Guess the pathology: an egg-sized lump in the groin. In this episode of “I Have a Client Who …” a massage therapist describes a client who comes in asking for groin work—to help with a “knot.”
What on earth is going on?
It turns out to be simple, but way, way outside our scope of practice—to label, or to treat.
Inguinal hernias are common injuries in men, because the passage of the spermatic cord into the abdomen creates a structural weak spot at the inguinal ring. When that spot gets stressed and stretched, loops of the small intestine can bulge through. This can be a minor issue, or it can become serious very quickly—and the only permanent solution is surgery.
This episode is sponsored by Anatomy Trains.
00:00 Speaker 1: Ruth Warner's best-selling book, A Massage Therapist's Guide to Pathology, is a highly regarded comprehensive resource that sets the standard for pathology education. Written for massage therapy students and practitioners, this groundbreaking resource serves up a comprehensive review of the pathophysiology signs, symptoms and treatment of more than 500 diseases and disorders. Learn more at booksofdiscovery.com.
00:39 Ruth Warner: Hi, and welcome to "I Have A Client Who," Pathology conversations with Ruth Warner, the podcast where I will discuss your real life stories about clients with conditions that are perplexing or confusing. I'm Ruth Warner, author of A Massage Therapist's Guide to Pathology, and I have spent decades studying, writing about and teaching about where massage therapy intersects with diseases and conditions that might limit our client's health. We almost always have something good to offer even with our most challenged clients, but we need to figure out a way to do that safely, effectively, and within our scope of practice, and sometimes as we have all learned, that is harder than it looks.
01:26 RW: On this episode of, "I Have A Client Who," Pathology conversations with Ruth Warner, we're gonna play a little game of Guess that Pathology. This massage therapist from Washington State shares this. I have a client who came in asking for groin work on a "knot." Red flags were up anyway due to the specific request for groin work. The client asked if he could show this knot. He pulled down his pants slightly in order to not expose himself too much, which was appropriate, and he had this big excised lump in his groin. We'll stop there, and I'll let you think about what we could be talking about for a moment. It's fairly obvious. Have you figured it out yet? Did you say inguinal hernia? Because that's what the situation was. In fact, the massage therapist told the client it was probably a hernia diagnosing. I know, I know, she shares. The client went to their primary care provider, had hernia surgery later and was able to resume regular massage.
02:39 RW: This is a really nice, simple, clear idea of a situation where someone, a client, who is unfamiliar with the kinds of things that bodies might do, develops groin pain and sees this bulge and assumes that it's muscular, and the best thing he can think of to do is to consult a massage therapist. This tells us that massage therapists are given sometimes more credit than we should be given for understanding medical situations. This therapist made a mistake by naming what she saw, but did the right thing, of course, by denying treatment and requiring that this client see their primary care physician before they were able to schedule again. So let's talk a tiny bit about hernias because they're pretty interesting, but before we do that, I wanna give my very deep thanks to this massage therapist who shared this "I Have A Client Who" story. And I want to invite you to do the same. You can share your "I Have A Client Who" stories at ihaveaclientwho, all one word, all lowercase, @abmp.com. That's email@example.com. And I really want to encourage you to send in your stories because what you are experiencing could really benefit lots of other listeners.
04:14 RW: Okay, let's talk about hernias. The word hernia means protrusion. Specifically, we're talking about something that is bulging through a wall or some kind of barrier, where it's not supposed to bulge. And the human body is capable of herniating in lots of different places. You probably are familiar with at least the concept of a herniated disc, and that's a situation where intervertebral disc is protruding through its normal boundaries and possibly causing a problem. But the kind of hernia we're discussing in this situation is called an inguinal hernia, and that is a situation where, because of the construction of the abdominal wall, specifically in men, there's a weak spot and the intestine can poke through.
05:05 RW: Hernias are pretty common. We see abdominal hernia is diagnosed about five million times a year, much more frequently in men than in women. And what we see when we see a direct inguinal hernia, which is almost certainly what this client had was that the place along the inguinal ligament, where the spermatic cord goes through is a structural spot where the layers of abdominal muscle do not overlap and there's a little opening. And when we do things like lift and twist at the same time, or cough really hard or sneeze really hard, or have some kind of event that radically increases abdominal pressure at a time when that part of the abdominal wall is not well supported, then there is a risk that that small opening at the inguinal ring can stretch large, and what will happen is that a loop of the small intestine will get caught.
06:10 RW: Now, one of the interesting things about inguinal hernias is that the smaller they are, often, the more dangerous they are. If it's a big hole, than that loop of small intestine that gets caught may have enough space to actually retreat and reduce on its own, although it may happen again, because now, we have a structural change in the quality of that tissue. But smaller holes where a loop gets caught, a piece of intestine gets caught, this is a situation that's much more likely to cause strangulation, infection, even gangrene. And this can become a medical emergency or even life-threatening, because there's just not enough space for circulation to continue to supply the bit of tissue that's been caught.
07:00 RW: Virtually, the only treatment that's permanent to manage an inguinal hernia like this is to surgically reduce it. If we're lucky, it can be manually reduced, but again, as I say, manipulating the abdominal wall, which is by the way, not in our scope of practice, so that that egg sized lump disappears is not a permanent solution because now, there's a weakness in the abdominal wall and the intestines may get caught again. A surgical repair for this involves reducing the hernia by moving the intestines back into place, and then usually, it involves inserting a piece of netting or that distribute the force across a pretty broad area. And this is a common surgery that usually doesn't have big complications, and typically, patients are back up on their feet and at a more or less full capacity again in just a couple of weeks.
08:00 RW: If we think about other things that might cause an excised lump in and around the groin, really, the only other thing I could think of would be a radically enlarged lymph node, and that's a possibility, although with that, we would expect it to be painful and there would be other signs of infection, because we'd see an enlarged lymph node like that, if someone were fighting something off, and there would be a slew of other signs and symptoms that would go along with it. So that excised lump in the groin when someone comes in asking for a massage is a great reason to refer people out to their primary care provider, and to delay the massage until after that person has been through their surgery and come out the other side. And at that point, gentle work around solidly formed scar tissue can possibly improve the quality of the scar tissue, speed the healing of the surgical scar, and contribute to a great outcome, but that has to be done with obviously, with appropriate education. This is a quick one, not terribly complicated, but the kind of thing that happens. This isn't the only time I've heard this, "I Have A Client Who" story, but now I wanna hear from you.
09:20 RW: Remember, you can send me your "I Have A Client Who" stories to firstname.lastname@example.org. That's ihaveaclientwho, all one word, all lower case, @abmp.com. I can't wait to see what you send me and I'll see you next time.
09:43 S1: Anatomy Trains and the Laboratories of Anatomical Enlightenment are excited to invite you to Dissection live stream, a regional and layered journey through the human body with Tom Myers and Todd Garcia. September 11th through 14th. Student Jan Ball, who attended the last dissection says, "The whole live stream dissection course was truly a unique educational experience. It was profoundly moving, I gained so much from it. It was one of the most valuable education opportunities that I've had. I'm truly grateful to Tom, Todd, and the whole team of people involved who made this unique opportunity available." This experience will be delivered through Zoom webinar with high quality audio and video, multiple perspectives and time for questions. Visit Anatomytrains.com for dates and details.