Relationship between groin pain & foot / leg pain

[jeanvic]

Hello Dr Towfigh,

from the journal Hernia a review of the accuracy of CT to diagnose groin hernias (inguinal and femoral). The very last paragraph is from my doctor to me.

Best, Jeanie

JOURNAL ARTICLE
Computed tomography scan diagnosis of occult groin hernia
J F W Garvey
Hernia: the Journal of Hernias and Abdominal Wall Surgery 2012, 16 (3): 307-14
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BACKGROUND: The value of computed tomography (CT) for the diagnosis of clinically occult (hidden) groin hernia was assessed in a series of patients presenting with undiagnosed groin pain.
METHODS: A total of 158 consecutive patients presenting over a period of 5 years with undiagnosed groin pain or lower abdominal pain and negative or equivocal clinical findings were radiologically assessed with non-contrast CT. The decision to manage operatively or conservatively was then based on a combination of the clinical and CT findings. Outcomes were assessed at 10 years follow-up.
RESULTS: The study cohort comprised 158 patients presenting with groin or lower abdominal pain and/or swelling, and was studied prospectively. Seven of these patients were re-investigated at a later date after developing new pain on either the ipsilateral or contralateral side, giving a total of 165 CT examinations. One-third of cases (54) had clinically occult groin hernias and most of the remaining cases had diagnoses that could be managed non-operatively. Of those who came to surgery, the pre-operative CT diagnosis of hernia had a positive predictive value (PPV) of 92% and a negative predictive value (NPV) of 96% (overall accuracy 94%). Lipoma of the spermatic cord was responsible for three of five false-positive CT results. The concept of sports hernia/groin disruption injury (GDI) was encountered, and this entity is discussed in this paper. In the group of patients without hernia findings on CT, the most common diagnoses were rectus abdominis and/or pyramidalis muscle injury which could be treated by physiotherapy (22%), GDI (16%), post-surgical problems (14%), miscellaneous (20%) and ‘no abnormality’ was identified in 15%. Overall, there were 111 patients with a ‘non-hernia’ CT diagnosis, of which urological, gynaecological, gastrointestinal and neuralgia contributed to the non-musculoskeletal diagnosis.
CONCLUSION: This prospective non-contrast CT study of patients with undiagnosed chronic groin pain detected the majority of occult hernias requiring surgical intervention. These results suggest that CT can be a useful adjunct to the evaluation of patients presenting with chronic undiagnosed groin pain, but that experienced clinical judgment remains a critical element in the diagnostic pathway.
Based on this large series— CT scan had a negative predictive value of 96%– meaning if the CT is negative there is a 96% that you truly do not have a hernia- which does leave a 4% or 1 in 25 chance there is a hernia.

So I would say complete the other evaluations and then we can talk. I could perform a diagnostic laparoscopy but as I said I think the chance of finding something in < 10% while this article with a large number of patients would say in the face of a negative CT for a hernia the chance of me finding a hernia as a cause of your pain is 4% (meaning the CT would be wrong). Now a 1 in 25 chance is not good but again even a negative laparoscopy may be helpful going forward as at least you would know that there is no intra-abdominal pathology to explain your pain.

[drtowfigh]

Jeanvic,

Can you share that article?
My research did not show that at all. And especially for occult inguinal hernias, CT scan is very poor. Ultrasound or MRI are much better.

https://jamanetwork.com/journals/jamasurgery/fullarticle/1893806

[jeanvic]

I have also described the burning pain as a very bad sunburn but sometimes it feels like my legs are on fire. Pretty unbearable pain. I will look up Dr Belyanski, thank you. Yesterday’s hernia surgeon emailed me an article from a hernia medical journal that did a study on CT scans predictability accuracy and it was around 95%. Thanks again.

[Jnomesh]

Hi. I’m a male. I will say from my experience it was more of a burning sun burn kind of pain that I felt in my outer calf and foot. But I do think you just need to try and rule everything out. I can only speak from my experience but since you already have a cat scan I would request a copy of the Cat scan they can put on a CD for you and i would send it to dr. Igor Belyanski in Annapolis MD. You can google him. Speak to his office staff and his assistant. I would type up a detailed letter explaining everything you are experiencing and send that in with your scan. He is an expert at reading cat scans. I would highly trust his opinion. If he doesn’t see a hernia I would then move on to other tests or therapies. Look into Myofascial release therapy and message therapy for the back.
it is also possible that you may have a weakeness in your abdominal wall and no true hernia yet but that weakenesss may be causing you the discomfort. If the cat scan is deemed normal by dr. Belyanski you may wish to use a MRI as that can find muscle tears and other stuff that a cat scan can’t. And of course since you are female there is a higher chance of you do have a hernia it ny be a femoral hernia and as I mentioned there are some different nerves associated with that type of hernia . Best of luck

[jeanvic]

One more question, Jnomesh, are you female or male? And thank you for saying pain can be below knee. That is most encouraging and I really appreciate you sharing your experience.

[jeanvic]

Thank you Jnomesh. You give me encouragement. I was feeling discouraged yesterday when the surgeon told me I had a less than 10% chance of having a hernia because my CT scan was normal. After the doctor pressed my abdomen and I felt pain but he couldn’t find a bulge, the top of my left pinky toe started to hurt after I went home. I assumed it was a seam in my sock that was scratching me but the pain is still there this morning, no sock and hurts just from walking barefoot. It feels like I have a series of scratches on the top of the toe but nothing visibly scratched. I thought ‘can the pressing of the abdomen cause this new pain’ or is it just a coincidence? There is some crazy connection! I will look for another doctor. Are surgeons the best doctors to call?

[Jnomesh]

For almost 13 months my hernias went undiagnosed-had both a MRI and a cat scan and saw two surgeons over that time. I had burning and heavy feeling in two places in the left groin. Sitting at times was unbearable at times. Lying down was the only thing that most of the times would bring relief. Finally after seeing a rx surgeon to rule out a sports hernia (even though i didn’t play sports but I was desperate to find an answer) he diagnosed me as under having a hernia. After surgery he informed me I had both a direct and indirect hernia. No wonder I was I so much discomfort. Imagine that two hernias and no one could diagnose them and I had to live with this pain for more than a year.
What I am learning through my very nightmarish journey with hernias is that there is for whatever reason a subset of people that just don’t present in the normal fashion. And how the medical field as a whole is really quite bad or poorly trained at helping this subset of people. Unfortunately my mesh failed and I had to spend another 6 months in excruciating pain being told by the medical field that everything was A ok. I was told by one hernia specialist that the pain I was going through definitely without a doubt had nothing to do with my mesh or anything to do with the hernia site. Dejected I asked in your expert opinion what should I do? And he said get a deep back massage. Thanks. Anyways I finally found an expert who after looking at the same cat scan this other surgeon looked at that my mesh had folded up. The take away is don’t give up and do your best to do whatever you can to find specialists who can read these scans even if the hernia doesn’t present itself in the typical way. They are out there.
And chaunce 1234 yes pain can absolutely extend below the knee from a hernia or mesh from a hernia. Again this is probably rare in most situations and uncommon but that doesn’t mean it can’t. When I had my mesh folded up I had burning in my thigh all over and in my calf and foot.
if you research the femoral nerve it shows that it can extend to the calf and even the foot.
And everyone just isn’t wired the same way.
when I wanted to rule out the lateral femoral cutsneous nerve as a nerve causing my burning pain the pain management doctor was convinced it wasn’t this nerve Bc I was comparing if not only thigh pain but pain just above the knee and he said this nerve doesn’t go to the front top of the knee-sure enough after they did the nerve block I felt numbness in the area I was complaining about. My case was probably an anomaly but it just goes to show you everything isn’t a textbook answer.

[jeanvic]

The abdominal pain is mostly on the left side, below belly button, groin region. When I’m sitting, it is right around the crease where my abdomen meets my left leg. The majority of my distress comes from burning sensations – it feels like I’m sitting on a bad sunburn, going down my legs to my knees. I sit with a bottle of ice water between my legs to relieve the pain. I just came back from a hernia surgeon who doesn’t think I have a hernia because my CT scan didn’t show anything. He said CT scan would be better than MRI for detecting hernias. He said he could try a diagnostic laparoscopy to rule out hernia. Thank you for your reply. I forgot to check this board before my doctor’s appointment and wish I knew to ask about the ultrasound with valsalva.

[Chaunce1234]

jeanvic,

Is the pain in a specific location or diffuse? Where do you ice to then gain relief?

Perhaps one of the best initial tests to have to check for a groin hernia is to a dynamic ultrasound with valsalva maneuver (bearing down as if you are attempting to pass gas or defecate) on the region with pain or symptoms, performed by a skilled radiologist or technician.

MRI with valsalva of pelvis/abdomen can be even better but finding hernias, but is a somewhat less common scan for that purpose and may have some confusion when you request it. Referring to studies may be helpful in such a case.

For NYC, you might try talking with Dr Brian Jacobs or on Long Island there is Dr Samer Sbayi, both names have appeared on forums discussing hernias and could be a good starting point.

Good luck and keep us updated.

[jeanvic]

I have both groin pain (left lower abdomen) and left foot pain! Pain started in my foot and spread to my abdomen. My abdominal pain is getting worse while the foot pain has stabilized. I have strong burning pain from groin to knees. Relieved by lying down or ice. I sit with an ice pack to relieve the pain. I am wondering if I have a hidden hernia. What kind of doctor do I need to see? I’ve seen podiatrists (foot MRI negative), neurologists (EMG negative), pain specialists, GI (pressed on my abdomen and felt pain – left to center, below belly button). Looking for a hernia specialist or urogynecologist near 11358. Any insights or input very much appreciated. Abdomen pain started in Sept and getting worse.

[drtowfigh]

Interesting reflexology information.

I must say, though: in my patients, from whom I can get a complete history and examination, I have never found their complaints below the knee to be hernia related. And they don’t get better after addressing the groin issue. It’s harder to judge the full story from patients who post their story online.