s a question. It says, Dr. Weiss mentioned osteoarthritic changes of the hip as a marker. Does isolated labral thinning have the same significance or is this so common in the elderly that it is not diagnostic?

Dr. James Wyss (00:30:27):

The latter. We all, and even at young ages, we have changes of our labrum. There’ve been some good studies. These on military recruits going through bootcamp who get screened for any, they have no current or preexisting hip pain and they have an MRI done and they have abnormalities of the labrum quite commonly. So then the wear and tear, the thinning, those to me are more common with just activity related and age acquired changes to the joint.

Dr. Towfigh (00:31:03):

That’s interesting. On

Dr. James Wyss (00:31:04):

Occasion they can be symptomatic, but the majority of the time it’s the latter that it’s just a normal change to the joint.

Dr. Towfigh (00:31:12):

Yeah, I see a lot of people who get hip MRIs or pelvic MRIs and it mentions femoral acetabular impingement or sorry, rephrase that. It mentions labral tear and they see a orthopedic surgeon and the orthopedic surgeon says, oh yeah, there’s tons of people that have labral tear on imaging, but it’s not the reason for your pain. Is there a way to tell whether a labral tear is a cause of pain or something else is a cause of groin pain?

Dr. James Wyss (00:31:45):

So mainly then the physical examination to see if you can provoke pain from the hip joint. If we’re still not certain, that’s when we’ll perform a hip joint injection, which can be done under fluoroscopy, under X-ray guidance or under ultrasound guidance. Nowadays the majority of them are performed under old ultrasound guidance. And that’s interesting for what you mentioned in terms of the location of the hip joint. So we do those through the front anteriorly and many times people are surprised we’re not doing them from the side. And then when they realize where the needle went, they say, oh, that was pretty close to where I feel my pain. So even just that part of that procedure can help enlighten,

Dr. Towfigh (00:32:34):

I’m told when you do the injection, you include, well, let me rephrase this for pain, when you do the injection, it involves local anesthetic. Is that correct?

Dr. James Wyss (00:32:45):

Correct.

Dr. Towfigh (00:32:46):

And then I’m told when you do Mr. Arthrograms or any type of arthrogram, x-ray that wants to look at the joint and they inject the contrast, they also include the anesthetic in the contrast. So sometimes besides it just being an injection for the contrast, so you can look at the imaging, it can be somewhat diagnostic too. If your pain goes away, it could be, is that true? Does everyone do

Dr. James Wyss (00:33:11):

That? It’s true except the majority do. Now at HSS, we do not perform any arthrograms. So yes,

Dr. Towfigh (00:33:22):

Because you’re that

Dr. James Wyss (00:33:23):

Good radiology. Right, right. So Dr. Hollis Potter has done some wonderful work where we think we can see everything we need to see without contrast and I think fantastic, fantastic. I think that’s true in 99% of the cases. Yeah, the problem I see a lot, since I’m out here practicing on Long Island, we have a presence on the island, but there’s also a lot of other healthcare systems providing care. So I see plenty of patients who come in with arthrograms of the hip that were done. And yes, that’s a common practice. The contrast eye with the anesthetics problem is you’re diluting everything. You’re also filling up the hip a lot. So sometimes your patient has a difficult time, the injection soreness, the volume that was put in the hip and did that anesthetic really help, which is very different than if I want to do an diagnostic injection or one of the surgeons I work with orders it, I could do a real low volume injection and examine them before and after and really help them to understand if that really made a difference on what they’re feeling. So I find that to be more helpful.

Dr. Towfigh (00:34:37):

We have a hernia protocol MRI and one of the radiology groups that offers our protocol, which is a Valsalva based pelvic MRI, the soft tissues looking for a little groin hernias, et cetera. They also give me some good shots of the hip, which is great because if I’m looking for that small of a hernia, there may be another diagnosis that I’m missing, which more likely will beated. So it’s kind of nice that they do that, I think because musculoskeletal radiologists, so they enjoy, take a little look at the hip and get a good information there. Yeah, I

Dr. James Wyss (00:35:18):

Mean when you get that coronal, that front of the view of the pelvis, I mean you’re seeing hip joint, you’re seeing lower lumbar spine tap iliac joints before

Dr. Towfigh (00:35:29):

Everything,

Dr. James Wyss (00:35:30):

You got a lot that you can look at.

Dr. Towfigh (00:35:33):

Yeah, it’s a great protocol. It’s available the website for anyone. We often give it to our patients to take to the radiologist if they’re from out of state to see if they can reproduce that protocol.

Dr. James Wyss (00:35:48):

And I have had patients who later on followed up with me for other orthopedic issues and when I found out how they figured out their groin pain, it was that protocol and then it was a hernia repair. And so I am assuming it’s done for a reason that those are some of the symptomatic cases.

Dr. Towfigh (00:36:07):

Yeah. Here’s a question. Is the presence of a CAM and pincer abnormality more diagnostic than labral thinning for I guess hip disorder?

Dr. James Wyss (00:36:20):

I would agree with that. The most common type of impingement is a little combination of the two. So basically CAM is referring to rather than it’s a, I think an engineering term rather than the ball of the ball and socket joint being perfectly spherical. It basically has a bump on it. I put my knuckle up to kind of describe that patient. That’s a good one. Then the pin, right. And then the fencer is just an extension of labrum it of the S tablum, the socket is larger, it covers more of it. And so now if you have a spherical ball with a bump on it, moving up against the socket that has a little extension and

Dr. Towfigh (00:37:04):

Overhang

Dr. James Wyss (00:37:05):

Down overhang, exactly. You can get more pinching. You can get more impingement. And I think that can be more suggestive of potential hip joint pain. And specifically from impingement than just the labral thinning alone.

Dr. Towfigh (00:37:20):

Yeah, very good. I see patients with muscle spasm, and lemme rephrase this. I see patients that come to me with possible hernia and they feel a popping in their abdominal wall. They’re like, oh, I felt a pop and I pushed it back in. And it’s in an area where there’s no way you can have a hernia on the side or something like that. And it seems to me what they’re having is a muscle spasm and when the muscle spasm it becomes really tight. You can actually feel it. It’s like a ball, but it’s not a hernia. Do you see that? What’s the mechanism of that? And then what do you recommend for treating?

Dr. James Wyss (00:38:00):

I do not common though. I think because the type of practice I have, I think if I were set up in the community and seeing people initially within 48 to 72 hours of their symptoms, I’d probably see more of that. I certainly saw more of it when I was a physical therapist working side by side with a chiropractor. I certainly saw a lot of that. I think it’s a protective response from something else that’s going on. So the patients always come in often saying, I have a muscle spasm and that’s the problem. I say that’s fine. But I think that’s a symptom of the problem. And so we need to figure out why your muscle is spasming. And I think it can be anything from faulty postures to kind of bad habits with movement to, and lots of this stuff I think can be spine related.

Dr. Towfigh (00:38:57):

Got it. Spine related

Dr. James Wyss (00:39:00):

Of spasms that I see that occur are somehow linked to the spine.

Dr. Towfigh (00:39:05):

Wow. I have some more questions about that, but here’s another question for Dr. Weiss and Dr. Toy’s opinion. Does the quality and location of pain associated with athletic pubalgia differ from that other location and pain associated with an inal hernia? That’s a good question. I think that’s a problem that we have is trying to differentiate a sports hernia from a true inal hernia in terms of location and pain.

Dr. James Wyss (00:39:34):

Can I ask you a question, Dr. Val on that? Yeah. With a typical inguinal hernia, I would assume that symptoms might somewhat be random and may be related to a lot of patterns of the day life activities. Is that true?

Dr. Towfigh (00:39:56):

Yes. So most anular hernia pain is activity related. So if you’re arresting and especially lying flat, the pain should go away. Mostly it’s like 90 over 90% of the time. And then some of the pain is gender-based. So the typical pain is groin pain. It can radiate to the inner thigh testicle around the lower back in women, it can radiate into the vagina, but you can have these, what I call atypical signs. So nausea, bloating could be a sign. Many patients have pelvic floor spasm associated with their ankle hernia, so they complain of painful bowel movements or pain with the full bladder or difficulty like urinary frequency, painful intercourse, men have pain with orgasm. So those are kind of side effects of the hernia that you don’t usually see with sport hernias. I feel sport hernias are very localized to that muscle group with the understanding that you can have tears in the groin where a hernia would be. Those are, I think the most difficult to figure out is if it’s a hernia or an actual tear. And so for those people where first of all, you have to be active, you can’t just sit around and say, oh, now I have a sports hernia. Right?

Dr. James Wyss (00:41:23):

Yeah, right.

Dr. Towfigh (00:41:25):

Assuming you’re a sportsman,

(00:41:29):

Then sometimes I don’t offer laparoscopic surgery to those people because then I can’t assess if there’s a concomitant tear. So I had this actually medical surgeon, she’s now a surgeon who used to be a professional figure skater, really bad growing pain. And I said, it’s hard for me to tell if you have, because her hernia was super, super small, which in some women can hurt. Also pain with men, menses makes the groin pain worse in women. But I’m like, you may also have a tear because of, and so that’s exactly what she had. She had a super small hernia, which I fixed, very disrupted pelvic floor. She had so much scars, especially I said, on your right leg, so much scar I had to cut through for the laparoscopic portion of the repair. And she says, oh, well, I’m a figure scare. That’s my landing foot. So that made sense. But she indeed had a tear, fascial tear, which I repaired. But if I didn’t have that understanding, a lot of these patients would just, oh, we fixed your hernia, you’re fine. Go home. And it was laparoscopic. So you never see the anterior fascia.

(00:42:52):

That’s where it is.

Dr. James Wyss (00:42:54):

Yeah. I mean, I personally find that just with athletic pubalgia, other than the occasional in males, some testicular related symptoms, which might be some referred pain or nerve irritation, I don’t find those other secondary or atypical symptoms you were reporting. And it also is often fine with your everyday activities. It’s truly with sporting activities with a large portion of, if it’s a real serious injury to that whole complex erectus, abdo na duct, they might then become painful just getting up from a chair and getting out of bed. But if you talk to them, their initial symptoms were only sports related.

Dr. Towfigh (00:43:39):

Yes, especially if they wanted, they

Dr. James Wyss (00:43:42):

Didn’t have to completely lie down to get rid of the symptoms. They just had to stop competing at the highest level, higher level just had to a martial artist, they just have to not do one certain kick or take everything else they could do fine. So I think part of it with the history can be helpful.

Dr. Towfigh (00:44:00):

Yeah, you’re absolutely right. They can run ’em, but they can’t sprint. They can

Dr. James Wyss (00:44:05):

Change directions might be the problem, but they can run a marathon with minimal symptoms.

Dr. Towfigh (00:44:10):

Yeah. Yeah, that’s very, very true.

Dr. James Wyss (00:44:12):

When I see endurance athletes with athletic pubalgia, they ask me if they should fix it, if I can help them rehab through it, I tell them, if you want to also play flag football, you should probably get it fixed. But if you really just want to run in a straight line, you probably don’t need to. And I can’t tell you how many people have sent me picture after their marathon and they were like, thanks, doc. You were right. I got through it.

Dr. Towfigh (00:44:36):

Don’t knock flag football. It’s going to be one of the Olympics in LA late 2028.

Dr. James Wyss (00:44:42):

Absolutely. But a lot of change in direction. So don’t do that with athletic pubalgia. It’ll be hard on it.

Dr. Towfigh (00:44:49):

The problem with general surgery is they don’t understand a lot of this. So if they see someone who truly has a hernia, but it’s not a big bulging hernia and the imaging therefore is normal, even though technically it’s not. They call it a S sports hernia, which is really what it really is. It’s an occult inguinal hernia. That’s what I call it. Got it. But they call it spor, and then the poor patient falls the wrong pathway towards diagnosis and treatment. Can I ask you about red light therapy? Sure. What is it and why do the right

Dr. James Wyss (00:45:25):

Turn here? Maybe a U-turn.

Dr. Towfigh (00:45:27):

Well, I mean I guess it’s used for certain strains, right? Muscle strains. And maybe can you explain?

Dr. James Wyss (00:45:36):

So yeah, and for this, I’m tapping into a little bit of my physical medicine and rehabilitation training, but even more in my physical therapy training. Okay,

Dr. Towfigh (00:45:46):

Great.

Dr. James Wyss (00:45:47):

I personally have stopped using almost all modalities over the years. I’ve been trained in using electrical stimulation and ultrasound and laser and even shortwave dither, the number of modalities for physical treatment have been out there. I personally haven’t been that impressed with most of those treatments I have over the past two to three years, taking a deep dive into a shockwave therapy, electrical shockwave therapy.

Dr. Towfigh (00:46:27):

Is that the one where you’re going to the bath

Dr. James Wyss (00:46:29):

And now with It’s a handheld device.

Dr. Towfigh (00:46:32):

Oh, a handheld device, okay.

Dr. James Wyss (00:46:34):

Yeah, yeah,

Dr. Towfigh (00:46:34):

Yeah. But not like the Thera.

Dr. James Wyss (00:46:37):

No, no, that’s different. Thera times like 50 with more focal applications. And I’ve actually been fairly impressed by the results and the literature that’s come along for treating. At first, a lot of it was treating like foot disorders, like plantar fasciitis, but a lot of it has been extended into treating a lot of different tendon problems throughout the body. And the hip and diarrhea has responded reasonably well in my practice. I have a couple college soccer players who don’t have the time to repair an athletic pubalgia or sports hernia, and they’re hoping they can get by with a backup treatment. And

Dr. Towfigh (00:47:25):

So is it a handheld device? It is like the Thera gun?

Dr. James Wyss (00:47:29):

Yes. Yes. It’ll look similar, but what you deliver feels very different for the

Dr. Towfigh (00:47:37):

Patient. It has a point to it.

Dr. James Wyss (00:47:40):

Yeah, I can,

Dr. Towfigh (00:47:42):

Oh, you have one in your office? I love it. Show it to, oh, it’s like a probe. Got it.

Dr. James Wyss (00:47:51):

You have all different tips for application. There’s actually two different types of shockwave called radial and focus, and the research for orthopedic applications really just evolving. But I’m more impressed with this than the 20 plus years of using different therapeutic modalities.

Dr. Towfigh (00:48:15):

There’s a question about core. The core, this poor lady, she says, Dr. Weiss, I had a pedicle tram flap with lots of abdominal wall repairs and some of these tramp flaps when they go awry or flaps, I should say, not just tramp flaps as well as they lose their core. What do you recommend for those of us with no core?

Dr. James Wyss (00:48:42):

Find a good physical therapists?

Dr. Towfigh (00:48:44):

Yeah,

Dr. James Wyss (00:48:45):

That’s what I really think, because where some PTs are getting into using ultrasound just as a biofeedback to show people what they should be activating. There’s biofeedback devices, there is electrical stimulation. I think some of these therapeutic modalities have a certain role when you’re trying to retrain muscles, but really you need somebody who’s willing to be patient and help you kind of find it in whatever way you find it. And then you have to find it before you can train it. And in most cases, even in a situation like that, there’s enough core musculature that you can find some help and you can find some of these muscles to train them. Again,

Dr. Towfigh (00:49:29):

Some people who have denervation injuries from surgery, either from a flank hernia, sorry, flank incision, let’s say for spine surgery, sometimes they injure the nerves, kidney surgery or these abdominal wall flats for breast reconstruction, they ding the nerve. So you get one dermatome of denervation. Is there any hope in those patients when you’re talking about physical therapy, do they bulk up the rest of the muscles to make up for that one adjacent muscle, or how does that work?

Dr. James Wyss (00:50:05):

I think so. I think it’s far more challenging if you have less muscle to be able to recruit or you’re also dealing with chronic pain and scar tissue and everything else. But I still don’t think I’ve found anyone who couldn’t train some of these muscles. They might be starting at a really low level, but I still think it’s possible progress.

Dr. Towfigh (00:50:29):

So as hernia surgeons, we’re struggling with regard to what kind of therapy we should be offering patients postoperatively, most general surgeons, they take out a gall bladder or colon, whatever the situation is. Patient goes home. There’s no physical therapy involved. On the opposite side, most orthopedic surgeons and spine surgeons, there’s always some type of physical therapy involved. So do you think that abdominal wall surgery and groin surgery should have a physical therapy component afterwards? And is it focused on strength training or scar or what do you think about these?

Dr. James Wyss (00:51:15):

I think that’s a little bit tough for me to answer from my perspective, just because I think it could be all of the above. I think if you’re not really worried about a muscle being able to be trained or some sort of complication related to the surgery, they should be able to basically be guided through some exercise to get back to it. But I think the problem is is that we don’t always have the time, and some of us don’t have the comfort just providing some basic exercise counseling.

Dr. Towfigh (00:51:56):

So when someone has, let’s say, hip surgery, what’s the purpose of physical therapy? Is it to strengthen or to reduce scarring where the surgery was performed?

Dr. James Wyss (00:52:07):

I think that’s all of the above. Okay. I think that in most cases, early mobilization does lead to some better outcomes. I think that then it was certain surgeries, anything related to FAI the hip, we often see a combination of gluteal muscles that shut down. Some of the therapists often call it glute amnesia.

Dr. Towfigh (00:52:34):

People can’t, my trader calls it gluteal amnesia.

Dr. James Wyss (00:52:38):

Yeah, exactly. And then the core shut down a little bit. So I think in certain situations there are certain muscle groups that will have their challenges. So having guidance on how to find and train those muscles are important. And then I think some of it is also offering the appropriate supervision so someone doesn’t hurt themselves. So they’re guided through the phasix of rehabilitation. Not everyone knows that you want to get good, you need to control pain and swelling first, then you need to get good motion back. Then you need to find those muscles and build strength. If you don’t go in the right order, things get messy. And so I think that’s where really a physical therapist can shine and really make a huge difference in the outcome.

Dr. Towfigh (00:53:29):

There’s a group out of the Ohio State University, Dr. Ben Paul, he was one of our guests. He’s really into trying to understand this. So he has a whole lab dedicated towards the physicality of abdominal wall core and then surgical how the surgery changes it. So he’s worked with his physical therapist and came up with a physical therapy for early postop rehabilitation after abdominal wall reconstruction that’s available free on their website. It’s the Ohio State University website and also the ACHQC dot org. It’s free for patients. You can just go onto the patient section and look at, it’s pretty good. a lot of different, it’s basically core based. But Paige always ask me, and I feel really embarrassed saying, we don’t really have, I do their hernia repair in the groin. Especially like, oh, so what do you do for, can I get a physical therapy referral? I’m just like, yes, but we don’t have anything coordinated.

Dr. James Wyss (00:54:46):

I wish we did. I think that lots of these things happen from just good collaborations, some multidisciplinary care. I mean, maybe there’s a role, but maybe there’s a limited role. And I think working with the right PTs, you can figure that out. Sometimes there’s just need for education and sometimes I think there’s a need for a very supervised formal physical therapy program.

Dr. Towfigh (00:55:12):

So one of the viewers here is from New York and she, she’s asking for physical therapy recommendation. So for people with core dysfunction, do they go to any specific physical therapist or how do they find a good physical therapist? Are there questions they should be asking? Yeah, I assume pelvic floor physical therapist won’t be addressing core or am I mistaken?

Dr. James Wyss (00:55:41):

So there’s some overlap there. I think if you’re really training the core, you can’t ignore the pelvic floor. But then there are a physical therapists who will focus on pelvic floor therapy and pelvic rehab, and that’s kind of a different subspecialty of pt. But I really tell patients just to ask around in your community, you don’t always want to be traveling long distances to find a good pt. And you should be able to find someone locally and even asking a primary care physician usually know who’s providing good care. And then I think my advice when you pick a facility is that you should feel like you’re getting some individualized care. You shouldn’t feel like you’re being passed along to different therapists. You should not feel like you’re doing the same exercises that a number of other people are doing. And there should be some one-on-one time. There should be one PT who’s in charge, even if there’s others helping out. I think that’s a big part of it.

Dr. Towfigh (00:56:57):

Very good. Thank you. Here’s a question that was submitted. I have both C six seven cervical and L five S one lumbar hernias. I also had incisional hernias. Is there any relationship between abdominal and spine problems? I mean, they’re all hernias.

Dr. James Wyss (00:57:17):

Sure. There’s a common word and threat

Dr. Towfigh (00:57:20):

Herniated disc and abdominal wall hernia. It’s the same.

Dr. James Wyss (00:57:28):

I would say. I’m sure there’s some indirect connection, but I’m not aware of there being any really landmark paper that says if you are prone to symptomatic disc herniations in the spine, that you’re then prone to other hernias. I don’t know if you’re aware of anything different.

Dr. Towfigh (00:57:50):

No. And it’s not a college, is it a collagen disorder in the spine? I don’t think so. I don’t know. I know the genetic,

Dr. James Wyss (00:57:58):

Both of them. Yeah. I mean the intervertebral disc is, but it’s also, I think, just very human. It’s just very common to have changes to the spine and changes to the disc. And in many regards that even a hernia, a disc herniation in the spine can be asymptomatic in large groups. True.

Dr. Towfigh (00:58:26):

And sometimes people come to me with a bulge in their belly. They’re told it’s a hernia, but it’s not a hernia. It’s actually a nerve impingement usually in the, I’ve mostly seen it lower thoracic upper lumbar, and it’s usually a bulge kind of anteriorly as opposed to the flank or anterior, but also around the anterior flank and it’s linear and you get your spine decompressed and the bulge goes away assuming you don’t wait too long.

Dr. James Wyss (00:59:04):

I did not think I was going to learn something about spine care on this. Amazing.

Dr. Towfigh (00:59:09):

Yeah. I have a couple spine doctors that help me out with those. And there are others that think that doesn’t happen. There’s no pain. I’m like, I know there’s no pain, but they’re presenting with a muscle weakness. It’s not a hernia. But yeah, it’s

Dr. James Wyss (00:59:25):

Basically, yeah, I mean that’s the innervation of the lower thoracic spine.

Dr. Towfigh (00:59:29):

Yeah, yeah. Abdominal bulging. Yeah. So I’m here to teach. We’re all here to learn. Yes,

Dr. James Wyss (00:59:37):

We are.

Dr. Towfigh (00:59:39):

Let’s do one last question. Sure. How dangerous is cervical manipulation of the neck?

Dr. James Wyss (00:59:44):

Ah, question. So I do refer to chiropractors quite frequently. I think that cervical manipulation does have some risk beyond manipulation of the thoracic or lumbar spine. There are the rare case reports of vertebral artery dissections. They do tend to actually be in younger rather than older patients more commonly. I think part of that might be how far the neck could go if you were manipulating it.

Dr. Towfigh (01:00:16):

So if you

Dr. James Wyss (01:00:18):

Completely right, you think about

Dr. Towfigh (01:00:21):

An Indian rub of your

Dr. James Wyss (01:00:22):

Vertebral artery, 75-year-old neck, how far it can go. Right. Wow. But I think with good technique, that is not a common problem. I think that is a very much a one-off, very rare complication. And so good judgment, good chiropractic skills, I think it can be safe and effective.

Dr. Towfigh (01:00:44):

Well, this was very fun.

Dr. James Wyss (01:00:46):

Yeah. I had a lot of fun too.

Dr. Towfigh (01:00:48):

Did you see how soon the hour went by?

Dr. James Wyss (01:00:50):

So fast?

Dr. Towfigh (01:00:51):

So fast. Except it’s 8:30 PM

Dr. James Wyss (01:00:55):

Except it’s later. It went from there being some daylight to it’s now dark.

Dr. Towfigh (01:01:01):

Oh. But congratulations on your new puppy.

Dr. James Wyss (01:01:04):

Oh, thank you.

Dr. Towfigh (01:01:04):

That’s very, very

Dr. James Wyss (01:01:05):

Cute. He’s wonderful.

Dr. Towfigh (01:01:09):

Well, that’s it everyone. Thanks so much for joining us, and thank you, Dr. Wyss, for your time. I learned a lot and I hope to share more patience with you. And everyone, appreciate your time here. We have another great guest next week, and I hope to see you again. Go to YouTube, subscribe. You can watch all of these videos on your own time to share it with others or listen via podcast. And don’t forget to follow me so you’ll know who’s coming on every week as we enjoy talking about hernias on Hernia Talk. Thank you.

Dr. James Wyss (01:01:44):

Thanks so much for having me.

Dr. Towfigh (01:01:46):

Thanks. Take care. A great

Dr. James Wyss (01:01:47):

Bye.