Yesterday I was able to go and see the surgeon in Montreal who had so successfully found and repaired what others had missed. That surgery was just over two years ago, in July of 2012. Then we jump forward through a difficult recovery to a cross-country ski in early spring of 2013 that lead me to admit out loud that something was still amiss and thought maybe there was something else wrong with my obturator nerve and canal, and managed to get sent to the lovely gastroenterologist who ended up booking me a different kind of MRI. And once again I am going to bore you with the details of the article about athletic pubalgia for the sake of anyone suffering from similar pain, and also with the tale end of my post about what the MRI showed, which will finally get us to yesterday:

And on a completely different topic, MRI’s, pain and spreading the word

… And so it was, that almost to the day of the non-surgery un-booked at the Shouldice clinic, I ended up getting a sports protocol MRI.  Before going, I carefully researched what this should entail, and went to the hospital appearing to be well-informed.  The technician was very willing to read what I had brought, and did perform almost exactly this test, which is described in detail in an excellent article with the exciting title: Athletic Pubalgia and “Sports Hernia”: Optimal MR Imaging Technique and Findings.

This is the introduction, and please bear with me, as I am hoping to up the searchability of this detailed diagnosis, in the hopes that others find it:

Groin pain is a common result of athletic injury, but it poses a diagnostic challenge for radiologists, athletic trainers, team physicians, and consulting surgeons. Athletes in sports that rely on quick acceleration, rapid changes in direction, kicking, and frequent side-to-side motions (eg, soccer, ice hockey, American- and Australian-rules football, fencing, track and field events such as high jumping, and baseball) may be particularly subject to injuries that lead to groin pain. Between 2% and 8% of all athletic injuries involve the groin, and up to 13% of soccer injuries are groin related (1–3). According to one report, 58% of soccer players had a history of groin injury (4).

Clinically, athletes frequently present with pain in the inguinal region, which may radiate to the thigh adductor muscle origins or to the scrotum and testicles. At physical examination, point tenderness is often localized to the external ring of the inguinal canal and the pubic tubercle, the lower rectus abdominis musculature, or the pubic symphysis, but there is no palpable hernia. Although groin injuries may be acute, they more often have an insidious onset and progress over a period of weeks or months. They are a significant cause of missed practice and playing time (5,6). Although many acute groin injuries are successfully treated with a conservative regimen including rest and a nonsteroidal anti-inflammatory drug (NSAID), groin injuries often recur and may lead to the premature termination of athletic careers.

The pathophysiologic conditions that cause groin pain are complicated and poorly understood. Misunderstandings may easily occur, leading to misdiagnoses, for several reasons. To begin with, the anatomy of the pubic symphyseal region includes a number of interrelated muscle attachments that are located in close proximity to one another. The interrelation of these muscle attachments causes complex interactions between the forces exerted through the muscles across the pubic symphysis. Furthermore, the differential diagnosis of groin pain in athletes is extensive because various pathologic entities may cause similar clinical signs and symptoms and overlapping findings at physical examination (Table 1). In addition, patients may be unable to precisely identify the location of their pain or to recall the mechanism of injury. Moreover, they may present with multiple coexisting injuries that could cause groin pain, a circumstance that makes it difficult to establish which injury is the major contributor. Given these complexities, it is not surprising that both conservative management and numerous invasive therapies, including herniorrhaphy, adductor tenotomy, pelvic floor relaxation, and surgical repair of the posterior wall of the inguinal ring, have been applied with variable success to treat refractory groin pain. It also stands to reason that injuries with a poor surgical response may have been incorrectly or incompletely diagnosed, leading to a suboptimal treatment plan. The variety of terms used in the medical literature to describe entities that are either identical or at least close neighbors in the same spectrum of disease—including sports hernia, sportsman’s hernia, pubalgia, Gilmore groin, hockey goalie syndrome,adductor dysfunction, and osteitis pubis —likely adds to confusion in the diagnosis and treatment of groin pain

And the wonderful punchline of all of this, is that I do seem to have something wrong where my adductor magnus attaches to my pelvis, and it is the obturator nerve that operates that muscle.  I produced “minimal T2 signal intensity” at the proximal (close to the trunk not knee) adductor magnus.

Here is a slightly unfocused, but good picture of the anatomy of the thigh showing the adductor magnus muscle:

As my daughter said, I get full marks for proximity.

Nobody knows yet what my minimally intense T2 signal from my proximal adductor magnus means exactly, and whether this is fixable or not, but the gastro guy was terribly excited to be able to tell me that it really did mean something, having feared, he said, that I would burst into tears in his office if he had to tell me they found nothing, once again.  He said he asked the radiologist if they scanned a hundred healthy people could they get that result and he said no, it really is something.  So I have now been referred to a sports medicine doctor, and after prodding the system again (thanks to the prodding of my aforementioned excellent hubby) and rescuing my file from a dusty pile, am seeing him on the 30th.  A trifecta of injuries?  I sure hope there isn’t a quadfecta lurking in my future!

Back to the present …

Oh, I said that would get us to yesterday, but I lied. That sports medicine doctor hadn’t heard of an obturator hernia, but he sure had heard of a hip. The first segment of which saga is here, Well, that was a bust, and I don’t mean Dolly Parton!, and the second segment went unrecorded, involving a cortisone shot in the hip which was a strangely tortuous experience for me and missed the mark. Then there was the general surgeon who misunderstood my file leading to a dis-appointment, but who did the right thing and got me an appointment back at the McGill University Health Centre, with the delightful surgeon. Life is full of unexpected twists, and not burning medical bridges has been an essential mantra.

Now we make it to yesterday. [It is a family problem, these longwinded stories, and an interruption just leads back to the beginning, so don’t get tempted it only makes it worse. We are almost there, really, not just like a dad would say.] And guess what he confirmed? I have something wrong with my adductor muscle and, sad to say, pubic bone where it attaches. Imagine that! And he thinks that physiotherapy to lengthen the muscle will help a great deal, that I need to ice every night not morning. He shook his head three times during the appointment, and when I said I iced it every morning, that was one of them. He looked at me like I was disappointingly foolish, and said to ice it at night when it would have been aggravated during the day, and then maybe I would sleep better … and then I looked at me like I was disappointingly foolish and we moved on.

But the long and the short [too late, ed.] of it is that both the charming gastro guy and I were correct to be excited that the MRI showed a result in my groin as well as in my hip. And my delightful Montreal surgeon said it was not so terrible as to suggest surgery which is done if you have a “level three tear” which sounds awful, and which is not necessarily very successful in terms of pain management anyhow, and indeed he said it was the inguinal nerve they would excise in extreme cases, and that ship had sailed. He actually got excited when I said that I had had a sports protocol MRI and practically ripped the results out of my hand. He popped me on the table and compared me to the written results. He poked me where it said it would hurt and I yelped and he said the irritated lump was all on the bone and also relieved my mind of the terrible idea the surgeon I have skipped over put in my mind that that was where he had attached the mesh, which turns out to be nonsense.

All along my GP has claimed that pain can make you nauseous, and I think he might just be right about that, especially with an irritated obturator nerve, and I can ask him again when I darken his doorstep to suggest strongly that he find me a hands on physiotherapist and we get after an injury that is now a good decade old. But thank the heavens it is a musculoskeletal diagnosis, and not pathological.

Once again I feel incredibly lucky.