This post is designed to give you some guidance through the myriad of information regarding inguinal hernias. Perhaps you have one? Perhaps you’re not sure? Perhaps you fear an operation? Perhaps you’re fearful of an old inguinal hernia coming back? Perhaps you just want to avoid one? Or perhaps you’ve had one surgically repaired but still have some symptoms. If you are any of those then this article is for you.
We’ll be going into the detail about what inguinal hernias are, their symptoms and what you can do about them. Surgery or otherwise. To make it real and relevant we’ll do this through a case study of a client of ours who has avoided the need for a second hernia as a result of the information that follows. He’s called Joel and he doesn’t mind being talked about here, I checked. I’ll put his sections in italics.
What Is An Inguinal Hernia?
Firstly what is a hernia? The NHS website defines it as:
“A hernia occurs when an internal part of the body pushes through a weakness in the muscle or surrounding tissue wall.”
And encouragingly goes on to say:
“In many cases, it causes no or very few symptoms.”
They are generally in and around the abdomen. The inguinal hernia is the most common. This post is all about inguinal hernias but the principles we discuss here work well on abdominal hernias too. We have even helped people with hiatus hernias, which are internal, by creating more space – the detail on that one is for another time.
Your inguinal region is literally the fold between your pelvis and your leg. If you want to be absolutely sure where whilst wearing minimal clothing look down in the region where your pelvis meets your leg. Now lift your leg up and it’s where a fold appears.
If your symptoms are in this region carry on reading…
The most commonly seen symptoms are:
- A bulge in the groin region
- A burning or aching sensation on the bulge
- Pain or discomfort in your groin, especially when bending or coughing
- A heavy or dragging sensation in your groin
- Weakness or pressure in your groin
- Men occasionally get pain and swelling around the testicle
On top of these issues we often find associated muscular pain from guarding against the hernia or fearing making it worse.
When Joel first came to see us he had confirmed by his doctor he had a recurrence of his hernia. He was able to feel the bulge popping out and it felt a bit painful when he pressed it. It was occasionally quite painful at random times and he was unable to play football or tennis due to this pain, especially when twisting.
Why Do Hernias Occur?
Quite simply too much pressure. Or increased load. That’s why things like lifting heavy things, sneezing, coughing or sport can cause the pain. Pre-disposing factors can be non-optimal bio-mechanics (more on that later) and obesity.
In this article we’re focusing on inguinal hernias but all kinds of the hernias have a similar cause. You’re asking the tissues to do too much for a prolonged period and eventually something pops through a little weakness in your abdomen somewhere between your pelvis and your rib cage.
What Are The Potential Complications Of Inguinal Hernias?
Before we can even consider what we can do about your average hernias we just need to be respectful of the complications so these have been ruled out before we do such a thing.
The two most common complications of hernias are obstruction and strangulation. Neither of which sounds very nice! Quoting the NHS website:
Obstruction is where a section of the bowel becomes stuck in the inguinal canal, causing nausea, vomiting and stomach pain, as well as a painful lump in the groin
Strangulation – where a section of bowel becomes trapped and its blood supply is cut off
If you have either of these issues chances are you’re not reading this article for the answer!
What Can You Do About Inguinal Hernias?
Quite a lot. Many people fear, and conversely other people want, a surgical intervention. This can be the right thing to do but you need to weigh up exactly what this will mean to you.
The surgical procedure can open the area up or go in arthroscopically. The bulge is pushed back and held in place with either stitches or a mesh. The advent of this latter technique has lead to a dramatic reduction in recurrences.
Which all sounds very good. And for the large part it is. But clinically we have seen many cases over the years whereby clients have been left with long lasting residual pain from the operation or even left with similar symptoms. Thankfully when we do see those post operative complications they do invariably calm down with the right kind of treatment based on the principles we discuss below.
This piece of research looks into the post-operative implications on long standing pain. 31% of people reporting pain of some kind after the operation, with 6% of people suffering with pain affecting daily activities. So you can see it’s worth looking into options and ways of clearing up those residual symptoms.
Which is exactly what Joel did when we first spoke on the phone. He was interested in our approach and whether we would be able to help him avoid a second hernia operation.
We explained that our approach had helped people many times before get rid of their residual post-operative pain and in theory the same should be possible for him. After a bit more chat about how we would achieve this he was keen to give it a go and booked himself in.
No. Once the hole in the abdominal wall is there it’s there. But remember how did that hole get there in the first place? Increased load. So if we can reduce the load on the bit with the hole we are often able to reduce the pain.
Should You Always Operate On Inguinal Hernias?
Our experiecne would say no. But then we would! In the interests of balance we’ve had a look for some more independent research comparing surgical and non-surgical interventions on inguinal hernias.
This nice piece of research showed in follow up studies that there was no difference in outcomes from those who had surgery and those who didn’t! It’s very important here that we mention that this study was done on people who were minimally symptomatic.
We have helped many people with a high level of pain and dysfunction at the clinic but these have all been post-surgery. It would be fascinating to conduct a larger study on those like Joel, and also those in more pain. How far we can bring those with a confirmed hernia? Can we avoid surgery for those in significant pain? Any volunteers?!
What’s The Alternative To Inguinal Hernia Surgery?
There’s a few underlying principles we used to help Joel that hopefully can help you too. It’s not the same as being assessed and treated by a trained professional but I’m hoping it will give you some hope and some ideas of what can e done.
– Biomechanics and Alignment
When we first assessed Joel he looked wonky. We’re not talking Quasimodo here. But to the trained eye he wasn’t well aligned. This immediately got our attention and our brains whirring as to what muscles would be over working and tight and how those muscles would affect the load in the groin.
Why were those muscles getting tight? In Joel’s case it was mostly the orientation of his pelvis in relation to his rib cage. Commonly this can be affected from as far afield as the head or feet. But in Joel’s case it was the more local tightness that was increasing the load on his hernia and, we suspect, led to it’s appearance in the first place.
The rotational nature of this imbalance suggested that his oblique muscles (the muscles that rotate the torso) where having a disagreement with each other and contributing to his symptoms. This was confirmed by Joel who had mentioned in our initial chat that his symptoms were definitely aggravated by hoeing! That’s what we love about our work. There’s always new and unusual things to consider in every individual’s case.
– How Sensitive Are You?
Joel sought us out when his stress levels were high. Simply put when we’re more stressed we’re more physically sensitive. We feel more of what’s going on. Part of our work was to get Joel in a more relaxed place.
Firstly, allaying his fears about having another hernia op. In many cases the fear of what it might be or what it could be is in large part the cause of the pain. To further elaborate on this consider this definition of pain from one of the world’s leading pain scientists Professor Lorimer Moseley:
“Pain is an unpleasant conscious experience that emerges from the brain when the sum of all the available information suggests that you need to protect a particular part of your body”
We also needed to build his confidence and take better care of himself to his nervous system to help him feel less pain. This was individual to Joel but you can find examples of how to calm your life down in our previous post on mindfulness.
– Hands On Work To Release Inguinal Hernias
In our work we look to remove those unhelpful compensations through your body that are keeping you in pain. Those fearful, protective patterns. Some of these compensations can be very localised. Some of them can be a long way from the current issue and often stem back to an older injury or time of extreme stress or trauma.
Our in person work is to work through releasing those compensations and find out which ones most positively affect your symptoms. This helps guide and personalise your rehabilitation. If we tell you it’s your foot that’s causing your hernia you may understandably be sceptical. If we do something to your foot which makes your hernia symptoms feel better you’re more likely to pay attention!
This personalised treatment and rehab plan may well include work to the localised area. It is important to assess and treat the localised area. But it is very rarely the sole cause of the issue.
What kind of release would we recommend? As a practice we like to use both fascial and muscular release. What works best for each person varies from case to case. If you don’t know what fascia is – and you will be forgiven – here’s a link explaining more.
In Joel’s case it was a nice combination of fascial work to get his body lined up better and then some muscular work to reduce the load on the symptomatic painful region in his groin.
– Stretches To Loosen Muscles That Can Affect Your Inguinal Hernia
Reading this right now you don’t have the luxury of our hands on treatment. So we’ll now consider what you can try to release yourself.
Due to the scope of this article we’ll only consider muscles that can have a direct bearing on the symptomatic area. Rather than looking at the full biomechanical picture. These are the ones we’ve seen best affect the areas of the inguinal region.
DISCLAIMER: All of these stretches are for guidance only and inspiration to get yourself checked out by a professional. If you do choose to attempt these you do so at your own risk. We cannot be held liable.
Legal stuff said. You’d have to be doing something pretty stupid to make a mess of these! Particularly given my next bit of advice. DO NOT STRETCH TO PAIN. Don’t get competitive with yourself or others when you’re stretching! We are all unique. Accept where you’re at. Stretching should be enjoyable, not tortuous. With all of these stretches just take them to the point where you start to feel a slight stretch.
We find a yoga approach to stretching most effective. That is breathe into the area you’re trying stretch and then relax the area you are stretching on the out breath. Then move to the next point where you start to feel the stretch again. If you don’t move and it’s still the same place. That’s fine. Be patient.
Start with 30 seconds for each stretch and increase the duration as you gain confidence that they are feeling good and you’re not taking them too far. You can build up to holding the stretches for 3-5 minutes in a yin yoga style.
As I refer to in the video we use a gem of biomechanical knowledge from Grey’s Anatomy to explain why these stretches can reduce load on the inguinal ligament. I’ve linked to it here so you can see the illustration for yourself where the lats and obliques merge into the ilioinguinal ligament. The quadricep and leg pit stretches work by the same theory. Releasing muscles that attach into or affect that inguinal ligament region. If you were in for treatment we’d work out which combination of these is most important for you.
– Avoid Core Exercises!
Yes, we said it! Regular readers will know we’ve said it a lot. We’re not quite as anti-core exercise as we were when we wrote the Is There Any Point To Core Exercise post. But this is one of those cases where we think it’s really important to consider going against the accepted norms. It may well be that using your core more is actually making things worse not better.
This is because effectively your obliques, and therefore your inguinal region, are part of your core and so loading these muscles up repetitively, especially if your body is out of line, increases the load on them and can exacerbate the issue. There is a sweet spot and sometimes core exercises may actually help. But you have to tune in to what is right for your body and not put up with things just because someone told you to do something.
At our clinic we prefer to focus on optimising the length of muscles. When muscles are at their optimal length they just work beautifully. Over working muscles can lead to shortening them and so a reduction in strength, not increase. Most clients we see tend to be too tight rather than too weak. It’s the tension that causes the weakness. Not underlying weakness. So, more often than not, we need to focus on lengthening our muscles not shortening them.
In a follow up email Joel, having been symptom free for a couple of months, asked if he was allowed to resume core training. We had previously talked around all of the above but we’d not put it quite so black and white. Instead of pandering to him by saying yes, or having a rant as above and saying no we instead asked why he felt the need to do core work.
What came back was the vanity admission we see so often. His need to do core was just to keep a flat tummy and not for any functional reason. Don’t be tempted. Two reasons.
One, it simply doesn’t work. You cannot lose fat locally by training the muscles that sits beneath it. You lose fat evenly throughout your body when you burn off more calories than you need. Even if you put on weight in certain places e.g. stomach, bum or thighs.
Two, you’re asking overworked muscles to do more work. Why would you do that? In Joel’s case we’d improved his wonkiness and so we were tempted to say he could do some basic core exercises. But then if he’s symptom free and doing everything he wants to, why bother?
– Postural Correction and Awareness
Another key area for Joel was to understand how he got so wonky in the first place. For the vast majority of people we see we’ll back ourselves to be able to release off what needs to be released to reduce your pain. But can you keep it that way?
With Joel our conversation led us to realise it was how he held himself at his work desk and also how he ‘relaxed’ on the sofa in the evening. This was driven by his body. Looking at it and asking ‘Joel when do you get into a position like this?’
Thankfully Joel was a diligent student and identified the causes quickly. Like all of us, he still has tendencies back to his naughty posture. But he’s quick to be aware of how he’s holding himself and correct it.
This is easier to do when we’re calmer. Which circles back round to looking after ourselves better. It always comes back to the whole person in our experience. When we address the person as a whole that’s when we see the most amazing changes.
The following video is an easy thing to have a look at to see how you should be sitting to best align yourself specifically with the aim of reducing load on the inguinal region:
It’s easier to get into this position and stay in this position when we connect with our breath to help ground us. Particularly focusing on elongating our out breath which promotes a calming of our nervous system. The opposite is true when we inhale which is why we get anxious when we hyperventilate.
Conclusion – What Should You Do About Your Hernia?
Are we suggesting you don’t need surgery. If you’re not massively hampered by it and it’s not causing huge amounts of pain then perhaps. But, if you haven’t already, get to your doc and ensure that the bulge can be pushed back in. This will rule out any serious complications from the inguinal hernia.
We then urge you to consider the following questions. How much pain are you in? What do you want to be able to do with your body? How good can you feel without surgery? How good can you feel with surgery? What can you do to reduce your risk of any chronic pain whether you have surgery or not?
From our biased standpoint we recommend seeking out some kind of physical therapy to see how good you can get it feeling. Whether that’s with ourselves or any other provider really doesn’t matter.
You could be like Joel, playing football and tennis and simply have no awareness of your hernia. Wouldn’t that be nice? Of course we can’t guarantee that will be the same with you but we urge you to do all that you can to minimise your risk of long standing pain. Whether that is before or after surgery. Or in Joel’s case both.
Joel’s is a lovely example of what is possible. But is this exception? I would argue not but then this research suggests that simply waiting and watching a hernia ultimately means that you’ll need surgery anyway. The key thing here is we didn’t watch and wait. We did something. And that something seems to have worked.
And what of Joel? I checked in with him after 6 months and again now on refreshing this article 18 months later. He’s still pain free. Is he in perfect alignment? No. But he’s better than he was. And he’s doing his stretches to do his bit to keep himself that way. We don’t need to aim for perfection. Just better than we were. And what does Joel feel about all this. Well here’s his thoughts from the Google Review he left for us:
“I came to Jamie and Brighton Sports Therapy after being told by my GP that I had suffered a recurrence of a previous hernia and needed another hernia operation (3rd in 10 years!). Keen to explore an alternative route to more surgery, Jamie initially provided a thorough assessment and treatment along with recommended daily exercises which four months later has enabled me to continue playing football, tennis and other physical activity without any adverse impact on my hernia and will hopefully mean I can avoid the surgeon’s knife again! I would thoroughly recommend him for anyone who finds themselves in a similar situation”
If you’d like to ask us about your inguinal hernia or any other injury then we’d love to speak to you. If you live locally or for those far away too we can always start the process with a video consultation. Please press the Get I Touch Button below.
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