so, you want to become a doctor?
Avoiding ambush begins with understanding what’s out there [Figure 15-1] .
—Current advice provided to Baltimore, Maryland, law enforcement officers.
So, you want to be a surgeon, do you? Well, it’s not all red carpets, private planes, and yachts. Although most of it is! (Sarcasm.)
Consider the downside, like the orthopedic surgeon in Vermont who was conducting pelvic exams on women who were complaining about pain in the area. It made sense—except for the fact that he wasn’t an OB/GYN doctor, and that several women complained that he had violated them.
Figure 15-1.
We’re talking about a very tenuous area here, especially for women. But while diagnosing the problem with some of the soft tissue around the hip isn’t easy, the pain is very real. And a lot of it is found in people who aren’t trying to stop a hockey puck from going into the net, drive a golf ball 300 yards, or dunk a basketball. People who sit often can have significant issues around their hips. Women can experience tremendous pain during sex.
A lot of this is quite new. We’re just learning about some of the relationships between certain behaviors and the problems they can cause in this area. It’s complicated and produces some odd complaints that lead to nontraditional diagnoses and outcomes. Of course, the more we investigate, the more we learn.
And the more Oscar parties we get invited to. (Sarcasm.)
Ideas that require people to reorganize their picture of the world provoke hostility.
—American journalist/author James Gleick, Chaos: The Making of a New Science.
THE WAY IT WAS
We already talked about the way things used to be (and to some degree still are) when it comes to these core injuries. The player/patient goes from specialist to specialist. Still no clear diagnosis emerges. The player quits or does not make the squad. The health administrator says: “We tried our darnedest to help you.” The fact is, or was, that no one was smart enough to figure out the diagnosis.
That type of ambush was almost acceptable back then. Life was short. The player might even have been a malingerer. We knew no better.
THE WAY IT IS NOW
Look at things today, from the standpoint of the athletic trainer. The pressure mounts. The same athletic trainers and docs as yesteryear need a cure, for sure, for their star players. The athletic trainers are smart, they recognize a problem exists, yet they don’t know exactly what the injury is, nor how much intervention may be necessary. They send the player to a hip surgeon or general surgeon.
At this point, various things happen. The quality of these consultations varies. It is easy for athletic trainers to be left “holding the bag.” For the most part, coaches and general managers won’t understand. They expect the athletic trainer and team doctor to come up with a definitive treatment or, in the least, a good plan. If the player doesn’t do well, no matter the medical advice, the blame gets dumped on the athletic trainer. The coach thinks that, somehow, the athletic trainer either didn’t get the player into good enough shape to begin with, or didn’t inform the coach soon enough, or perhaps didn’t pursue the right medical opinions. Somehow, the athletic trainer did something wrong.
So then, what keeps us from making the correct diagnosis? Why do so many patients continue to do badly with these types of injuries? Where are the ambushes?
No doubt, the biggest culprit remains in thinking these pelvic pains are “occult hernias.” We’ve discussed this subject already. These traps come mostly from human glitches.
New ideas about pelvic pain in athletes (ie, the statement: “There is no such thing as a ‘sports hernia’”) force most people to reorganize their picture of the world. Just like Gleick said in the above quotation, paradigm-shift ideas provoke hostility.
Many types of ambushes loom with respect to this region of the body. Most traps relate to the narrowness in the way health care workers think (ie, the way we have been trained). Training of physicians dictates that we follow the empirical management rules handed down by our specialty predecessors—Primum non nocere. Doing things “that same way it always has been done” minimizes the chance of harm. Empiricism still dominates the way physicians are taught—“It works, so accept it.”
THE WAYS WE GET AMBUSHED (TABLE 15-1)
We get ambushed in 2 ways:
- By missing an important diagnostic possibility
- By considering the right possibilities yet evaluating the patient badly
None of us are perfect, and this developing field is tricky. Thus, we are all ripe for ambushes.
As we get more experience, the ambushes shall decrease in number. We are amidst a learning curve. Hopefully, the curve shall soon be steep (steep curves are good; we may initially pay the price, but learn things quickly). Unfortunately, so far, the core learning curve has been gradual (which is bad). Misdiagnoses remain common. In fact, misdiagnoses still sometimes seem acceptable. Silly rationalizations abound. “After all, I told you there is no such thing as a sports hernia.”
Let’s not accept misdiagnoses or poor outcomes anymore. It is past time to bear responsibility for making every possible attempt to understand the anatomy and the potential anatomic problems in this region of the body.
TABLE 15-1 TYPES OF CORE AMBUSHES |
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Type 1 Ambushes: Missing the Diagnosis (Table 15-2)
The most common ambushes come from:
- Not knowing the anatomy: The number one ambush comes from not knowing the anatomy of the core muscles and hip. Even obvious clinical and MRI findings of muscular avulsion, pubic plate separation, and hip impingement problems still surprise people. The team doc recognizes some sort of adductor avulsion and presumes it will heal on its own. “Adductor releases are the way to treat these things anyway.” Hopefully, this book will shrink the prevalence of this ambush type.
- Lack of experience: Nothing substitutes for long-standing clinical expertise. No matter the type of training (eg, gastrointestinal surgery, physical therapy, athletic training, orthopedic sports medicine), nothing substitutes for just “having been around a lot” and observing the nuances of clinical situations. For example, recognizing that Crohn’s disease and a huge paralabral hip cyst may cause similar pelvic signs and symptoms does not come from a book. It comes from experience. The overall problem here is that the core has not been recognized as deserving of a distinct specialty. Specialists are way too much in their silos and ordinarily don’t immediately recognize the correct differential diagnosis may involve a totally different specialty. In the absence of a distinct specialty right now, experience is the only way to come up with the right diagnosis for many cases.
- The back: This is a fun one. We’ve got to keep the hair up on our own backs to recognize some of these tricky diagnoses. Of course, back pain is extremely common in athletes—actually everyone. Over the years, all of us compress the cartilaginous padding between lumbar vertebrae, and no doubt repetitive pounding exacerbates the microtraumatic injuries and speeds up slipped discs and arthritis that inevitably ensue.
Diagnosing such problems is okay when the pain lies in the back or follows certain radicular patterns down into the toes. The diagnosis is trickier when the only manifestation of a problem in the back is pain in the abdomen, pelvis, or thigh.
Think about it. The nerves are all over the place and originate back at the spine. This is the anatomy… To quote Coach Belichick again, “It is what it is.” The nerves make things confusing. Here are some pertinent details. Memorize them…just kidding.
The seventh intercostal nerve arises from the T7 (T = thoracic spine) nerve root, runs below the seventh rib, and sends branches anteriorly below the rib cage. The anterior cutaneous branch of the 10th intercostal nerve ends at the umbilicus. The anterior cutaneous branch of the iliohypogastric nerve, from T12 and L1 (L = lumbar spine) spinal nerves, innervates the suprapubic region. L1 and L2 supply sensation to the groin, and the adjacent roots L3 and L4 may serve as additional possible groin pain culprits. Essentially, the same nerve roots innervate the internal organs. Branches shoot out from nerve tangles called plexuses. For example, the iliohypogastric nerve, the same one that signals pain in the suprapubic region, enters the spinal cord alongside the nerves that monitor the ovaries and fallopian tubes.
Think about it some more. This same spinal nerve roots (from T7 to L4) keep watch over the internal organs, the skin, plus all the superficial and deep muscles and bones of the core. By their nature, nerves cross their signals routinely. What the heck? Talk about ambushes. How are we ever going to come up with an accurate diagnosis?
Again, the problem here comes from our specialty silos. Have orthopedic general or urologic surgeons ever been taught these neurological pathways? Again, we are talking about the experience and the learning curve thing.
The above discussion brings up one practical, and really important, pearl to avoid neurologic traps: The neurological anatomy has multiple ways it can fool us. Even when we think we know the nerve root involved, do not congratulate ourselves too early.
The following real example illustrates this warning. After an exhaustive search for a regional cause of a patient’s groin pain, we decided to inject the spine. We injected a particular spinal nerve root with local anesthesia and the pain immediately and totally went away. We congratulated ourselves. The pain had to be coming from the back! We thought we had found the cause (ie, the spine). Did it turn out to be the spine? Not!
Remember, anesthetizing the spine does not mean the problem is in the spine. As we have mentioned, spinal roots innervate everything from the spine to the skin. Thus, the positive response showed that spinal injection would provide only a route for palliating the chronic pain and definitely did not solve the mystery. That ambush happened recently to the wife of one of our colleagues. A hip surgeon ordered a spinal injection. The pain went away totally, and he concluded, incorrectly, that her disc disease was the culprit. For 7 months, interventional treatment of the spine failed miserably. Don’t worry, the ending turned out happily. Her pain totally and permanently went away after total hip replacement.
TABLE 15-2
TYPE 1—DIAGNOSTIC AMBUSHES
- Not knowing the anatomy
- Lack of experience
- The back
- Peripheral nerves
- Complex regional pain syndrome and other neurological syndromes
- Tumors
- Benign gastrointestinal processes
- Benign and malignant genitourinary puzzlers
- Obstetric and gynecologic conundrums
- Vascular challenges
- Lymphatic enigmas
- Pelvic floor disorders
- Not knowing the anatomy
- Peripheral nerves: This type ambush flows from the previous discussion of the back. Think about the many peripheral nerves that we run across in the pelvis: the “3” anterior inguinal nerves (iliohypogastric, ilioinguinal, and genitofemoral); the obturator, femoral, lateral and anterior femoral cutaneous, pudendal, and sciatic nerves. Let’s make 3 ambush-prevention points.
First, rarely are any of these a primary culprit. It is true that any can be pinched by adjacent anatomic structures, but then we have to figure out why (ie, what is the primary pathophysiologic culprit). Complete correction of a problem treatment rarely just involves just the freeing up or ablation of the nerves. Clues to a more central nerve impingement problem include profound weakness and/or atrophy. Surgeons frequently fall into traps like these. In just 1 month’s time frame, we saw 4 patients with “obturator hernias” wrongly diagnosed by the same surgeon. Even to the general surgeon, diagnosis of an obturator hernia is a rare event. Indeed, all 4 patients had signs and symptoms that involved muscles innervated by the obturator nerves. The CT, MRI, and ultrasounds that supposedly showed the diagnoses all turned out to be baloney. All 4 patients had distinct core injuries that had nothing to do with hernias at all.
Second, all of these nerves have considerable anatomical variability. For example, in the first paragraph of this section on peripheral nerves, we said there were “3” anterior inguinal nerves. We intentionally put the number 3 in quotation marks relating to the anterior inguinal nerves. While most anatomic textbooks say there are 3, just about any general surgeon will tell you that at inguinal exploration, there are often 4, 5, or more main identifiable nerve trunks.
And third, remember that the pudendal and sciatic nerves lie posteriorly in the pelvis. Sometimes, people speculate that these nerves are injured during inguinal surgery. The only way that might occur anatomically is if somehow the pelvic bones dramatically shift. That’s difficult to do in the absence of concomitant hip or other bony pelvic surgery. Watch out, on the other hand, when one works on the bones or dissects in the posterior pelvis. These nerves then do come into play. We should learn the gross anatomy of the latter-mentioned 2 nerves.
- Complex regional pain syndrome and other neurological syndromes: Neurologists attribute many seemingly primary nerve problems to an entity called complex regional pain syndrome (CRPS). The problem supposedly has a real biochemical basis. Its pathogenesis relates to damage or malfunction initially of the peripheral nerves and then of the entire nervous system. The best prognostic scenario comes when there is a clearly delineated mechanical injury triggering the whole syndrome. If this mechanical injury can be corrected, the whole syndrome may go away. The first line of treatment for CRPS, therefore, may be to correct all structural damage that can be identified in regions where the pain seems maximal or to have begun. Dr. Robert Schwartzman, the guru of CRPS,1 routinely states: “Without repairing the mechanical factors that trigger the pain, one has no chance to control the nervous system that has gone haywire.”
While most people consider CRPS a diagnosis of exclusion, it does not have to be. Even the most experienced of us diagnosticians see a lot of tricky patients. Never forget the possibility of CRPS.
But also, do not dwell too much on the possibility of this diagnosis. Just entertaining the diagnosis sometimes sentences a patient to a lifetime of experimental therapy and pain clinics. Read more about CRPS and other neurological considerations in Chapter 18.
- Tumors: Professional sports come full of stories about cancers and other tumors discovered in the unusual setting called sports medicine: Lance Armstrong,2 Mario Lemieux,3 Saku Koivu,4 Eric Davis,5 Jon Lester,6 Billy Mayfair,7 Darryl Strawberry,8 and John Kruk9—to name a few. Remember that cancers do occur in the younger age groups and they occur more often in the core than other areas of the body. My first encounter with cancer and groin pain came in the late 1980s: a pro hockey goalie with a real muscle injury, but also with some extremely large superficial inguinal lymph nodes that turned out benign. Those lymph nodes, fortunately (so it turned out), were early harbingers of a rectal cancer that had metastasized to the liver. I remember this patient well because he was alive and well 28 years later, when he texted me to give me a hard time about the Philadelphia Flyers. I remember him also because, against medical advice, he played goalie in a pro playoff hockey game on the fifth postoperative day after a big (segment IV) central liver resection.10 Here are a couple of MRIs of other tumors that we have picked up in our practice. The message here is to stay alert for this potentially devastating ambush, tumors tend to mimic core muscle injuries or hip problems (Figures 15-2 and 15-3).
Figure 15-2. CT of an endometrioma of the right rectus abdominis muscle, a benign lesion mimicking a tumor in a female soccer player. The painful lesion was removed surgically.
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- Complex regional pain syndrome and other neurological syndromes: Neurologists attribute many seemingly primary nerve problems to an entity called complex regional pain syndrome (CRPS). The problem supposedly has a real biochemical basis. Its pathogenesis relates to damage or malfunction initially of the peripheral nerves and then of the entire nervous system. The best prognostic scenario comes when there is a clearly delineated mechanical injury triggering the whole syndrome. If this mechanical injury can be corrected, the whole syndrome may go away. The first line of treatment for CRPS, therefore, may be to correct all structural damage that can be identified in regions where the pain seems maximal or to have begun. Dr. Robert Schwartzman, the guru of CRPS,1 routinely states: “Without repairing the mechanical factors that trigger the pain, one has no chance to control the nervous system that has gone haywire.”
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