This document provides guidance from Dr. Brian Jacob on examining patients presenting with groin pain. It outlines taking a thorough history, including the onset, nature and location of pain, as well as factors that make it better or worse. The physical exam involves examining the back, hips, abdomen and groins/hernia sites. Imaging like CT or MRI may be needed to identify potential causes like hernias, injuries or nerve issues. Dr. Jacob stresses the importance of thoroughly evaluating prior hernia surgery patients and distinguishing between nociceptive and neuropathic pain to guide treatment, which may involve injections, physical therapy or surgery. The goal is a comprehensive diagnostic workup to accurately diagnose the source of groin pain.
Liverpool FC is an English football club founded in 1892 that has won 18 Premier League titles and 8 League Cups. In 2011, Liverpool striker Luis Suarez was accused of racially abusing Manchester United defender Patrice Evra, which led to an 8-match suspension and $62,000 fine for Suarez after he was found guilty. The verdict was controversial and divided opinions between those supporting Suarez and the FA.
La rodilla está conformada por estructuras óseas, tendinosas y ligamentosas. Las estructuras óseas incluyen la rótula y los condilos femorales y tibiales. Las estructuras tendinosas y ligamentosas extraarticulares son los músculos, tendones y ligamentos como el rotuliano, colaterales y poplíteos. Dentro de la articulación se encuentran los meniscos medial y lateral, y los ligamentos cruzados anterior y posterior.
Reinventing the Los Angeles Lakers Through AnalyticsRoderick Head √
The document discusses the lack of analytics use by the Los Angeles Lakers basketball franchise. It notes that in 2015, the Lakers were ranked 113 out of 122 teams across major sports leagues in terms of their analytics capabilities. This low ranking was due to the franchise historically not prioritizing analytics and only recently establishing an analytics department. The Lakers' poor record in recent years is attributed, in part, to this lack of long-term strategic planning and player development that analytics can provide, as the new CBA favors such an approach over simply spending to solve problems.
Drs. Rossi and Shreve’s CMC Abdominal Imaging Mastery Project: December CasesSean M. Fox
Dr. Brian Shreve is an Emergency Medicine Resident and Dr. Isolina Rossi is a Surgery Resident at Carolinas Medical Center in Charlotte, NC. They are interested in medical education. With the guidance of Drs. Kyle Cunningham and Michael Gibbs, they aim to help augment our understanding of emergent abdominal imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides on:
▪ Traumatic diaphragmatic hernia
▪ Internal hernia after Roux-en-y
▪ Inguinal hernia
Errors medical decision making, MGB-OAGB Different and Better!Dr. Robert Rutledge
This document discusses the history of the mini-gastric bypass (MGB) surgery and the cognitive biases that led American surgeons to oppose it for 20 years while supporting the failed laparoscopic adjustable gastric banding (Lap Band) surgery. It notes that for 20 years, American surgeons rejected the MGB despite data from thousands of patients showing its effectiveness, due to biases that led them to believe the MGB would fail based on preexisting beliefs. It argues that standardization, education, and recognition of expert MGB surgeons is needed to properly perform the MGB and prevent complications from surgeons without proper expertise or understanding of the procedure.
Cesarean hysterectomy is really two separate operations: cesarean section and hysterectomy. Cesarean hysterectomy can be accomplished through most abdominal wall incisions. A vertical incision provides best exposure, but often when performed as an emergency a transverse incision has been used and may be adequate.
Liverpool FC is an English football club founded in 1892 that has won 18 Premier League titles and 8 League Cups. In 2011, Liverpool striker Luis Suarez was accused of racially abusing Manchester United defender Patrice Evra, which led to an 8-match suspension and $62,000 fine for Suarez after he was found guilty. The verdict was controversial and divided opinions between those supporting Suarez and the FA.
La rodilla está conformada por estructuras óseas, tendinosas y ligamentosas. Las estructuras óseas incluyen la rótula y los condilos femorales y tibiales. Las estructuras tendinosas y ligamentosas extraarticulares son los músculos, tendones y ligamentos como el rotuliano, colaterales y poplíteos. Dentro de la articulación se encuentran los meniscos medial y lateral, y los ligamentos cruzados anterior y posterior.
Reinventing the Los Angeles Lakers Through AnalyticsRoderick Head √
The document discusses the lack of analytics use by the Los Angeles Lakers basketball franchise. It notes that in 2015, the Lakers were ranked 113 out of 122 teams across major sports leagues in terms of their analytics capabilities. This low ranking was due to the franchise historically not prioritizing analytics and only recently establishing an analytics department. The Lakers' poor record in recent years is attributed, in part, to this lack of long-term strategic planning and player development that analytics can provide, as the new CBA favors such an approach over simply spending to solve problems.
Drs. Rossi and Shreve’s CMC Abdominal Imaging Mastery Project: December CasesSean M. Fox
Dr. Brian Shreve is an Emergency Medicine Resident and Dr. Isolina Rossi is a Surgery Resident at Carolinas Medical Center in Charlotte, NC. They are interested in medical education. With the guidance of Drs. Kyle Cunningham and Michael Gibbs, they aim to help augment our understanding of emergent abdominal imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides on:
▪ Traumatic diaphragmatic hernia
▪ Internal hernia after Roux-en-y
▪ Inguinal hernia
Errors medical decision making, MGB-OAGB Different and Better!Dr. Robert Rutledge
This document discusses the history of the mini-gastric bypass (MGB) surgery and the cognitive biases that led American surgeons to oppose it for 20 years while supporting the failed laparoscopic adjustable gastric banding (Lap Band) surgery. It notes that for 20 years, American surgeons rejected the MGB despite data from thousands of patients showing its effectiveness, due to biases that led them to believe the MGB would fail based on preexisting beliefs. It argues that standardization, education, and recognition of expert MGB surgeons is needed to properly perform the MGB and prevent complications from surgeons without proper expertise or understanding of the procedure.
Cesarean hysterectomy is really two separate operations: cesarean section and hysterectomy. Cesarean hysterectomy can be accomplished through most abdominal wall incisions. A vertical incision provides best exposure, but often when performed as an emergency a transverse incision has been used and may be adequate.
Errors medical decision making Why 20 Year Wait for the Mini-Gastric BypassDr. Robert Rutledge
This document discusses the 20-year history of the mini-gastric bypass (MGB) surgery and the cognitive biases that led American surgeons to oppose it while supporting the laparoscopic adjustable gastric band (Lap Band). It notes that during this 20-year period, the Lap Band had high failure and complication rates, including a 34% revision rate in New York, while randomized controlled trials showed the effectiveness of the MGB. The document argues that standardizing best practices, educating surgeons, and recognizing excellence in MGB surgeons is needed to maximize benefits and prevent complications from the procedure going forward.
Drs. Lena, Avery, and Davis’s CMC Abdominal Imaging Mastery Project: Septembe...Sean M. Fox
1) The document discusses several adult abdominal imaging case studies presented by physicians from Carolinas Medical Center and Levine Children's Hospital.
2) It provides an overview of the ongoing abdominal imaging interpretation project, which is co-sponsored by emergency medicine and surgery residency programs and shares cases internationally.
3) The document reviews a systematic approach to reviewing abdominal CT scans, focusing on following blood flow and anatomical structures from top to bottom and right to left.
This document outlines the design of an enhanced recovery pathway for hip fracture patients. It reviews evidence that preoperative peripheral nerve blocks provide better pain control and reduce complications. Neuraxial anesthesia like spinal anesthesia is shown to be superior to general anesthesia for hip fractures based on reduced mortality, length of stay, and complications. The pathway emphasizes multimodal analgesia, delirium prevention strategies, and multidisciplinary post-operative care to optimize outcomes for hip fracture patients.
There are a variety of surgical management options for groin pain in the young adult hip that is resistant to non-surgical management. The cases included in this presentation highlights some of the more common causes of hip and groin pain in the young adult and their surgical management. For more information, visit my website.
- A 4-year-old Thai boy presented to the hospital with pain in his right elbow for 6 hours. He fell and injured his elbow at school.
- On examination, he had mild swelling of his right distal forearm with limited range of motion due to pain but no external wounds.
- He was diagnosed with a closed fracture of the right lateral condyle. Lateral condyle fractures are less common than supracondylar fractures in children and rarely associated with other injuries.
- Treatment depends on the classification but may include closed reduction, pinning, and long arm casting or open reduction and pinning for more severe fractures.
Drs. Rossi and Shreve’s CMC Abdominal Imaging Mastery Project: January CasesSean M. Fox
Dr. Brian Shreve is an Emergency Medicine Resident and Dr. Isolina Rossi is a Surgery Resident at Carolinas Medical Center in Charlotte, NC. They are interested in medical education. With the guidance of Drs. Kyle Cunningham and Michael Gibbs, they aim to help augment our understanding of emergent abdominal imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides on:
● Chilaiditi syndrome
● Retroperitoneal hematoma
● Rectus sheath hematoma
This study evaluated the technical feasibility and safety of using a novel endoscopic suturing device to repair gastrointestinal fistulae in 7 patients. The procedure was technically successful in all patients with no early complications. At follow up of 5.1 months, 6 patients had resolution of symptoms and average weight loss of 22.8 pounds. While the study was limited by its small size and short follow up, the results suggest endoscopic repair of fistulae using this suturing device can be achieved safely and warrants further study.
Does Your Child have a Hernia ? Inguino Genital Conditions in Children By Dr. Vivek Rege.
Lot of silent conditions that may require surgical intervention at the right time by the doctor.
For info log on to www.healthlibrary.com
Drs. Lena, Avery, and Davis’s CMC Abdominal Imaging Mastery Project: April CasesSean M. Fox
Dr. Kelsey Lena is an Emergency Medicine Resident and Drs. Michael Avery and Joshua Davis are Surgery Residents at Carolinas Medical Center in Charlotte, NC. They are interested in medical education. With the guidance of Drs. Kyle Cunningham and Michael Gibbs, they aim to help augment our understanding of emergent abdominal imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides. This month’s topics include:
- Large Bowel Obstruction
- Blunt Aortic Injury
- Abdominal Aortic Aneurysm with Rupture
Adult Orthopedic Imaging Mastery Project - Pelvic Ring FracturesSean M. Fox
The document discusses different types of pelvic ring injuries including lateral compression, anterior-posterior compression, and vertical shear fractures. It emphasizes the importance of early resuscitation, pelvic stabilization, and considering advanced measures or angiography to control hemorrhage in unstable patients. The case examples demonstrate imaging features and management approaches for different pelvic fracture patterns.
La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr...VitamineB
La hernie du sportif : diagnostic et traitement, technique mini-invasive
Par le Docteur Ulrike MUSCHAWECK
Lors de la 1ère Journée Européenne de la pubalgie
Clinique du Sport Bordeaux Mérignac
Dr. Kelsey Lena’s CMC Pediatric Orthopedic X-Ray Mastery Project: October CasesSean M. Fox
This document provides a summary of 4 pediatric orthopedic imaging case studies involving femur fractures in patients aged 5 to 17 years old. It then reviews key anatomy, techniques for reading x-rays systematically, and classifications and management of pediatric femur fractures. The cases include femoral head, shaft, spiral and Salter-Harris fractures from injuries like gunshots, motor vehicle collisions and falls. The document emphasizes the importance of anatomy and assessing integrity of soft tissues and neurovascular status. Treatment options like casting or intramedullary nailing are discussed.
This document discusses six breast-related cases:
1) An 18-year-old female with a 1 cm breast mass that moves freely inside the breast. Diagnosis is uncertain and further testing is needed.
2) A 35-year-old female with cyclic breast pain and tenderness and a new 2 cm breast mass. She likely has fibrocystic disease and the mass is probably a cyst, but it could be carcinoma and further testing is needed.
3) A 52-year-old female with spontaneous nipple discharge for months and no palpable breast mass. Diagnosis is uncertain and further investigation is needed to rule out carcinoma.
Drs. Rossi and Shreve’s CMC Abdominal Imaging Mastery Project: May CasesSean M. Fox
Dr. Brian Shreve is an Emergency Medicine Resident and Dr. Isolina Rossi is a Surgery Resident at Carolinas Medical Center in Charlotte, NC. They are interested in medical education. With the guidance of Drs. Kyle Cunningham and Michael Gibbs, they aim to help augment our understanding of emergent abdominal imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides on:
• Splenic Laceration
• Necrotizing Pancreatitis
• Hepatic Abscess
1. The document discusses various injuries that can occur to the birth canal during childbirth, including classifications, causes, symptoms, diagnosis, and management.
2. Injuries include perineal tears, cervical and vaginal lacerations, hematomas, and complete uterine rupture. Causes may include obstructed labor, instrumentation, or congenital factors.
3. Diagnosis involves investigations like ultrasound and symptoms like pain, bleeding, and shock. Management depends on the type of injury but may include suturing lacerations, draining hematomas, or laparotomy for severe injuries like uterine rupture.
This randomized controlled trial compared amputation-free survival rates between a surgery-first versus angioplasty-first strategy for treating infrainguinal limb ischemia in 452 patients over 5.5 years. After 6 months, there was no significant difference in amputation-free survival between the groups. There was also no difference in health-related quality of life, but the surgery-first strategy had about one-third higher hospital costs in the first year. The study provides level 1 evidence that for infrainguinal disease, initial angioplasty or bypass surgery results in similar amputation rates with angioplasty being less costly in the first year.
HIFU in the Management of Uterine Fibroids .pptxabayomi ajayi
HIFU is a non-invasive technique using focused ultrasound to ablate uterine fibroids. It was developed in the 1950s and first used commercially in Europe in 1994. HIFU kills fibroids through coagulative necrosis, leading to shrinkage and symptom relief. Studies show HIFU can shrink fibroids by 32.5-52.5% within 6 months. HIFU has advantages over other treatments as it is non-invasive, spares the uterus, allows for future pregnancies, and has a faster recovery time of 1-2 days. Initial evidence also suggests HIFU does not negatively impact fertility or ovarian reserve. Larger clinical trials are still needed to further evaluate HIFU's effects on
Errors medical decision making Why 20 Year Wait for the Mini-Gastric BypassDr. Robert Rutledge
This document discusses the 20-year history of the mini-gastric bypass (MGB) surgery and the cognitive biases that led American surgeons to oppose it while supporting the laparoscopic adjustable gastric band (Lap Band). It notes that during this 20-year period, the Lap Band had high failure and complication rates, including a 34% revision rate in New York, while randomized controlled trials showed the effectiveness of the MGB. The document argues that standardizing best practices, educating surgeons, and recognizing excellence in MGB surgeons is needed to maximize benefits and prevent complications from the procedure going forward.
Drs. Lena, Avery, and Davis’s CMC Abdominal Imaging Mastery Project: Septembe...Sean M. Fox
1) The document discusses several adult abdominal imaging case studies presented by physicians from Carolinas Medical Center and Levine Children's Hospital.
2) It provides an overview of the ongoing abdominal imaging interpretation project, which is co-sponsored by emergency medicine and surgery residency programs and shares cases internationally.
3) The document reviews a systematic approach to reviewing abdominal CT scans, focusing on following blood flow and anatomical structures from top to bottom and right to left.
This document outlines the design of an enhanced recovery pathway for hip fracture patients. It reviews evidence that preoperative peripheral nerve blocks provide better pain control and reduce complications. Neuraxial anesthesia like spinal anesthesia is shown to be superior to general anesthesia for hip fractures based on reduced mortality, length of stay, and complications. The pathway emphasizes multimodal analgesia, delirium prevention strategies, and multidisciplinary post-operative care to optimize outcomes for hip fracture patients.
There are a variety of surgical management options for groin pain in the young adult hip that is resistant to non-surgical management. The cases included in this presentation highlights some of the more common causes of hip and groin pain in the young adult and their surgical management. For more information, visit my website.
- A 4-year-old Thai boy presented to the hospital with pain in his right elbow for 6 hours. He fell and injured his elbow at school.
- On examination, he had mild swelling of his right distal forearm with limited range of motion due to pain but no external wounds.
- He was diagnosed with a closed fracture of the right lateral condyle. Lateral condyle fractures are less common than supracondylar fractures in children and rarely associated with other injuries.
- Treatment depends on the classification but may include closed reduction, pinning, and long arm casting or open reduction and pinning for more severe fractures.
Drs. Rossi and Shreve’s CMC Abdominal Imaging Mastery Project: January CasesSean M. Fox
Dr. Brian Shreve is an Emergency Medicine Resident and Dr. Isolina Rossi is a Surgery Resident at Carolinas Medical Center in Charlotte, NC. They are interested in medical education. With the guidance of Drs. Kyle Cunningham and Michael Gibbs, they aim to help augment our understanding of emergent abdominal imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides on:
● Chilaiditi syndrome
● Retroperitoneal hematoma
● Rectus sheath hematoma
This study evaluated the technical feasibility and safety of using a novel endoscopic suturing device to repair gastrointestinal fistulae in 7 patients. The procedure was technically successful in all patients with no early complications. At follow up of 5.1 months, 6 patients had resolution of symptoms and average weight loss of 22.8 pounds. While the study was limited by its small size and short follow up, the results suggest endoscopic repair of fistulae using this suturing device can be achieved safely and warrants further study.
Does Your Child have a Hernia ? Inguino Genital Conditions in Children By Dr. Vivek Rege.
Lot of silent conditions that may require surgical intervention at the right time by the doctor.
For info log on to www.healthlibrary.com
Drs. Lena, Avery, and Davis’s CMC Abdominal Imaging Mastery Project: April CasesSean M. Fox
Dr. Kelsey Lena is an Emergency Medicine Resident and Drs. Michael Avery and Joshua Davis are Surgery Residents at Carolinas Medical Center in Charlotte, NC. They are interested in medical education. With the guidance of Drs. Kyle Cunningham and Michael Gibbs, they aim to help augment our understanding of emergent abdominal imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides. This month’s topics include:
- Large Bowel Obstruction
- Blunt Aortic Injury
- Abdominal Aortic Aneurysm with Rupture
Adult Orthopedic Imaging Mastery Project - Pelvic Ring FracturesSean M. Fox
The document discusses different types of pelvic ring injuries including lateral compression, anterior-posterior compression, and vertical shear fractures. It emphasizes the importance of early resuscitation, pelvic stabilization, and considering advanced measures or angiography to control hemorrhage in unstable patients. The case examples demonstrate imaging features and management approaches for different pelvic fracture patterns.
La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr...VitamineB
La hernie du sportif : diagnostic et traitement, technique mini-invasive
Par le Docteur Ulrike MUSCHAWECK
Lors de la 1ère Journée Européenne de la pubalgie
Clinique du Sport Bordeaux Mérignac
Dr. Kelsey Lena’s CMC Pediatric Orthopedic X-Ray Mastery Project: October CasesSean M. Fox
This document provides a summary of 4 pediatric orthopedic imaging case studies involving femur fractures in patients aged 5 to 17 years old. It then reviews key anatomy, techniques for reading x-rays systematically, and classifications and management of pediatric femur fractures. The cases include femoral head, shaft, spiral and Salter-Harris fractures from injuries like gunshots, motor vehicle collisions and falls. The document emphasizes the importance of anatomy and assessing integrity of soft tissues and neurovascular status. Treatment options like casting or intramedullary nailing are discussed.
This document discusses six breast-related cases:
1) An 18-year-old female with a 1 cm breast mass that moves freely inside the breast. Diagnosis is uncertain and further testing is needed.
2) A 35-year-old female with cyclic breast pain and tenderness and a new 2 cm breast mass. She likely has fibrocystic disease and the mass is probably a cyst, but it could be carcinoma and further testing is needed.
3) A 52-year-old female with spontaneous nipple discharge for months and no palpable breast mass. Diagnosis is uncertain and further investigation is needed to rule out carcinoma.
Drs. Rossi and Shreve’s CMC Abdominal Imaging Mastery Project: May CasesSean M. Fox
Dr. Brian Shreve is an Emergency Medicine Resident and Dr. Isolina Rossi is a Surgery Resident at Carolinas Medical Center in Charlotte, NC. They are interested in medical education. With the guidance of Drs. Kyle Cunningham and Michael Gibbs, they aim to help augment our understanding of emergent abdominal imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides on:
• Splenic Laceration
• Necrotizing Pancreatitis
• Hepatic Abscess
1. The document discusses various injuries that can occur to the birth canal during childbirth, including classifications, causes, symptoms, diagnosis, and management.
2. Injuries include perineal tears, cervical and vaginal lacerations, hematomas, and complete uterine rupture. Causes may include obstructed labor, instrumentation, or congenital factors.
3. Diagnosis involves investigations like ultrasound and symptoms like pain, bleeding, and shock. Management depends on the type of injury but may include suturing lacerations, draining hematomas, or laparotomy for severe injuries like uterine rupture.
This randomized controlled trial compared amputation-free survival rates between a surgery-first versus angioplasty-first strategy for treating infrainguinal limb ischemia in 452 patients over 5.5 years. After 6 months, there was no significant difference in amputation-free survival between the groups. There was also no difference in health-related quality of life, but the surgery-first strategy had about one-third higher hospital costs in the first year. The study provides level 1 evidence that for infrainguinal disease, initial angioplasty or bypass surgery results in similar amputation rates with angioplasty being less costly in the first year.
HIFU in the Management of Uterine Fibroids .pptxabayomi ajayi
HIFU is a non-invasive technique using focused ultrasound to ablate uterine fibroids. It was developed in the 1950s and first used commercially in Europe in 1994. HIFU kills fibroids through coagulative necrosis, leading to shrinkage and symptom relief. Studies show HIFU can shrink fibroids by 32.5-52.5% within 6 months. HIFU has advantages over other treatments as it is non-invasive, spares the uterus, allows for future pregnancies, and has a faster recovery time of 1-2 days. Initial evidence also suggests HIFU does not negatively impact fertility or ovarian reserve. Larger clinical trials are still needed to further evaluate HIFU's effects on
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Groin pain and hernia exam final by dr. brian jacob
1. Groin Exam
for the general surgeon:
chief complaint – groin pain
Brian Jacob, MD
Big Sky, MT 2018
2. Dr. Brian Jacob Disclosures
• Equity
• International Hernia Collaboration, INC
• LifeBond™
• ViaSurgical
• Consultant
• Medtronic
• Intuitive
• Ethicon
• Verb
• Board Member
• SAGES
• AHS
Brian Jacob 2018
• Thanks to
• Bard, Intuitive, Yuri,
Columbia University
• *Upcoming meetings*
• AHS – Miami, Florida (March
12-15)
• SAGES – Seattle, WA
(April 11 – 15)
• IHC 2018 - New Delhi, India
…(May 3 to 5)
• RAW – Ghent, Belgium
• May 23 to 25
4. Chief complaint: History
•Groin pain
Inguinal Hernia
No Inguinal Hernia
•Where is it located, exactly?
•When did it start?
•Why did it start?
•Constant or intermittent?
•What makes it worse or better?
•Does it radiate / to where?
•Severity (vas score 1 – 10)Brian Jacob 2018
5. Chief complaint: History
•Groin pain
Inguinal Hernia
No Inguinal Hernia
•When did it start?
•Why did it start?
•Constant or intermittent?
•What makes it worse or better?
•Does it radiate?
•Severity (vas score 1 – 10)
Sport / Exertion
injury?
If patient recognizes
a single event…
Brian Jacob 2018
6. Injury or athletic pubalgia:
History documentation – let’s be consistent
• Sport
• S (starting event)
• P (pain description, mapping, photo)
• O (objective exam)
• R (radiology)
• T (treatment intervention)
Brian Jacob 2018
7. Chief complaint: Exam
•Groin pain
Inguinal Hernia
No Inguinal Hernia
•Back
•Hip
•Abdomen
•Groin/ hernias / pubic tubercle
•Legs
•Photograph
Brian Jacob 2018
8. Exam: Back
• Palpate
• Flexion
• Extension
• Rule out obvious disc disease
•SI dysfunction
•TLS ?
• Thoraco-lumbar syndrome
Brian Jacob 2018
11. Exam: Hip
(for the hernia surgeon)
•Flexion
•Extension
•Rotation
•C-sign
•FABER exam
• Flexion/external
rotation/abduction
1) FAI (femoral – acetabular impingement)
2) Intraarticular Tear of the Labrum
Brian Jacob 2018
18. Exam: Intra-Abdominal
• Right side
• Appendicitis (chronic relapsing)
• Epiploica Appendigitis
• Adhesions
• Hidden hernias
• Fallopian tubes, Ovaries
• Endometriosis
• Sigmoid or Ascending
diverticulitis
• Left side
• Adhesions
• Epiploica appendigitis
• Hidden hernias
• Fallopian tubes, Ovaries
• Endometriosis
• Sigmoid diverticulitis
Brian Jacob 2018
19. Exam: Groins / legs
(inguinal canals and pubic tubercles)
• Internal rings (inguinal hernia exam)
• Standing with Valsalva, and laying down
• Round ligament or spermatic cord
• Vulva or testicles
• Rectus insertions
• (sit-up maneuver or leg lifts)(reproducible symptoms or not?)
• Pubic tubercles and symphysis (tender or not?)
• Hip flexors, Aponeurotic plate, and adductor longus insertions
• Adductor squeeze maneuver
• Palpation between adductor tendons and rectus insertions
• Hip flexors (iliopsoas tendons) with straight leg raises
Brian Jacob 2018
20. “conjoint tendinopathy”
• Lower part of the tranversus abdominis as it inserts into the crest of the pubis
and pectineal line
• Pain at internal ring
• No hernia bulge
Rectus insertions:
Brian Jacob 2018
21. Rectus sheeth avulsion or tear
• Lower part of the rectus tears or avulses off the pubic
tubercle
• Pain at insertion site
• medial
• Acute or chronic
• No hernia bulge
Rectus insertions:
Brian Jacob 2018
22. Pubic Tubercle: the most underappreciated joint
drandyfranklynmiller.com Brian Jacob 2018
25. Groin pain is not so simple: need MRI to help
• Iliopsoas
• Rectus
• Pubic bone
• Adductors
http://www.clinicalsportsmedicine.com/
Brian Jacob 2018
27. MRI: What can be the problem?
•Main buckets : athletic pubalgia
• Osteitis
• Rectus sheeth insertion
• Aponeurotic plate
• Adductor longus tendon origin
• Inguinal ligament
• Weak floor with tension or pressure
on nerves or fascia
• (sportsman groin)
MRI pelvis: Athletic Pubalgia Protocol at Mount Sinai, NYC
Brian Jacob 2018
32. MRI: Aponeurotic plate avulsion
Saggital mri view of left pubic tubercle
Brian Jacob 2018
33. MRI: coronal view
left adductor longus tear
• Look for the fluid
• (white on these images)
Brian Jacob 2018
34. Positive MRI Management options
•Acute injury: to surgery
•Chronic injury: to physical therapy first
•6 to 12 weeks of gradual rehab
•Need to find one or two you like to refer
to
•NOT just a work out….
Brian Jacob 2018
35. Repair options for acute injuries: surgery
•Prefer no mesh
•Rectus sheeth avulsion
•Reattach with 0 ethibonds
•Aponeurotic plate avulsion
•Reattach with 0 ethibonds
•Adductor pain or tear or avulsion
•Leave alone or tenotomy at level near pubic bone
Brian Jacob 2018
38. Repair options for weak floor (sportsman groin):
•Diagnosis made with sonogram or MRI with Valsalva
•Repair can be open or MIS with mesh
•Concept is to release pressure on nerves and tissue,
but in the end do a hernia repair
• Lloyd release (TEP with medial release, mesh)
• Moshe release (TEP with mid release, mesh)
• Muscaleck (open release with primary repair)
• Myers, Brunt, others (open releases with primary
reconstruction, no mesh)
Brian Jacob 2018
39. Nerves: Neuroanatomy (open)
• Iliohypogastric nerve
• Ilioinguinal nerve
• Distal genital branch of the
genitofemoral nerve
• Femoral branch of the GF nerve
• Vas deferens (paravasal fibers)
Brian Jacob 2018
41. Chief complaint: History
•Groin pain
No Inguinal Hernia
•When did it start?
•Why did it start?
•Constant or intermittent?
•What makes it worse or better?
•Does it radiate?
•Severity (vas score 1 – 10)
Inguinal Hernia
Brian Jacob 2018
42. Groin Pain with History of an inguinal hernia or a repair:
Diagnostic Evaluation
• Review All Operative Reports
• Focused history and physical exam (with photo)
• xray, Ultrasound
• CT with marker
•MRI with marker or AP protocol
• Never , never assume a recurrence or a hernia is
the cause of the pain until a thorough work up is
completed
•Mapping is strongly encouraged
•Nociceptive vs neuropathic pain
Brian Jacob 2018
43. • Nociceptive:
• inflammation, meshoma, in one spot
• Neuropathic:
• nerve injury, scarring, radiating
• Combination
• Overlap of symptoms / signs
• Psychological, social, genetic factors
Ways to document type of
Chronic Pain
Brian Jacob 2018
44. A word about mapping with previous hernia history
• I always draw on patients in exam room, and right before surgery.
59. Open right groin
Staples and mesh found b/t external oblique + internal oblique
Staples seem to be from inside to out (look closely)
Pubic tubercle
(right)
69. Let’s Review
• History (work from back to hip to groin to leg)(then to abdomen and gyn)
• Review of previous Op reports
• Exam with mapping, put photo into EMR
• Imaging (CT scan with marker or MRI)(or both)
• Rule out back and hip issues
• Label as nociceptive or neuropathic or both
• Decide if pt needs injections, PT before offering surgery
• Surgery catered to patient’s history and the above
Brian Jacob 2017