Chronic Sports Hernia: What to Do When Rehab Has Not Worked

This is session number 36 of the Performance Place Sports Care Podcast. I'm literally staring at a wall. Welcome to the Performance Place Sports Care Podcast, where you can learn about sports injury theory, rehab, diagnosis, and how to understand the doctor lingo you didn't understand at your appointment. And now, your host, Dr. Sebastian Gonzales. Hey, everyone. It's Dr. Sebastian Gonzales again with Performance Place Sports Care Podcast, the place where you can go to submit your questions and listen to some of the experts, answer them. And we talk about sports injuries and make it really, really simple, hopefully really simple, to understand why doctors and PTs and chiros and ACTs or athletic trainers recommend what they do for certain sports injuries.

So we have a caller today, and his name is Matthew. We'll listen to him right now. He left a message on the website on the SpeakPipe button that's right on the site. You get about a minute and a half, so this is what Matthew left. Hi. It was just a comment in regards to your Session 7 video recap sports hernia injuries from November 9, 2016. And he talked about healing injuries, both through rehab and surgeries. And I'm someone who's had this injury for about a year now, and I've seen therapists for about eight months, three times a week. I've undergone platelet-rich plasma injections into the injury site of the symphysis.

I've even seen Dr. Myers out of Philadelphia, and his recommendation was surgery. My issue is I would do the surgery, as you suggested. You know, there's no reason to live with a chronic injury that can be successfully healed. But the problem is insurance companies no longer pay for this procedure. It's considered experimental. Dr. Myers himself charges about $20,000 to repair injury. I'm just not sure of how to heal. What are the next steps in healing if I've been unsuccessful in all areas? I feel like surgery is probably the last option, but I just, as a teacher, I just am no way financially able to pay for that.

Are there other doctors around the country who will attempt to bill insurance companies? And if not, how does someone where surgery is just out of the option heal from this injury? Now, thanks for calling in, Matthew. It was really good of you. And when I heard that, actually, I listened to it in the morning. Actually, I was sitting there having my coffee, and I listened to it. I'm blown away. I'm blown away at the concept that the procedure is still considered, quote-unquote, experimental. There's a lot of conditions still, or a lot of procedures that they would consider experimental. I think PRP still would, I guess, be, quote-unquote, experimental because a lot of the health care or the health plans won't cover it as well as STEM.

But the frustrating part that I see with some of these, quote-unquote, experimental procedures are, even if they have really good success rate, I feel like they really don't get acceptance from the insurance companies or third-party payers until years and years and years after. If I had to guess, I'd say 10 years later, you know? Some of the procedures that I've been, like, one of the topics, actually, is PRP and STEM. I've been hearing about it for a while, especially PRP. By the way, if you guys don't know what PRP is, because Matthew mentioned that, it's platelet-rich plasma. There's also other types of injections that are designed to facilitate growth or, like, a regenerative therapy.

By the way, if you guys haven't listened already to other sessions of this podcast, session 23, we actually go over regenerative cell therapy. So if you do have more questions on PRP or STEM, that'd be a good place to start. It's a really, really good session. I actually learned a lot from it. But anyways, back at these seminars that I go to, I've heard about this for years and years and years. And they keep coming out with more studies to show that it's productive or that there's not a lot of negative side effects and so on. And they're things, actually, that I refer patients of mine to if I find that their care is uneventful here.

And the sad thing is that since it is considered, quote-unquote, experimental or not picked up by an insurance company, there's quite a bit of out-of-pocket expense a lot of times. And I actually have a patient who has a hip injury right now that she's still considering whether she wants to do something like an injection for the hip of PRP or STEM. And I asked her, I'm like, look, if this was a free procedure, would you do it? And she's like, yeah, I'd do it all day. But the fact that it costs, you know, a few grand is a whole different story to her. I'm like, look, if, you know, is it worth a few grand to take the chance to feel better?

Because she's had this thing for like two, three years. And that's a hard question. And so for Matthew here, it seems like, so he's done, he's had this thing for almost a year, he said. Eight months, three times a week in therapy is, it should be enough if it's going to repair. And if you've gone to my, actually just put a new infographic up on the sports hernia page on the P2 site. So if you want to follow along and look at this while I'm talking about it, it'd probably be a good idea. It's p2sportscare.com slash sports hernia. And this goes over basically about 12 points that you should know about sports hernias.

And at the very top, there's a section where one of the best definitions I've seen about sports hernias is there. So it's a phenomenon of chronic activity related groin pain, which is unresponsive to conservative therapy and improves significantly with surgical repair. So I'm going to digest that down a little bit again. So it's groin pain related to doing activities that doesn't really respond extremely well to rehab, but it gets better with surgery. And I think it's kind of profound to think of it that way that when there's, we won't really 100% know, I feel like, that it's a sports hernia until it repairs well with surgery.

So you might wonder, why do we do rehab with it anyways? Well, there's other types of groin pain as well. There's also incidental findings on images. An example would be, say, like MRIs, like you find degenerative findings of the spine or like bone spurs and disc herniations all the time. And it doesn't always mean it's the pain generator. So sometimes we play this game where we get to identify the pain generator or hopefully with rehab, we're going to address a lot of the other possible pain generators. And what with sports hernia is it's really hard since the area that's kind of torn away, it's ideally with, like, say, an adductor strain, which is higher up on the list of possibilities, we kind of want to stabilize the trunk, you know.

But if there is a tear in the transverse house fascia, it's hard to produce load in that trunk area. So a lot of times if you repair it, it's more eventful and you rehab after. Now, I guess going back to Michael really seems to have an issue with knowing where to go next because the procedure does cost a lot of money. I have no idea how much money it costs with other health care providers. But I would go back to that idea of is it worth it to you? And are you willing to take the gamble? And that, you said $20,000, I mean, it's a bit of money, but what is it worth for the rest of your life on it?

And there is always the possibility that procedures don't go well. And there's a possibility that you just threw all the money away, okay? But with that all being said, I think you should take the necessary steps to confirm that you're going to be addressing the correct thing in a procedure. So I didn't hear anything about ultrasound findings, really, or MRIs or anything of that nature. I think I didn't. But I would confirm that everything is possibly the sports hernia or beyond reasonable doubt. And there's nothing else there. Because some of the other procedures could be covered by your insurance company, for all we know.

Labral tears are usually high on the list, or hip impingement, high on the list of possibilities of a differential diagnosis for sports hernias. But it sounds like you've been through a lot of health care providers, and they seem to be all agreeing, from what I hear, about the possibility of a sports hernia. So if everyone else listening to this, you're probably wondering, like, what the heck a sports hernia is, if you haven't heard that other session of the podcast. That's number seven. So going back to that page, we have that sports hernia page, or ptsportscare.com slash sports hernia. It usually occurs in cutting, pivoting, kicking, and turning sports.

Baseball, hockey, football, soccer, things of that nature, usually I would consider change of direction or higher on the list. I actually saw a girl one time that she had it with Ultimate Frisbee. That was just her thing. She liked doing meetups.com and going to meet people and playing Frisbee. And it was really hindering because she couldn't throw a Frisbee. It's a rotational sport. But usually there's not a pop. You don't fall. It's a slow onset. It just kind of develops, you know. A lot of times it's on one side and it radiates to the front part of the thigh. So that radiating to the front part of the thigh is kind of similar to, like, heart attacks, kidney stones.

Like, you, those are examples of visceral types of radiation or organ-based radiating pain. But you can also have muscle, fascia, tissue, or joint-related referred pain as well. So a lot of times you'll get, with the sports hernia, you'll get it to kind of the upper thigh. You'll get it into the, quote-unquote, rectus femoris area. And a lot of people will consider that it's a quad strain. But this is the reason why they're kind of hard to pinpoint. And a lot of times you won't really know that it's a sports hernia or you won't even get the idea of it unless you palpate or feel into, like, there's a, they call it a pubic symphysis.

But if you slide your hand down, like, your six-pack muscles and you kind of hit something hard, when you get into that area right there, if it's abnormally tender on one side and not in the other, but it's really hard to pinpoint other than that, a lot of times I, that's one of the first things I check on people if they're talking about groin pain. Number six on there, I hope you guys are following along. I guess some of you could be driving, but check this thing out later, actually. It's a really good infographic. So number six is that you could feel pain within the scrotum if you're a guy. But also, too, it could feel like tightness.

There was a guy I worked with that he was, he was actually doing a very long run. It was across the country, and he described it as that tightness within the scrotum. And the more that you look in the research, you find that that is a possible symptom of it. I actually had no idea at the time. So, but the other types of possible diagnosis there are with it, there's an adductor strain, also joint-related pain, hernias, labral tears. These are all possibilities of it, and there is other ways to confirm it, okay? Obviously, if it doesn't respond to rehab extremely well, we have to assume there's a possibility that it supports hernia.

But imaging can also be helpful. Diagnostic ultrasound or ultrasound imaging is a non-treatment, but image. You'll actually see a picture of it on the site if you go in and look at this graphic. It's really cost-effective. It's really sensitive at finding things. I've found quite a few with this. It's a movement-related image, and you don't really have to get any dye injected, which is super cool. Because sometimes with other types of images, by the way, I'm not saying with an MRI, to look for or an x-ray to look for this type of thing would have dye. But just overall, ultrasound doesn't have dye, which is super cool because you can have complications with contrast dye.

But that's kind of it. That's kind of where, and if you look through the workflow of this infographic, you'll see at the bottom, if rehab's unsuccessful, surgery could be the thing. And I believe on this, I'm going to scroll down to the bottom of the page because I'm kind of using this as a reference to work through today. Rehab's supposed to be really good with it. And one reference says it's 92% success rate. Let's see, there was 87% on a different one within four weeks, then when they go back to partial play. So I guess, Michael, what I'm getting at here is I think we have to play, I would play this.

And by the way, I'm not allowed to give medical information if I haven't met anybody. So, Michael, I understand that. So I'm going to kind of put this into the universe, and hopefully it comes down and you hear it the right way. But I think we have to ignore what people will allow to pay. Because the insurance company or what someone else is allowing to be done to you is really not right. Obviously, that's how their business works. They approve some things and not others. But the doctor's recommendations are typically what's right for you and not what's right for your pocketbook. And I know you said you're a teacher, and the sad reality is it's, I mean, I know teacher salaries aren't exceptionally high.

But you might find another doctor that might try to bill it. Insurance companies, at least with, I'm probably going to do a whole, I'll probably do a whole topic one day on just the understanding insurance for patients and athletes. Because we do find that's a very under, not very well understood on their part. And a lot of people think they have insurance coverage for everything, and they don't. And I think it's just a misunderstanding. So first off, there's in and out of network. I don't know if you've gone through this or not with your doctors who are recommending certain things. But there's in and out of network.

A lot of times when you look at your insurance benefits, the in-network is a lot of times what they'll quote. And I know that when we do calls to insurance companies, we have to stop them. And a lot of times they'll default and tell us about in-network of the patient's benefits. And we have to stop them oftentimes and then revert them back down to out-of-network benefits, which is what we bill if we choose to. Which, by the way, we only see about, I'd say, 10% of our patients ever use insurance because coverage is so rare for actually doing what we're doing as well. But you have to steer them down that road and make sure they're talking about co-insurance and not co-pays.

Co-pays is insinuation that you're talking about in-network. In-network is only people who have clinics and doctors who have actually signed on the dotted lines and said, we're going to agree to take this and this and that. So they're in contract. Other places that are out of contract, you can still do it if you have a PPO, but there might be more out-of-pocket costs to you as a patient. And a lot of times the deductible, which might be non-existent on the in-network, would be five times the amount. A deductible, if you don't know what it is, it's where they will not cover anything if you have not paid a certain amount for your care up to that.

So an example would be that if you, say it's the beginning of the year, and in January you came in, you had a sports hernia, but you've been paying all through your rehab, it sounds like. So eight months, three times a week in January, all of a sudden you don't, you have to start paying again. And you might be wondering, well, what the heck? Well, a lot of times these ones are on calendar years. So you have to pay that extra $1,000 before they'll start paying for your services again. Some of them aren't calendar years. Some of them I've seen July to July. So it's very different based upon each one.

And also, too, like every doctor or every doctor's office bills a little bit differently, or they might choose not to bill based upon their experience. We personally don't bill much anymore just because we found that the lack of understanding of patients about their policy gave us a little bit of, the patients had a little bit of animosity or hesitation of having actual care. A lot of times when you just have them pay out of pocket, we wash that whole, they'll cover it or they won't out of it. If they cover it, it's just a bonus, you know. So I guess back to your question is where do you go from here?

I would confirm that it is one first. And once you've confirmed that it is one, and by the way, this is saying nothing against the doctors or therapists who have already worked with you. But I would make sure for you that you understand that it is one because you're making the decisions from here on out. And especially that if you are paying out of pocket, I think you should know what it is and you should feel really good about it, okay? It's kind of like if you were to bet at a, you know, if you're going to bet on an NFL game. Like you kind of want to know all the facts about the game. I think next I should probably just guide you to a video which I did on, this was on YouTube, and I'm going to find the actual name of the video.

It came out in early 2017, and it's labeled how to gain control of your injury, and it's basically just me writing on a piece of paper. And basically through that, what I'm going through is just figuring out in your head which things hurt, which ones don't, and so on. And with the game, I kind of play with it is that I want all my patients and athletes to understand which types of movements they cannot tolerate. And that's why I have them make a list. There's three parts to the list. Number one is these things hurt. The far right side, if that was the far left, the far right side might be these things don't hurt.

And the middle is I have no idea, okay? The reason why I have them do this is because a lot of times understanding your injury means that we have to break movements down and rehab down into parts. Example. So say squatting hurts. If squatting hurts, then perhaps we break that down and we go sideways or we go into like a quadruped rock. So, by the way, squatting, we'd say we do it with outweight at first. And then if we figure out that all of a sudden the movement of the squat doesn't hurt, like say you're doing it on the ground. By the way, if you don't know what a quadruped rock is, it's kind of like you're on your hands and knees and you're going into a squatting pattern.

Except for now we're not on our feet. So, but on your feet hurts, but on your knees it doesn't. So the movement of the joint is the same. The loading of it is a little bit different. So then that would make me believe that possible rehab means that it's somewhere between those two. It doesn't mean you cut out squatting completely, but it means that there's a possibility that the joint is not compromised. It just means that you can't load it while you're standing. So I think you should look at that video some, how to gain control of your injury. If you're having trouble finding my YouTube channel, just go on to YouTube and type up Performance Place Sports Care.

And then go on to the channel and find all the way down, you'll find this one has the thumbnail of basically just writing. So it looks like a very bland thumbnail. It is white paper and you'll see my hand in it. Okay, it's only about a seven minute video. I think that'll actually greatly help you. And I recommend that everyone do that for all their injuries actually. I did it for my oblique strain. I did it for my hamstring tears. So it really helps develop a little bit of sanity and a little bit of control. Because I know that the patients that I've worked with in the past that are so frustrated about their condition, it's mainly because they don't understand it.

Okay. If we can understand it, I think it gives a little bit of empowerment and it gives you the possibility of knowing what you can and can't do. And in the case of Michael here, he might now get to weigh his options saying, well, if all I couldn't do was play Ultimate Frisbee, but I could walk. You know, I like going outside and walking with my wife, say. You know, like maybe he can't run outside, but the whole point was to hang out with his wife. So it depends what you're looking for in life. Okay. So if he's looking only to spend time with his wife just because that's his, that's what he needs to do and wants to do, it doesn't mean he has to run doing it.

Okay. And now you might say, well, what's he going to do for cardio? Well, maybe there's other types of cardio that he can do. And this is where that list comes into play. Perhaps he tries swimming. Perhaps he tries elliptical. You know, perhaps he tries biking. And maybe half these things don't bother him. And it's something that he's able to live with and not pay 20 grand out of pocket to do. These are the things that I think you have to gain control. And I see it a lot of times with runners and a lot of times with people that have single sport hobbies. I was talking to my neighbor today about mountain climbing or about mountaineering and rock climbing.

And he's talking about how common it is for people to get pulley injuries or like in the fingers. And he was telling me about one of his friends who had, he had a finger injury. And I guess he was a young guy, like 18, 20, something like that. And he went to his doctor and the doctor's like, look, you just have to stay off it for six months. So we stayed off it for six months. He tried climbing again, started hurting again. So we went back and he said, stay off it for another three months. And the guy just decided to finally, he's like, look, I don't want to climb that much. I think I'll change sports.

And I think that's a great call. If you actually listen to, there's another podcast that we have with Billy Lister. I would have to see which episode is it? It's already been published. So that's session number 24, Billy Lister. He's a good example of overcoming injuries. And if you listen to what his story was with things, when I met him, he was actually, he was doing triathlons and he was running. And if you'd ever seen Billy run, it's, it's nothing compared to how he bikes. Um, I never saw him swim, but, but biking, I mean, I, in, in that episode, I told a story about, and Billy remembers it too, about we were, we were biking together.

And I mean, he's really only got like one leg, which works extremely, extremely well. The other leg just, I mean, it's there kind of along for the ride. He can't generate as much power out of it. Um, but he just dominated me with that single leg. So his ability to bike. And so he's, he's a Paralympian. His ability to bike was so good that why not just cut the running out? So I guess back to Michael again, what does he want out of life? I think is where I would take it from there. We have to do, a lot of times we have to do mental mindset changes with people. And I'm definitely not the one who would tell someone to stop doing something completely.

But if I knew playing, so I'm playing baseball this weekend. If I knew that I could not sprint anymore to get a, get a fly ball in the outfield, probably my next rational thing is not going to be to completely stop, but it's probably going to be to say, Hey, maybe I can play second base. There's less running, less sprinting. There's more of just like a reaction type of thing, like diving, like third base. Like you don't really run that much. You just kind of dive and react to the ball. First base, the same thing, you know? So I might ask to do that type of thing. I have a lot of guys on my team that used to ask for pinch runners all the time.

So they still wanted to hit. They want to play second base, first base, but they didn't want to run. And when, so anyways, I guess the point is go back to changing the mindset and figure out what you really need because it is a big decision. I hate, I hate to say it, but if it's, if, if you've tried a lot of this other rehab and you feel confident that the rehab was done well and you feel confident about the diagnosis, I think you have to, I think you have to go and look at the potential of the procedure and then talk to surgeons, different surgeons, and then see what's your success rate. How confident are you that this is a sports hernia?

You know, what if, what if this doesn't get better? Like what, you know, like just ask them questions, feel comfortable with it. If you don't feel comfortable going to different surgeons and asking them, talk to your, talk to your therapist. I'm sure that spending eight months, three times a week with them, you probably know them extremely well. And this is what we run into a lot with rehab with people here. They, they have no problem with asking us a lot of questions and, you know, you see them on a weekly, biweekly basis. So you'll get more into an understanding of the reason why the therapist might say, well, look, this is what I would want you to do.

You know, we've already tried X, Y, and Z. Most people get better with, you know, X amount of percentage of time or X amount of percentage with X amount of time. And if, and if you weren't getting better, then we have to take the X, the necessary extra step. So, um, I think I will stop this podcast into here. And this has only been about 25 minutes. It's a short session, but, um, I really want to put this one through, uh, and get it out there because, um, I could really feel, and I don't know if you guys could feel as well, that the frustration that Michael's having, um, I don't even know, you know, where you live, how old you are and so on.

But I'm really sorry that, um, you know, it happened to you. Um, but I really want you to understand that you need to ask everyone who's worked with you to collaborate as a team and make sure that that's the best decision if you're going to go that way. So if anyone else has questions, again, go on to the P2 sports care site and there is a button. It says send voicemail for the podcast. And this is specifically for this purpose. You get a minute and a half to state your case, tell them about your story, be as concise as you possibly could be. And I'll answer it kind of like this on a podcast. And I really do, I really like helping people with this type of stuff.

And I don't always get the time to do it, um, and spend, you know, 30 extra minutes in the office to tell everyone else that I'm working with, you know, and repeat the same stories over and over again. But a lot of times when you, when you present it in an open forum like this, you'd be surprised how many other people are helped. And I know there's probably, there's probably 50 more people that are probably thinking right now, oh my gosh, this is exactly what I'm experiencing, you know? So, um, thank you for, for calling in. Go to p2sportscare.com. Again, look at that sports hernia page. Um, there is more than enough time that I spent on that trying to make it the best reference for sports hernias you can possibly find on the internet.

So, um, share it with friends and, uh, share, uh, you should share what you have, you know, with people or what you believe you have. The more information you can share, uh, I think the better we're all going to be in the long term. Because in the long term of this thing, like, just like, uh, we're having an issue here with non-covered, uh, non-covered surgeries. At some point, healthcare is going to go this route, I feel like. At some point, patients are going to need to understand really, really well what their condition is, and since there'll be probably, uh, less and less coverage for them, they're going to have to do stuff on their own.

And I know that you probably, uh, probably the medical profession doesn't want me really saying that, mainly because I know that we have to diagnose. And I, I know that we got, we have to, we have to diagnose, we have to treat. I have a good friend who says there's, it's really hard for patients to do their own rehab and we shouldn't expect that from them, but I think we should. And, and I know that he, he said multiple times before, he's like, you know, it takes a long time to get to know this. You can't teach someone something on a video or on the internet. And I'd pose it the other way and I'd say, perhaps we haven't done it the right way yet.

You know, I think there's an effective way for people to learn, effective way for people to move. So this is where I see things going, honestly. And this is again, why I started this podcast. So, um, I don't think I offend anyone in this episode. So, um, but if I did, I, uh, apologize. And it's, this is mainly just for everyone to learn. So I don't, uh, it's, there's no malice to anybody. Uh, that's not why I'm on here. So I'm not bashing anybody. So, okay, take care, and I will talk to you guys next week.