Looking to get in touch with our office? Send us a message here. We are in Costa Mesa CA but we can help people virtually very efficiently. In this episode, we delve into the often misunderstood realm of sports hernias and the classification of muscular injuries associated with them. Sebastian Gonzales attempts to unravel the complexities of sports hernias, shedding light on their diagnosis, treatment, and the importance of accurate classification. Listeners will gain insights into the various types and severity levels of muscular injuries, from mild strains to full-blown tears, and understand how proper classification is crucial for effective treatment strategies. Dr. Sebastian Gonzales DC breaks down the diagnostic criteria, discussing the role of imaging techniques and clinical assessments in determining the extent of muscular damage. From professional athletes to weekend warriors, understanding the nuances of sports hernias and muscular injuries is essential for both prevention and recovery. Join us as we navigate through the intricacies of these injuries and empower listeners with knowledge to make informed decisions about their athletic pursuits. Enjoy! Sports Hernia Book Reference: https://p2sportscare.com/product/understanding-sports-hernias-unveiling-the-mystery-behind-groin-pain/ Sebastian's Groin/ Hip Books: https://www.p2sportscare.com/product/understanding-hip-diagnosis-book/ DOCTOR LINKS BELOW PREMIUM PODCAST LINK (for Clinicians only) FREE GROIN WEBINAR (LAYPUBLIC) References: https://pubmed.ncbi.nlm.nih.gov/23080315/ (00:41): Hey, everyone, it's your host, Sebastian, with the Restoring Human Movement podcast. Thanks for joining the Movement Movement in this podcast. Today we're gonna cover the topic of sports hernias. Again, we've done this quite a few times over the last few months, and hopefully we're gonna be the biggest resource of sports hernia information on the internet. I guess this podcast would be on the internet. Strangely, this is a condition that plagues a lot of people, but the story that we tend to hear a lot at Performance Places. You know, people just don't have any good understanding of what's going on. There's a lack of information out there. They're not sure what to do, they're frustrated and so on, which is why we're putting these out. We've covered in past podcasts, mechanics, symptom generating structures, and today we're gonna cover more in understanding a strain versus a tear. (01:29): This topic coincides with various different types of conditions as well. If you consider a hamstring, what is a strain versus a tear? How do you know which one you have? I did have someone the other day talk about how we're dealing with back pain with this person, and they said, what do you think about the muscle? I said, well, what about the muscle? And they said, well, do you think it's the muscles causing the problem? Well, you didn't have any bruising or swelling there. There was no discoloration in the skin. There was no pop or feeling like you got shot by a gun. So all those would be indications of some type of fiber disruption in that case. Yeah, the muscle is probably part of the problem, but in this case, the muscle spasm and feeling of muscle pain may be protective or compensatory. (02:13): And so this topic of, is the muscle the issue, or is there any damage to the area? Is it the primary symptom generator, I think is a big topic. And so I want to cover that a bit with you today just so you can get an understanding and not worry so much about the muscle and maybe worry more about or in, in some scenarios, the let's worry more about what to do, about what you feel versus thinking. The muscle's, the big old problem, which honestly, most of the time it's not. Just let you guys know too, if you subscribe to the podcast, you'll get all the great old episodes that we have on various different topics like shoulders and necks and ankles and hips and knees and thighs, and sports hernias, and disc degeneration, and disc herniations and what have you. (03:01): We have lots of different topics, topics on things. We have other hosts that are gonna come in pretty soon. I work with Mandy Wainfan and Dawne Constantino, who have a wealth of knowledge. And, and in order to try to get the Keep This Podcast going with a consistent basis, I need help. And so they're gonna host some of the shows coming up at some point in the future. Please know that I, I do verify they know exactly what they're talking about, so learn from them as well. So, some of the information I'm gonna be sharing today is based upon an older, older, I wanna say older publication at this point in time. It's from 2012 at this point, or 2013 rather. If you look it up and you go online and type up terminology and classifications of muscular injuries in sport, the Munich Consensus Statement, this is again from the British Journal of Sports Medicine. (03:51): And I've been referencing this for quite a while because I think it provides some understanding and a better, a, a better idea of how to manage people. For patients or clients. It's, it's a good idea to understand, do you have any, are you gonna have a positive MRI? Are you gonna have a positive ultrasound if you decide to go that route? Or you just on a, on a goose hunt where you're not really gonna find anything because you're really not in the land where there's any tissue disruption. So in this in this research article, by the way, I'll post well consensus statement rather we're gonna post, I'm gonna post it reference on the show notes so you can't link and read it and do your due, do your own due diligence. But essentially what happened was, they were trying to establish a better terminology for how to manage people with muscular injuries. (04:45): And so what they did was they went through and asked what do you mean by strains? And they ask various different healthcare providers of very different, various different class classifications or expertise. And they found that there really wasn't a precise terminology. It was kind of wishy-washy. One person would explain it one way, one person would explain it, another and so they, they really decided that how do we, for, for people who are experiencing "strains," which is includes about 70% of in this case, they mentioned mainly soccer players that I'd say that extrapolates over to a lot of different sports as well. For a majority of the people who are dealing with muscular injuries, how can we appropriately give them a timeline of recovery and manage them if we don't know exactly what we're talking about? And so I'll read a couple of these things verbatim. (05:36): So the first step in establishing a precise diagnosis, which is critical for reliable prognosis, is knowing how long it'll take, when they can return to sport, when things will dissipate on a day-to-day basis and try to find each provider's clear guidance for treatment and management. We need to, we need to be able to find precise terminology again. So how can we reasonably, reasonably give a timeline for re-repair and recovery for the air if we don't exactly know what's going on? So for those of you who don't have fiber tears, which are gonna be found on imaging, your return to sport and activity without any major disability or fear of making things super bad, is really a quicker return. There's less disability. There may be a little bit of pain, but then there's always this idea of, if I, if I work through pain a little bit, am I gonna make things worse? (06:33): Now, if you have fiber disruption, which is gonna coincide with positive images then your timeline is longer. And there may be a chance that we need to change the management protocol to let those areas heal up a little bit and then return you back into sport again. Now, it's important to note too, I'm not saying by healing them up, I'm not telling you to do a certain PRP or prolotherapy or rest excessively. I'm not saying any of that. I'm just saying the management changes, which may require you to do different types of things in the beginning of your recovery, versus people who are only dealing with "strains", which don't have fiber disruption. Now, on the flip side I've met a lot of people who have been dealing with the feeling of a strain or pain into the lower abdominal area, into the groin, into the hip, into the hamstring, wherever. (07:25): And they're unaware of what is happening and how bad it could be. Or if there's tears, their mind is what takes them out of the sport. And they say, you know what? I'm gonna listen to what this person says. I'm gonna give it six weeks of doing nothing, and I'm gonna see what happens. But the reality is, if you don't have any real tears, then you could return faster than you think. And the time spent off, "resting it for six weeks" actually gives you a little bit more of a higher risk factor for other conditions. Tendinopathies other aches and pains that come out of doing less and then doing more, or spikes of exposure. I think I mentioned an old podcast that we saw a lot of this during the shelter in place, covid type of scenario. People did, a lot of people did a lot less even kid sports. (08:17): Child sports were not, were not in existence. They weren't doing anything. And all of a sudden, once they came back into sports and they could do it again, there was a lot of exposure. There was a lot of activity, not only with one sport, but multiple. And because of that, we saw in our clinic, I believe, a lot of different odd conditions that we typically don't see kids have. And it was related to, in my opinion, doing less than doing a lot. And reasonably, like, if you're gonna run a marathon, you don't just run a marathon on day one. Like, that's ridiculous. So you would probably build up, and that's what happens if you give it a lot of time off, you have to build up. Okay. So as we go through this before I do I should mention, if you have not, if you don't know what a sports hernia is, I cover that in pretty much detail in other podcasts. (09:05): So for the most part, it's gonna be a lower abdominal type of pain or discomfort. Some people have testicular tightness. Some people have into the front of the hip, into the upper adductor area too, kinda the crease of the hip. But if you want more details, you should listen to the podcast. Now, I'm gonna read a couple things just verbatim from the consensus statement. 'cause I think that'll make it easiest on all of us, and I'll boil it down to clarify anything I see in the middle. So when they asked people about strains, they mentioned that the responses confirmed marked variability in the use of the terminology relating to muscular injuries with the most obvious inconsistencies for the term strain in the consensus, meaning practical and systematic terms were defined in established meaning they actually tried to narrow things down and make them more specific. (09:52): In addition, a new comprehensive classification system was developed, which differentiates between, between four types of muscular injuries. The ones we're gonna be covering today are going to be mainly ones that we can do something about at least in regards to rehab. But there were functional muscle disorders describing disorders without evidence of fiber tears. Okay? And these are all, they're sub-classifications of these two, which I'll talk about a little bit later. So functional muscle disorders are ones that will not have a muscular muscular injury on imaging. That's ultrasound or MRI X-rays, by the way, don't show muscles. So those are kind of exempt from this. And then there's the structural muscular injuries, which are partial tears, total tears, avulsions, muscles torn off of bones, which is, they say , macro evidence of fibro tears. And these are going to have positive MRI ultrasound findings. (10:46): Again, x-rays don't really matter in this scenario. So, again, probably about 70% of the people that have muscular injuries are functional-muscle injuries without any actual imaging findings. But it's funny that a lot of people, when they're in pain, really wanna see what's wrong. You see the discrepancy in that. You won't see anything, which makes it hard for the person to understand what's going on. Like, I don't know what's wrong with me. I, I, you know, maybe it's hereditary. If they can't see anything, then what else could it be? You know, there's a lot of unknowns that happen outta that. If you don't take the logic of knowing that you can have muscular pain without any MRI or ultrasound findings, okay? And that's a majority of you, a strong majority. (12:10): A lot of the lower abdominal findings we have in sports hernias, I'd say easily 90% of them have no findings whatsoever. A lot of 'em don't have hernia findings. By the way, hernias in sports hernias are different. We don't find anything on imaging indicating tendinopathies or tears of tendons and muscles. Some people have some findings, but as we mentioned in the prior podcast, not all imaging findings are a hundred percent related to their symptoms. Sometimes you find 'em, sometimes you don't. Okay, now, just this, let's take a now another logical approach to this, because I've, I've been in around enough sports injuries and I've had some of my own, where if you feel a pop, when you're, say, sprinting or you hit a hockey puck, or you kick a soccer ball, you feel a pop. And it's followed by swelling to the area where the pop occurred. (13:02): And then a few days later, you notice bruising or discolorations, like it feels like someone shot you. It feels like someone threw a ball at you. You feel a tho you feel a thunk, right? In the muscular area, yeah, this is probably a structural muscular injury that has a positive imaging finding. In that case, your timeline changes a little bit. And we talked about how to rehab things in other podcasts, okay? But, and I'm, I'm trying to narrow this down the best I can, because I don't want you guys to go on this long hunt for imaging findings when there's probably not gonna be any, and it's a big waste of money too. How many MRIs and ultrasounds can you do before you realize that there, you didn't have the mechanics, you didn't have the history, nor the exam findings to merit the image in the first place, okay? (13:50): And have the unknown in your mind about, well, what could it be? Now, you know, you're probably a functional-muscular injury, which is okay, all of 'em can be rehabbed. Almost all of them can be solved without surgery. And there is a way out of this, okay? Most of you can recover back to normal activity, and most of you can get back into sport, but you need to have some guidance typically 'cause all this information on the internet and the lack of information or the wrong information is pretty prevalent, and it makes people get a little confused about what to do. Okay? Now I'm gonna go over some of the other parts of the, of the, of the classifications that there used to be. So the old classification was mostly used. It was called the O'Donohue, and was from 1962. (14:32): This system utilizes the classification to, based upon injury severity related to the amount of tissue damage and associated to functional loss. So it categorizes muscular, muscular injuries into three grades. And this is what most people still use when they talk about muscular injuries, which I think should be eradicated. I think we should go to the Munich Consensus Statement type, because this gives better education to the patient, but also gives us a better idea of how to manage the problem without wasting all the time and resources on imaging. So grade one has no appreciable tissue tear, which is the functional muscle disorder category, broken up into subtypes. Now, there's grade two, which is a tissue damage and reduction of strength in the musculotendinous junction, which is where the muscles and tendons come together. So you'll see a change of function. (15:23): It won't just be pain, it'll be a change of function or a change of strength. Reduction of strength, because now the tissue has damage, which can be recovered from, but it has appreciable tissue damage. It will be found on an MRI or ultrasound. Grade three is a complete tear of the musculotendinous junction, a complete fun complete loss of function. It's funny people that I've met who have actually had ruptures of, of,musculotendinous junction,musculo tendon off of bone.,They actually don't really have a ton of pain. They just can't move their limbs, okay? Like a shoulder. If you tear a supraspinous off of the off of the shoulder, usually you just, you can still move the shoulder to some degree. But then there's a loss of range and function in a certain range. Uwe had a kid come in recently that had a fracture of his elbow, and it was about two weeks old. (16:14): He had no pain, but he couldn't move it. Okay? So there's a difference between pain and full range and full strength. 'cause A lot of you who have functional muscle disorders, the ones that are more of a "strain" category, actually have pain. You have full function and you have full strength. Okay? So that's the difference between 'em. And when you have an actual tear or a tissue disruption, there's actually a loss of strength and a lot of time function too, or range of motion. The current ultrasound based grading scale, which is from 1995 is used quite a bit less than MRI, by the way, I should mention that. I think ultrasound is actually a really useful tool for sport hernias for shoulder conditions as well. If we're not talking about inside the joint, I think they're kind of useless for spine conditions. (17:07): But I think for muscular injuries, I think you can see a lot with an ultrasound if you find a good sonographer per, personally, I wish we see more ultrasounds because there's no claustrophobia associated with going in the machine. 'cause The machines just put on your skin. And seeing things close to the surface is really, really easy. And it's cheaper. So I think there's a lot of benefits to doing ultrasound to diagnose some of these fiber disruption types of conditions. But I don't know if that'll be something that's really in the quick future. Back on some mentions in the study. So the MRI based criteria was from 2007. Uit's from Stoller and so grade one the MRI is negative. So again, if we're, if we're matching these from the O'Donohue 1962 version, grade one, no appreciable tissue damage, no MRI finding,so the MRI based one from 2007 is grade one MRI negative for, for structural damage. (18:09): Okay? And then grade two is MRI positive tearing up to 50% of muscle fibers. And then grade three is muscle rupture, which is a hundred percent structural damage complete tearing with or without muscle retraction. And so those match up, okay? But again, most of you are gonna have grade one, which is gonna be negative, any imaging findings. Other things that were evaluated in this questionnaire that they sent the doctors that the sports medicine experts associated with the disconnect with the terminology was so they actually found marked variability with other definitions as well. So marked variability and definitions for hypertonicity muscle hardening, muscle strain, muscle tear bundle, or fascial tear and laceration. But the most obvious inconsistencies were associated with muscle strain. They found relative inconsistencies with pulled muscle in that laceration. So again, their decision in this questionnaire was that there's really no clear definition. (19:15): And so their goal was to define better. And that's where we get these results from. And now we're gonna talk a little bit more about the functional muscle disorders and the structural muscle disorders, and how these may relate to a little bit more of like sports hernia. So as mentioned before, functional muscle disorders can be acute, indirect muscle disorders mean that they don't have to be trauma based. There are trauma based ones in here, like contusions, which is a direct muscle disorder, but a functional muscle disorder, it's pretty, it's indirect. It's not like you experience any trauma to the area. There's not any EV evidence of MRI or ultrasound findings of tissue disruption. You probably won't even notice any swelling in the area, although you may. But there's usually no discoloration in the skin. There's not a pop, there's not a clunk associated with the original injury time either. (20:03): Some people even notice with some of these disorders within the functional muscle disorder category the four different subsets, some of them wake up with it. It's not even related to actual motion. Now, there's four basic categories in this functional muscle disorder category, okay? The first two I will mention, but we're not gonna spend time on it because it's not gonna be relevant to a lot of people. The last two are gonna be the most relevant for your understanding. So first, there's fatigue induced muscle disorders, and then there's delayed onset muscle soreness. I'm gonna start with delayed onset muscle soreness or dorms, because most people who do exercise, they know what DOMS is. Several hours. After doing an activity, they start to feel soreness in their muscles. Technically, this is a muscular injury, but we all know that no one goes to the doctor for them. (20:57): And there's no MRI ultrasound findings. There's also fatigue based muscular injuries as well, or fatigue induced. So there's stiffness during the activity due to poor warmup. Typically we believe this could be a predisposition for an injury. So it's something that you should be weary of. And just note, because over the course of time, you may experience other conditions in that area. But those two are ones that people typically don't go to doctors four because they usually dissipate on their own. The other two are the ones that we see a lot of people for. So there's spine related, and then there's muscle related neuromuscular muscle disorders. Okay? Spine related one is the easiest one I think for most people to relate to. An example would be an L five S one nerve root impingement either created from stenosis or foraminal stenosis, or a pinched nerve or disc herniation, whatever it may be. (21:52): If it affects the S1 nerve root, then the person may experience tightness of the hamstring or calf, which limits flexibility or the ability to bend forward or stretch those muscles. And so this may mimic a muscle injury, and it will last for quite a bit of time until that actual root cause is solved. This may require different forms of treatment beyond simple muscle treatment, beyond simple stretching and tissue work and massage and red lasers. And by the way, I'm not bashing all these things. These are just things that people do and ice and heat and rest and so on. There's other things that need to be done. And so for spine related disorders, a lot of times there's core involved. There's internal pressure management, as I call it. But the actual technical term is intra abdominal pressure coaching from diaphragmatic breathing. (22:47): A lot of times there's, there's other ways to solve the issue rather than just beat the snot out of the muscle. That's, that's tight. Okay? Many clinicians also believe that athletes with lumbar spine pathologies will have a greater disposition for tears of, say, the hamstring. Now if we relate this back into our sports hernia, people, lower abdominal scenarios, we find that people who have bend points of L1-T12, L 1-L2, like that's their, we call it a spinal hinge. It's there, like, there's like a sinkhole right there because they use it a lot too, to move from those people tend to have a lot more lower abdominal strain feelings. And again, I'm using strain very loosely on purpose. 'cause now we've already defined those, some of those terms. So in that case, settling down the spine may dissipate the feeling of the strain in the lower abdominal area. (23:41): Now spine related disorders, now you might find positive imaging findings in the spine, but it's not a hundred percent needed to do that. A good examiner can actually figure out how to manage you without having to get the images done, which again, wastes time and money. You're, if you have a good skilled examiner, they can also figure out if you need the image. So they may find in your history and exam that you actually need to have an image performed, which helps them make a decision about how to help you. Okay? But there are normal findings in the spine images that are not anything you need to worry about. We've done podcasts about disc degeneration before and disc herniations and stenosis. We've done 'em on all of these. And generally speaking a lot of them are not surgical based. (24:33): Some of them are re: it relates mainly to how you present in your functional loss. But a lot of 'em are just a lot of hard work and guidance. People just need guidance on what to do. The last category here is that muscle related neuromuscular muscle disorder is a big, a big word there, right? And these ones are more of what I call as a reciprocal ambition. One. First, some of you have been through physical therapy, rehab, or even reading some of these articles online. You may have figured out that term of overuse. Some of you may even have gone into the rabbit hole of regional interdependence or the joint by joint approach to training or rehab. And this basically relates to how the body not only neighboring joints, but muscles within the same joint work together. (25:26): And so if you have a hip flexor that's tight, chronically tight, or "strained," it may be due to your glute max and other glute muscles not working well. And rather than focusing on that hip flexor and figuring out what you gotta do to relax that thing directly, it may be easier to take the overused chronic workload away from it so it stops becoming so tight. Similar to the spine related one, if you take the spine insult away, then it decreases the amount of tightness you feel in the innervated tissue. Same thing with the reciprocal inhibition type, which is basically opposing muscle groups. So in a lower abdominal area, you may wanna make it. So also the hip works better. You also may wanna make it so the other musculature in the abdominal area works well with the muscles that are working too much. (26:24): And you may also want to help out with improving your internal pressure so that you can decrease the insult on that. We called it the shutter effect, and we covered it in the other podcasts as well, which is more associated with the onset of people with sports hernias. Okay, so now just to reiterate, we have fatigue-based muscular injuries, which is, again, no imaging findings, delayed onset muscle soreness or doms, which is no imaging findings. Spine-Related neuromuscular disorders, which have no imaging findings of the local muscle tissue. And then muscle-related neuromuscular muscular disorders, which is, again, no positive imaging on the area of concern, but you may find other muscles around it which are not working well. So that basically encompasses, in a nutshell, the majority of you experience either spine-related or reciprocal inhibition base, which is other muscles and around it are not helping. (27:22): Okay? So I cannot stress this enough. Do not always focus on the area that hurts. If you find what is creating that muscle to become tight, either protective, which is spine-related or overworked, which is muscle-related, then you can solve the issue long-term. Nothing's more frustrating than going back into your activity. After you've rested it and it feels better, then it comes right back, okay? Which is a common scenario for a lot of people with this, if they don't address the underlying cause. Now structural-related muscular injuries, which is again, gonna be positive. Imaging findings don't always have a direct trauma to it, either. No one has to hit you to create it. I had this experience when I tore my hamstring. I was sprinting for a baseball, and it felt like someone threw a baseball and hit my leg. (28:14): And I looked down, there was no ball there. I fell over. I felt a clunk. And then what ensued after was swelling into the area and bruising, that's a, that's a structural muscular injury, and I probably would've had a positive image whether I had gone, but in that case, I didn't need to because I knew what it was. Again, you may feel a snap, it may be a minor partial muscle tear, it might be a moderate partial muscle tear, which may include a little bit of retraction, a part of the unit or maybe a total an avulsion. If it's something like an avulsion, you're gonna know because you won't be able to move the area and you'll, your movement will be arrested and you'll have quite a bit of bruising. In that case, it may be important for some areas like the shoulder or the bicep or certain muscles to actually have 'em reattached. (29:04): And this is a little bit more outta my realm, but I, I don't do surgery to reattach things, but from my understanding, the sooner you get it reattached, the better because then it won't mat down and attach to other surrounding tissues, because if you leave it long enough, it'll, it'll start to find an attachment point, and then it'll mat down with its scar tissue. Now, I'm gonna go back to the consensus statement now and give you just some line item things that I thought were really interesting, and they were talking about terms that need to change. So, muscle injury terms with highly inconsistent answers in the survey were strain, pulled muscle hardening and hyper tous, essentially across the board. There's no uniform answer for this. So we either need to stop using them or we need to define them better. And that was part of their goal. (29:50): They said the term strain should basically not be used anymore. And we should substitute that for these things that I just talked about, which is the four other categories, pulling muscles is a layman's term and is not really defining any types or grades of muscular injuries. So it shouldn't really be used as a scientific term. And they said that hardening and hypertonus also was not well-defined and shouldn't be used as scientific terminology. We can use 'em as slang, but essentially it's not gonna have a definition. Now lastly I'm gonna give you leave you guys with the idea again of is an MRI needed, okay? Because I think this is the biggest question that I get when I work with people who are tired of dealing with stuff for a long time, and they have pain in their full function. They don't have any bruising. (30:39): You know, it just came on. There was no pop. Do I need another MRI done? Well, probably not, you know, and I mean that mainly because if you have a good examination, you don't need one done. Okay? If it's a structural injury and you suspect a possible fiber tear, or, and you have the history and exam findings to indicate that it matches, then maybe probably essentially if you think that there's more of an a complete detachment, I think that would be something that maybe reattachment sooner or later would be a, a better idea. But even with old tears, the body finds a way to get around it. I never had my hamstring tear addressed. There's no divot. It's not a big one. It's pretty small. It was probably more into the, the old category would be a grade two, which is some tissue damage with reduced strength, but really not any tearing off of the bone. (31:48): But it heals itself. That's the function of scar tissue. It's supposed to heal itself and the body finds a way, and then now the area doesn't hurt at all anymore. I didn't even notice it. But if we plan on changing our protocol and treatment plan, then yes, an MRI is needed based upon if you find what you think you'll find, okay? And I mean this with the best intentions, it's really an MRI should not be up to the patient or the cli or the client. It should be up to the, to the, to the clinician. It's a tool to figure out if we are managing this as we are or not. Okay? I had a really great instructor in school that they had, they had a case they talked about, which was a knee MRI, they had to redo a couple times. (32:39): It was a younger kid. He had a contusion direct trauma to the knee in that case. Trauma's a wild card. It could be anything. The kid wasn't getting better. They did an MRI and it was normal. And so a few weeks later, the kid still wasn't getting better. MRI normal, his kid still wasn't getting better a few months later, even though the insurance company wouldn't pay for it anymore, MRI positive bone marrow edema, which indicates small fractures of part of the spongy bone of the femur. In that case, since he thought he may find something that changes his judgment, he kept imaging or changing the image or asking the radiologist to figure out if there's something missing. I had, I had somebody years back that I had to call the radiologist to see if we can find finer slices of an MRI to make sure that there was no bony injury to the area. (33:38): And they did that for me, and it was clear and it was good. Okay? So, but if I found that I would probably refer this person out to an orthopedic, okay? And when my instructor found that he no longer tried tissue work, he no longer tried rehab, he took the kid outta the game and let the area heal itself. So if you think your management will change, then your doctor, your physical therapist, your chiropractor, your orthopedic doctor will probably suggest an image because you're not abiding by the same timeline of recovery. Okay? If I cut my finger with a, you know, like a paper cut, we should all know within, you know, three days, most of the pain goes away, it's still red, you know, within a week's period of time, it's scarred over within two weeks. You don't even know it's there. (34:28): You know, if it hurts like heck in the beginning do we need an image for that? No. Do we need blood work? No. It's abiding by the normal healing timeline. Okay? Now, something like a sports hernia, which should, the pain should reduce, especially if there's no bruising or swelling, there's no discoloration. It should reduce within about a week's period of time, maybe two. And it should feel normal doing day-to-day things. If it doesn't, then maybe we wanna do an image to see why. Now, if the person's being treated and the exam and the history indicates that they don't need an image, and they're gonna be treated for two to three weeks expected timeline, again, if you get the right treatment down, or you take the, you take the triggers away, triggering movement away, or the triggering activity, then two to three weeks, yeah. (35:20): Is, is enough time to find a really good result. And that's what we find at Performance Place. We find that two to three weeks is enough for most people. With even stubborn lower abdominal strains and adductor strains and groin pain in, in sports hernias, we find that a lot of 'em over the course of two to three weeks feel a lot better when we get the recipe right, okay? Now, if they don't, we may consider changing the treatment protocol, or we may decide to do an image. It's really our decision. Now, we, I've had people who have asked before, like, do you think I should get an MR? I'm done. You know what? It's up to you. You know, your, your money, your time, you may not, if you don't get it paid for, that's okay. You know, I've had enough things over my lifetime where I've got images done where probably my doctor wouldn't have sent me for them because I wanted what I call a clean bill of health. (36:11): I wanted to make sure there wasn't any muscle, muscle injuries. I wanted to make sure I didn't have an infection. I wanted, make sure I didn't have anything else that would change my protocol. And I wanted to know early, so I paid cash and it was negative, or I found normal things for the scenario. And I wasn't worried about non findings. I wasn't worried about normal activity and age related findings. I was worried about that one finding, was there an infection? Was there tuberculosis? Was there a fracture? Was there a tumor? Was a tendon torn off a bone? Those things weren't really found so cool. Let's just do what we're doing. And if people want that, by all means, I have no problem with that. But if you get hung up on the idea of finding and seeing something in there, you may be disappointed because not all pain is related to positive imaging findings. (36:56): And I think that's gonna be the whole takeaway in this podcast. Okay? So if you guys ever need help and you want advice, we are here. Okay? At Performance Place, we have virtuals. And in-person sessions we've seen people virtually for sports hernias with not a lot of problems. We're pretty transparent with, again, our timelines, as I mentioned on here, two to three weeks. Generally, things feel pretty good. Obviously this is a case dependent person, dependent, you know. But we also, because people may not, if they don't fall into those timeframes, they're also not something's wrong. Not like wrong, like disability or surgery wrong, but it's like we don't have the recipe, right? We may have given you the wrong exercise to do. You may have done it poorly. You may have interpreted differently how we want it. Maybe form is an issue. (37:49): Maybe we coached it poorly. Maybe it wasn't enough reps, so we need to reevaluate. But usually when we get the recipe right, people don't need surgery. They don't need medication, and they return to sport. Okay? So if you guys ever want help from us I, I don't wanna say we're the specialist of sports hernias, but we sure see a lot of 'em. We see a lot of groins lower, a lot of adductors, a lot of low backs, a lot of hamstrings. And especially in the regards to the sports hernia realm. If you're not finding help where you're at, come see us. We'd love to provide some clarity for you and some guidance and get you on the right track. And just make sure you get back to a, a, a healthy and fulfilled life. I know that if I was not able to play my sport, baseball, which I still love to play weekly, if I could spend 10 hours in a baseball uniform every week, I'd be very happy. But if I don't feel like I can play how I wanna play, I'd be very frustrated. And it degrades my quality of life. So I don't want that for you guys. Mandy and Dawne don't either. And so reach out to us info@p2sportscare.com or 714-502-4243. We have all of our contacts in the description for the, for the podcast, and we're looking forward to working with you. See you guys next time. Subscribe to the podcast for more of this to come.
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In this episode, we delve into the often misunderstood realm of sports hernias and the classification of muscular injuries associated with them. Sebastian Gonzales attempts to unravel the complexities of sports hernias, shedding light on their diagnosis, treatment, and the importance of accurate classification.
Listeners will gain insights into the various types and severity levels of muscular injuries, from mild strains to full-blown tears, and understand how proper classification is crucial for effective treatment strategies. Dr. Sebastian Gonzales DC breaks down the diagnostic criteria, discussing the role of imaging techniques and clinical assessments in determining the extent of muscular damage.
From professional athletes to weekend warriors, understanding the nuances of sports hernias and muscular injuries is essential for both prevention and recovery. Join us as we navigate through the intricacies of these injuries and empower listeners with knowledge to make informed decisions about their athletic pursuits.
Enjoy!
Sports Hernia Book Reference:
https://p2sportscare.com/product/understanding-sports-hernias-unveiling-the-mystery-behind-groin-pain/
Sebastian's Groin/ Hip Books:
https://www.p2sportscare.com/product/understanding-hip-diagnosis-book/
DOCTOR LINKS BELOW
PREMIUM PODCAST LINK (for Clinicians only)
FREE GROIN WEBINAR (LAYPUBLIC)
References:
https://pubmed.ncbi.nlm.nih.gov/23080315/
(00:41):
Hey, everyone, it's your host, Sebastian, with the Restoring Human Movement podcast. Thanks for joining the Movement Movement in this podcast. Today we're gonna cover the topic of sports hernias. Again, we've done this quite a few times over the last few months, and hopefully we're gonna be the biggest resource of sports hernia information on the internet. I guess this podcast would be on the internet. Strangely, this is a condition that plagues a lot of people, but the story that we tend to hear a lot at Performance Places. You know, people just don't have any good understanding of what's going on. There's a lack of information out there. They're not sure what to do, they're frustrated and so on, which is why we're putting these out. We've covered in past podcasts, mechanics, symptom generating structures, and today we're gonna cover more in understanding a strain versus a tear.
(01:29):
This topic coincides with various different types of conditions as well. If you consider a hamstring, what is a strain versus a tear? How do you know which one you have? I did have someone the other day talk about how we're dealing with back pain with this person, and they said, what do you think about the muscle? I said, well, what about the muscle? And they said, well, do you think it's the muscles causing the problem? Well, you didn't have any bruising or swelling there. There was no discoloration in the skin. There was no pop or feeling like you got shot by a gun. So all those would be indications of some type of fiber disruption in that case. Yeah, the muscle is probably part of the problem, but in this case, the muscle spasm and feeling of muscle pain may be protective or compensatory.
(02:13):
And so this topic of, is the muscle the issue, or is there any damage to the area? Is it the primary symptom generator, I think is a big topic. And so I want to cover that a bit with you today just so you can get an understanding and not worry so much about the muscle and maybe worry more about or in, in some scenarios, the let's worry more about what to do, about what you feel versus thinking. The muscle's, the big old problem, which honestly, most of the time it's not. Just let you guys know too, if you subscribe to the podcast, you'll get all the great old episodes that we have on various different topics like shoulders and necks and ankles and hips and knees and thighs, and sports hernias, and disc degeneration, and disc herniations and what have you.
(03:01):
We have lots of different topics, topics on things. We have other hosts that are gonna come in pretty soon. I work with Mandy Wainfan and Dawne Constantino, who have a wealth of knowledge. And, and in order to try to get the Keep This Podcast going with a consistent basis, I need help. And so they're gonna host some of the shows coming up at some point in the future. Please know that I, I do verify they know exactly what they're talking about, so learn from them as well. So, some of the information I'm gonna be sharing today is based upon an older, older, I wanna say older publication at this point in time. It's from 2012 at this point, or 2013 rather. If you look it up and you go online and type up terminology and classifications of muscular injuries in sport, the Munich Consensus Statement, this is again from the British Journal of Sports Medicine.
(03:51):
And I've been referencing this for quite a while because I think it provides some understanding and a better, a, a better idea of how to manage people. For patients or clients. It's, it's a good idea to understand, do you have any, are you gonna have a positive MRI? Are you gonna have a positive ultrasound if you decide to go that route? Or you just on a, on a goose hunt where you're not really gonna find anything because you're really not in the land where there's any tissue disruption. So in this in this research article, by the way, I'll post well consensus statement rather we're gonna post, I'm gonna post it reference on the show notes so you can't link and read it and do your due, do your own due diligence. But essentially what happened was, they were trying to establish a better terminology for how to manage people with muscular injuries.
(04:45):
And so what they did was they went through and asked what do you mean by strains? And they ask various different healthcare providers of very different, various different class classifications or expertise. And they found that there really wasn't a precise terminology. It was kind of wishy-washy. One person would explain it one way, one person would explain it, another and so they, they really decided that how do we, for, for people who are experiencing "strains," which is includes about 70% of in this case, they mentioned mainly soccer players that I'd say that extrapolates over to a lot of different sports as well. For a majority of the people who are dealing with muscular injuries, how can we appropriately give them a timeline of recovery and manage them if we don't know exactly what we're talking about? And so I'll read a couple of these things verbatim.
(05:36):
So the first step in establishing a precise diagnosis, which is critical for reliable prognosis, is knowing how long it'll take, when they can return to sport, when things will dissipate on a day-to-day basis and try to find each provider's clear guidance for treatment and management. We need to, we need to be able to find precise terminology again. So how can we reasonably, reasonably give a timeline for re-repair and recovery for the air if we don't exactly know what's going on? So for those of you who don't have fiber tears, which are gonna be found on imaging, your return to sport and activity without any major disability or fear of making things super bad, is really a quicker return. There's less disability. There may be a little bit of pain, but then there's always this idea of, if I, if I work through pain a little bit, am I gonna make things worse?
(06:33):
Now, if you have fiber disruption, which is gonna coincide with positive images then your timeline is longer. And there may be a chance that we need to change the management protocol to let those areas heal up a little bit and then return you back into sport again. Now, it's important to note too, I'm not saying by healing them up, I'm not telling you to do a certain PRP or prolotherapy or rest excessively. I'm not saying any of that. I'm just saying the management changes, which may require you to do different types of things in the beginning of your recovery, versus people who are only dealing with "strains", which don't have fiber disruption. Now, on the flip side I've met a lot of people who have been dealing with the feeling of a strain or pain into the lower abdominal area, into the groin, into the hip, into the hamstring, wherever.
(07:25):
And they're unaware of what is happening and how bad it could be. Or if there's tears, their mind is what takes them out of the sport. And they say, you know what? I'm gonna listen to what this person says. I'm gonna give it six weeks of doing nothing, and I'm gonna see what happens. But the reality is, if you don't have any real tears, then you could return faster than you think. And the time spent off, "resting it for six weeks" actually gives you a little bit more of a higher risk factor for other conditions. Tendinopathies other aches and pains that come out of doing less and then doing more, or spikes of exposure. I think I mentioned an old podcast that we saw a lot of this during the shelter in place, covid type of scenario. People did, a lot of people did a lot less even kid sports.
(08:17):
Child sports were not, were not in existence. They weren't doing anything. And all of a sudden, once they came back into sports and they could do it again, there was a lot of exposure. There was a lot of activity, not only with one sport, but multiple. And because of that, we saw in our clinic, I believe, a lot of different odd conditions that we typically don't see kids have. And it was related to, in my opinion, doing less than doing a lot. And reasonably, like, if you're gonna run a marathon, you don't just run a marathon on day one. Like, that's ridiculous. So you would probably build up, and that's what happens if you give it a lot of time off, you have to build up. Okay. So as we go through this before I do I should mention, if you have not, if you don't know what a sports hernia is, I cover that in pretty much detail in other podcasts.
(09:05):
So for the most part, it's gonna be a lower abdominal type of pain or discomfort. Some people have testicular tightness. Some people have into the front of the hip, into the upper adductor area too, kinda the crease of the hip. But if you want more details, you should listen to the podcast. Now, I'm gonna read a couple things just verbatim from the consensus statement. 'cause I think that'll make it easiest on all of us, and I'll boil it down to clarify anything I see in the middle. So when they asked people about strains, they mentioned that the responses confirmed marked variability in the use of the terminology relating to muscular injuries with the most obvious inconsistencies for the term strain in the consensus, meaning practical and systematic terms were defined in established meaning they actually tried to narrow things down and make them more specific.
(09:52):
In addition, a new comprehensive classification system was developed, which differentiates between, between four types of muscular injuries. The ones we're gonna be covering today are going to be mainly ones that we can do something about at least in regards to rehab. But there were functional muscle disorders describing disorders without evidence of fiber tears. Okay? And these are all, they're sub-classifications of these two, which I'll talk about a little bit later. So functional muscle disorders are ones that will not have a muscular muscular injury on imaging. That's ultrasound or MRI X-rays, by the way, don't show muscles. So those are kind of exempt from this. And then there's the structural muscular injuries, which are partial tears, total tears, avulsions, muscles torn off of bones, which is, they say , macro evidence of fibro tears. And these are going to have positive MRI ultrasound findings.
(10:46):
Again, x-rays don't really matter in this scenario. So, again, probably about 70% of the people that have muscular injuries are functional-muscle injuries without any actual imaging findings. But it's funny that a lot of people, when they're in pain, really wanna see what's wrong. You see the discrepancy in that. You won't see anything, which makes it hard for the person to understand what's going on. Like, I don't know what's wrong with me. I, I, you know, maybe it's hereditary. If they can't see anything, then what else could it be? You know, there's a lot of unknowns that happen outta that. If you don't take the logic of knowing that you can have muscular pain without any MRI or ultrasound findings, okay? And that's a majority of you, a strong majority.
(12:10):
A lot of the lower abdominal findings we have in sports hernias, I'd say easily 90% of them have no findings whatsoever. A lot of 'em don't have hernia findings. By the way, hernias in sports hernias are different. We don't find anything on imaging indicating tendinopathies or tears of tendons and muscles. Some people have some findings, but as we mentioned in the prior podcast, not all imaging findings are a hundred percent related to their symptoms. Sometimes you find 'em, sometimes you don't. Okay, now, just this, let's take a now another logical approach to this, because I've, I've been in around enough sports injuries and I've had some of my own, where if you feel a pop, when you're, say, sprinting or you hit a hockey puck, or you kick a soccer ball, you feel a pop. And it's followed by swelling to the area where the pop occurred.
(13:02):
And then a few days later, you notice bruising or discolorations, like it feels like someone shot you. It feels like someone threw a ball at you. You feel a tho you feel a thunk, right? In the muscular area, yeah, this is probably a structural muscular injury that has a positive imaging finding. In that case, your timeline changes a little bit. And we talked about how to rehab things in other podcasts, okay? But, and I'm, I'm trying to narrow this down the best I can, because I don't want you guys to go on this long hunt for imaging findings when there's probably not gonna be any, and it's a big waste of money too. How many MRIs and ultrasounds can you do before you realize that there, you didn't have the mechanics, you didn't have the history, nor the exam findings to merit the image in the first place, okay?
(13:50):
And have the unknown in your mind about, well, what could it be? Now, you know, you're probably a functional-muscular injury, which is okay, all of 'em can be rehabbed. Almost all of them can be solved without surgery. And there is a way out of this, okay? Most of you can recover back to normal activity, and most of you can get back into sport, but you need to have some guidance typically 'cause all this information on the internet and the lack of information or the wrong information is pretty prevalent, and it makes people get a little confused about what to do. Okay? Now I'm gonna go over some of the other parts of the, of the, of the classifications that there used to be. So the old classification was mostly used. It was called the O'Donohue, and was from 1962.
(14:32):
This system utilizes the classification to, based upon injury severity related to the amount of tissue damage and associated to functional loss. So it categorizes muscular, muscular injuries into three grades. And this is what most people still use when they talk about muscular injuries, which I think should be eradicated. I think we should go to the Munich Consensus Statement type, because this gives better education to the patient, but also gives us a better idea of how to manage the problem without wasting all the time and resources on imaging. So grade one has no appreciable tissue tear, which is the functional muscle disorder category, broken up into subtypes. Now, there's grade two, which is a tissue damage and reduction of strength in the musculotendinous junction, which is where the muscles and tendons come together. So you'll see a change of function.
(15:23):
It won't just be pain, it'll be a change of function or a change of strength. Reduction of strength, because now the tissue has damage, which can be recovered from, but it has appreciable tissue damage. It will be found on an MRI or ultrasound. Grade three is a complete tear of the musculotendinous junction, a complete fun complete loss of function. It's funny people that I've met who have actually had ruptures of, of,musculotendinous junction,musculo tendon off of bone.,They actually don't really have a ton of pain. They just can't move their limbs, okay? Like a shoulder. If you tear a supraspinous off of the off of the shoulder, usually you just, you can still move the shoulder to some degree. But then there's a loss of range and function in a certain range. Uwe had a kid come in recently that had a fracture of his elbow, and it was about two weeks old.
(16:14):
He had no pain, but he couldn't move it. Okay? So there's a difference between pain and full range and full strength. 'cause A lot of you who have functional muscle disorders, the ones that are more of a "strain" category, actually have pain. You have full function and you have full strength. Okay? So that's the difference between 'em. And when you have an actual tear or a tissue disruption, there's actually a loss of strength and a lot of time function too, or range of motion. The current ultrasound based grading scale, which is from 1995 is used quite a bit less than MRI, by the way, I should mention that. I think ultrasound is actually a really useful tool for sport hernias for shoulder conditions as well. If we're not talking about inside the joint, I think they're kind of useless for spine conditions.
(17:07):
But I think for muscular injuries, I think you can see a lot with an ultrasound if you find a good sonographer per, personally, I wish we see more ultrasounds because there's no claustrophobia associated with going in the machine. 'cause The machines just put on your skin. And seeing things close to the surface is really, really easy. And it's cheaper. So I think there's a lot of benefits to doing ultrasound to diagnose some of these fiber disruption types of conditions. But I don't know if that'll be something that's really in the quick future. Back on some mentions in the study. So the MRI based criteria was from 2007. Uit's from Stoller and so grade one the MRI is negative. So again, if we're, if we're matching these from the O'Donohue 1962 version, grade one, no appreciable tissue damage, no MRI finding,so the MRI based one from 2007 is grade one MRI negative for, for structural damage.
(18:09):
Okay? And then grade two is MRI positive tearing up to 50% of muscle fibers. And then grade three is muscle rupture, which is a hundred percent structural damage complete tearing with or without muscle retraction. And so those match up, okay? But again, most of you are gonna have grade one, which is gonna be negative, any imaging findings. Other things that were evaluated in this questionnaire that they sent the doctors that the sports medicine experts associated with the disconnect with the terminology was so they actually found marked variability with other definitions as well. So marked variability and definitions for hypertonicity muscle hardening, muscle strain, muscle tear bundle, or fascial tear and laceration. But the most obvious inconsistencies were associated with muscle strain. They found relative inconsistencies with pulled muscle in that laceration. So again, their decision in this questionnaire was that there's really no clear definition.
(19:15):
And so their goal was to define better. And that's where we get these results from. And now we're gonna talk a little bit more about the functional muscle disorders and the structural muscle disorders, and how these may relate to a little bit more of like sports hernia. So as mentioned before, functional muscle disorders can be acute, indirect muscle disorders mean that they don't have to be trauma based. There are trauma based ones in here, like contusions, which is a direct muscle disorder, but a functional muscle disorder, it's pretty, it's indirect. It's not like you experience any trauma to the area. There's not any EV evidence of MRI or ultrasound findings of tissue disruption. You probably won't even notice any swelling in the area, although you may. But there's usually no discoloration in the skin. There's not a pop, there's not a clunk associated with the original injury time either.
(20:03):
Some people even notice with some of these disorders within the functional muscle disorder category the four different subsets, some of them wake up with it. It's not even related to actual motion. Now, there's four basic categories in this functional muscle disorder category, okay? The first two I will mention, but we're not gonna spend time on it because it's not gonna be relevant to a lot of people. The last two are gonna be the most relevant for your understanding. So first, there's fatigue induced muscle disorders, and then there's delayed onset muscle soreness. I'm gonna start with delayed onset muscle soreness or dorms, because most people who do exercise, they know what DOMS is. Several hours. After doing an activity, they start to feel soreness in their muscles. Technically, this is a muscular injury, but we all know that no one goes to the doctor for them.
(20:57):
And there's no MRI ultrasound findings. There's also fatigue based muscular injuries as well, or fatigue induced. So there's stiffness during the activity due to poor warmup. Typically we believe this could be a predisposition for an injury. So it's something that you should be weary of. And just note, because over the course of time, you may experience other conditions in that area. But those two are ones that people typically don't go to doctors four because they usually dissipate on their own. The other two are the ones that we see a lot of people for. So there's spine related, and then there's muscle related neuromuscular muscle disorders. Okay? Spine related one is the easiest one I think for most people to relate to. An example would be an L five S one nerve root impingement either created from stenosis or foraminal stenosis, or a pinched nerve or disc herniation, whatever it may be.
(21:52):
If it affects the S1 nerve root, then the person may experience tightness of the hamstring or calf, which limits flexibility or the ability to bend forward or stretch those muscles. And so this may mimic a muscle injury, and it will last for quite a bit of time until that actual root cause is solved. This may require different forms of treatment beyond simple muscle treatment, beyond simple stretching and tissue work and massage and red lasers. And by the way, I'm not bashing all these things. These are just things that people do and ice and heat and rest and so on. There's other things that need to be done. And so for spine related disorders, a lot of times there's core involved. There's internal pressure management, as I call it. But the actual technical term is intra abdominal pressure coaching from diaphragmatic breathing.
(22:47):
A lot of times there's, there's other ways to solve the issue rather than just beat the snot out of the muscle. That's, that's tight. Okay? Many clinicians also believe that athletes with lumbar spine pathologies will have a greater disposition for tears of, say, the hamstring. Now if we relate this back into our sports hernia, people, lower abdominal scenarios, we find that people who have bend points of L1-T12, L 1-L2, like that's their, we call it a spinal hinge. It's there, like, there's like a sinkhole right there because they use it a lot too, to move from those people tend to have a lot more lower abdominal strain feelings. And again, I'm using strain very loosely on purpose. 'cause now we've already defined those, some of those terms. So in that case, settling down the spine may dissipate the feeling of the strain in the lower abdominal area.
(23:41):
Now spine related disorders, now you might find positive imaging findings in the spine, but it's not a hundred percent needed to do that. A good examiner can actually figure out how to manage you without having to get the images done, which again, wastes time and money. You're, if you have a good skilled examiner, they can also figure out if you need the image. So they may find in your history and exam that you actually need to have an image performed, which helps them make a decision about how to help you. Okay? But there are normal findings in the spine images that are not anything you need to worry about. We've done podcasts about disc degeneration before and disc herniations and stenosis. We've done 'em on all of these. And generally speaking a lot of them are not surgical based.
(24:33):
Some of them are re: it relates mainly to how you present in your functional loss. But a lot of 'em are just a lot of hard work and guidance. People just need guidance on what to do. The last category here is that muscle related neuromuscular muscle disorder is a big, a big word there, right? And these ones are more of what I call as a reciprocal ambition. One. First, some of you have been through physical therapy, rehab, or even reading some of these articles online. You may have figured out that term of overuse. Some of you may even have gone into the rabbit hole of regional interdependence or the joint by joint approach to training or rehab. And this basically relates to how the body not only neighboring joints, but muscles within the same joint work together.
(25:26):
And so if you have a hip flexor that's tight, chronically tight, or "strained," it may be due to your glute max and other glute muscles not working well. And rather than focusing on that hip flexor and figuring out what you gotta do to relax that thing directly, it may be easier to take the overused chronic workload away from it so it stops becoming so tight. Similar to the spine related one, if you take the spine insult away, then it decreases the amount of tightness you feel in the innervated tissue. Same thing with the reciprocal inhibition type, which is basically opposing muscle groups. So in a lower abdominal area, you may wanna make it. So also the hip works better. You also may wanna make it so the other musculature in the abdominal area works well with the muscles that are working too much.
(26:24):
And you may also want to help out with improving your internal pressure so that you can decrease the insult on that. We called it the shutter effect, and we covered it in the other podcasts as well, which is more associated with the onset of people with sports hernias. Okay, so now just to reiterate, we have fatigue-based muscular injuries, which is, again, no imaging findings, delayed onset muscle soreness or doms, which is no imaging findings. Spine-Related neuromuscular disorders, which have no imaging findings of the local muscle tissue. And then muscle-related neuromuscular muscular disorders, which is, again, no positive imaging on the area of concern, but you may find other muscles around it which are not working well. So that basically encompasses, in a nutshell, the majority of you experience either spine-related or reciprocal inhibition base, which is other muscles and around it are not helping.
(27:22):
Okay? So I cannot stress this enough. Do not always focus on the area that hurts. If you find what is creating that muscle to become tight, either protective, which is spine-related or overworked, which is muscle-related, then you can solve the issue long-term. Nothing's more frustrating than going back into your activity. After you've rested it and it feels better, then it comes right back, okay? Which is a common scenario for a lot of people with this, if they don't address the underlying cause. Now structural-related muscular injuries, which is again, gonna be positive. Imaging findings don't always have a direct trauma to it, either. No one has to hit you to create it. I had this experience when I tore my hamstring. I was sprinting for a baseball, and it felt like someone threw a baseball and hit my leg.
(28:14):
And I looked down, there was no ball there. I fell over. I felt a clunk. And then what ensued after was swelling into the area and bruising, that's a, that's a structural muscular injury, and I probably would've had a positive image whether I had gone, but in that case, I didn't need to because I knew what it was. Again, you may feel a snap, it may be a minor partial muscle tear, it might be a moderate partial muscle tear, which may include a little bit of retraction, a part of the unit or maybe a total an avulsion. If it's something like an avulsion, you're gonna know because you won't be able to move the area and you'll, your movement will be arrested and you'll have quite a bit of bruising. In that case, it may be important for some areas like the shoulder or the bicep or certain muscles to actually have 'em reattached.
(29:04):
And this is a little bit more outta my realm, but I, I don't do surgery to reattach things, but from my understanding, the sooner you get it reattached, the better because then it won't mat down and attach to other surrounding tissues, because if you leave it long enough, it'll, it'll start to find an attachment point, and then it'll mat down with its scar tissue. Now, I'm gonna go back to the consensus statement now and give you just some line item things that I thought were really interesting, and they were talking about terms that need to change. So, muscle injury terms with highly inconsistent answers in the survey were strain, pulled muscle hardening and hyper tous, essentially across the board. There's no uniform answer for this. So we either need to stop using them or we need to define them better. And that was part of their goal.
(29:50):
They said the term strain should basically not be used anymore. And we should substitute that for these things that I just talked about, which is the four other categories, pulling muscles is a layman's term and is not really defining any types or grades of muscular injuries. So it shouldn't really be used as a scientific term. And they said that hardening and hypertonus also was not well-defined and shouldn't be used as scientific terminology. We can use 'em as slang, but essentially it's not gonna have a definition. Now lastly I'm gonna give you leave you guys with the idea again of is an MRI needed, okay? Because I think this is the biggest question that I get when I work with people who are tired of dealing with stuff for a long time, and they have pain in their full function. They don't have any bruising.
(30:39):
You know, it just came on. There was no pop. Do I need another MRI done? Well, probably not, you know, and I mean that mainly because if you have a good examination, you don't need one done. Okay? If it's a structural injury and you suspect a possible fiber tear, or, and you have the history and exam findings to indicate that it matches, then maybe probably essentially if you think that there's more of an a complete detachment, I think that would be something that maybe reattachment sooner or later would be a, a better idea. But even with old tears, the body finds a way to get around it. I never had my hamstring tear addressed. There's no divot. It's not a big one. It's pretty small. It was probably more into the, the old category would be a grade two, which is some tissue damage with reduced strength, but really not any tearing off of the bone.
(31:48):
But it heals itself. That's the function of scar tissue. It's supposed to heal itself and the body finds a way, and then now the area doesn't hurt at all anymore. I didn't even notice it. But if we plan on changing our protocol and treatment plan, then yes, an MRI is needed based upon if you find what you think you'll find, okay? And I mean this with the best intentions, it's really an MRI should not be up to the patient or the cli or the client. It should be up to the, to the, to the clinician. It's a tool to figure out if we are managing this as we are or not. Okay? I had a really great instructor in school that they had, they had a case they talked about, which was a knee MRI, they had to redo a couple times.
(32:39):
It was a younger kid. He had a contusion direct trauma to the knee in that case. Trauma's a wild card. It could be anything. The kid wasn't getting better. They did an MRI and it was normal. And so a few weeks later, the kid still wasn't getting better. MRI normal, his kid still wasn't getting better a few months later, even though the insurance company wouldn't pay for it anymore, MRI positive bone marrow edema, which indicates small fractures of part of the spongy bone of the femur. In that case, since he thought he may find something that changes his judgment, he kept imaging or changing the image or asking the radiologist to figure out if there's something missing. I had, I had somebody years back that I had to call the radiologist to see if we can find finer slices of an MRI to make sure that there was no bony injury to the area.
(33:38):
And they did that for me, and it was clear and it was good. Okay? So, but if I found that I would probably refer this person out to an orthopedic, okay? And when my instructor found that he no longer tried tissue work, he no longer tried rehab, he took the kid outta the game and let the area heal itself. So if you think your management will change, then your doctor, your physical therapist, your chiropractor, your orthopedic doctor will probably suggest an image because you're not abiding by the same timeline of recovery. Okay? If I cut my finger with a, you know, like a paper cut, we should all know within, you know, three days, most of the pain goes away, it's still red, you know, within a week's period of time, it's scarred over within two weeks. You don't even know it's there.
(34:28):
You know, if it hurts like heck in the beginning do we need an image for that? No. Do we need blood work? No. It's abiding by the normal healing timeline. Okay? Now, something like a sports hernia, which should, the pain should reduce, especially if there's no bruising or swelling, there's no discoloration. It should reduce within about a week's period of time, maybe two. And it should feel normal doing day-to-day things. If it doesn't, then maybe we wanna do an image to see why. Now, if the person's being treated and the exam and the history indicates that they don't need an image, and they're gonna be treated for two to three weeks expected timeline, again, if you get the right treatment down, or you take the, you take the triggers away, triggering movement away, or the triggering activity, then two to three weeks, yeah.
(35:20):
Is, is enough time to find a really good result. And that's what we find at Performance Place. We find that two to three weeks is enough for most people. With even stubborn lower abdominal strains and adductor strains and groin pain in, in sports hernias, we find that a lot of 'em over the course of two to three weeks feel a lot better when we get the recipe right, okay? Now, if they don't, we may consider changing the treatment protocol, or we may decide to do an image. It's really our decision. Now, we, I've had people who have asked before, like, do you think I should get an MR? I'm done. You know what? It's up to you. You know, your, your money, your time, you may not, if you don't get it paid for, that's okay. You know, I've had enough things over my lifetime where I've got images done where probably my doctor wouldn't have sent me for them because I wanted what I call a clean bill of health.
(36:11):
I wanted to make sure there wasn't any muscle, muscle injuries. I wanted to make sure I didn't have an infection. I wanted, make sure I didn't have anything else that would change my protocol. And I wanted to know early, so I paid cash and it was negative, or I found normal things for the scenario. And I wasn't worried about non findings. I wasn't worried about normal activity and age related findings. I was worried about that one finding, was there an infection? Was there tuberculosis? Was there a fracture? Was there a tumor? Was a tendon torn off a bone? Those things weren't really found so cool. Let's just do what we're doing. And if people want that, by all means, I have no problem with that. But if you get hung up on the idea of finding and seeing something in there, you may be disappointed because not all pain is related to positive imaging findings.
(36:56):
And I think that's gonna be the whole takeaway in this podcast. Okay? So if you guys ever need help and you want advice, we are here. Okay? At Performance Place, we have virtuals. And in-person sessions we've seen people virtually for sports hernias with not a lot of problems. We're pretty transparent with, again, our timelines, as I mentioned on here, two to three weeks. Generally, things feel pretty good. Obviously this is a case dependent person, dependent, you know. But we also, because people may not, if they don't fall into those timeframes, they're also not something's wrong. Not like wrong, like disability or surgery wrong, but it's like we don't have the recipe, right? We may have given you the wrong exercise to do. You may have done it poorly. You may have interpreted differently how we want it. Maybe form is an issue.
(37:49):
Maybe we coached it poorly. Maybe it wasn't enough reps, so we need to reevaluate. But usually when we get the recipe right, people don't need surgery. They don't need medication, and they return to sport. Okay? So if you guys ever want help from us I, I don't wanna say we're the specialist of sports hernias, but we sure see a lot of 'em. We see a lot of groins lower, a lot of adductors, a lot of low backs, a lot of hamstrings. And especially in the regards to the sports hernia realm. If you're not finding help where you're at, come see us. We'd love to provide some clarity for you and some guidance and get you on the right track. And just make sure you get back to a, a, a healthy and fulfilled life. I know that if I was not able to play my sport, baseball, which I still love to play weekly, if I could spend 10 hours in a baseball uniform every week, I'd be very happy. But if I don't feel like I can play how I wanna play, I'd be very frustrated. And it degrades my quality of life. So I don't want that for you guys. Mandy and Dawne don't either. And so reach out to us info@p2sportscare.com or 714-502-4243. We have all of our contacts in the description for the, for the podcast, and we're looking forward to working with you. See you guys next time. Subscribe to the podcast for more of this to come.