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Out to um the next topic and the next entity which is, I don't know. Um uh uh hopefully it will be interesting for you. It's for not for orthopedic surgeon, but again, you see them in your um practice. So you need to feel comfortable to examine people with inguinal um and public related groin pain. So, inguinal related growing pain. Again, if we go to the um entities and the standardization of the clinical examination, one thing I have to say is that in the athletes, in the athletes and in my cohort that II have uh the soldiers that very uh strong and uh young and in 40 people you don't see quite often a hernia. So there's no palpable hernia. Uh they, they will have um tenderness in the inguinal canal. They will have this pain in the inguinal canal without a hernia. But also this pain is very important. We presented uh a few weeks ago with uh V and we had a uh practical examination as well, practical assession as well. It is what we call do you know when, when we examine the hip and we say, oh, I have here, I have we always ask, is this your pain, this can be any, any pain. So if they have anterior pain, but it's not that intraarticular, this is not their pain. For example, recognizable injury type of pain. Uh They will have pain with the resistance, uh the resistant testing of the abdominal. You see here much um um with uh doing the abdominal, they would normally I push, I push them back and then uh rotational abdominal as well. So they will rotate in the right or in the left and I push them back and normally they will have pain with that. Um They will have pain with uh sa cough and sneeze and going in and out of the car and uh changing direction sometimes. And because this is a sport again, that changing direction or sharp movement, changing direction. Uh One question I ask them quite often is as well. Um When you go to the toilet, for example, increase the abdominal pressure is a pain. So they have pain with uh with that. Um So if we see the not cell inguinal tenderness, pain in the canal, no palpable hernia, pain in the resistance testing, um or vasa a cough sneeze. So these are the things that um that you, you, you expect. But also, you know, sometimes, you know, they will have a, a bulge in the abdominal wall, so a wall or they will have a hernia, it's not common, but they will have to know how to examine the hernia. II saw you earlier in the, in that first picture where the spermatic cord was uh removed, the pub related growing pain. Uh They have typical tenderness in the pub synthesis in the adjustment bone. There's no specific testing here and something which is really nice. I love it. It's the public club we call it published by Frank Miller Frank. Um he used to, he used to work a lot with hernia. It was um growing pain in the past. And so these athletes present with the pain close to, sorry. Sorry, I didn't, I'm sorry, you didn't say sorry. Yeah, so, ok, I just want to double check and well, yeah, yeah, sorry. Um So we, that's the not of pain in the inguinal canal, recognizable uh type of pain. Uh This is the resistant abdominals. I asked them to do this and I push them back and then I asked them to turn right and, and left and again, um uh they will be in pain. Um And this is the uh public truck. Uh So the ace is very typical. They have this pain in the public tubercle. Uh If you touch them, they will jump and it's not the pain from the front, from the, from the pressure. Uh they will jump. Uh the symptoms, they will uh be worsening with kicking, twisting, sneezing or getting in and out of the bed of the car. Uh They will come and point high po point their tub pubic tuber ii quite often ask them. So, so I'm thinking, where is your pain? Sometimes? You know it because they um they can tell you. And again, there are many tendons. You can see there the conjoint tendon, the superficial ring, look at the ductal tendon, pectinous, lacunar ligament, inguinal ligament and conjoint tendon and the direct to. So this is the public clock where these people, they will have pain, the inguinal related groin pain. And again, the majority of vessels, they don't have uh uh hernia. What they say most of the ses, what they see. Obviously, these are abdominal uh ses uh that they, they did these operations and investigations, the pain arising from the specific ligaments, these ligaments of the joint where either will be very tense, there will be massive tension there and the techniques are tensioning and the tensioning techniques. So, with the treatment, we don't have strong evidence for rehabilitation, but we use protocols that um they have very good uh results. So we don't rush for surgery because we have seen that a lot of people are, you know, uh doing very well. We use the general principles of rehabilitation, strengthening of the muscle and work on balance and coordination. Pelvi is very important and when they're coming and quite often they will say, but why it's my doctor, let's say, oh, it's, it's not there. Why it should um strengthen my upper body uh strengthening the abdominal. Quite often, you will see that they are very weak. Um I do for them um dynamic ultrasound quite often uh to see if there is a little bulge and this bulge in the abdominal wall will um will touch them and this can cause uh pain. Um If all these will not work, we discussed earlier about blocks. I use a lot of uh blocks nowadays and professors with Robina Johnson who is also professor and uh in radiology. Uh they, they use the blocks a lot so ig blocks a lot and they see very good results. And if uh we have good outcomes the first time and then in six months time, they will be again, symptomatic or still a bit symptomatic, we can block them again or and we can use a blazer as well after the second block. So it works very well when all the uh conservative treatment is failed to improve the the symptoms. Um Then I refer, I refer to particular uh abdominal surgeons um as I said before, many surgical techniques of tensioning the tensioning Professor Lloyd uh from um um Lester um created this procedure and he operated in many football players. That's why Pony wasn't. And well known if you asked me about the results, I'm not sure I've seen good results. I've seen bad results, what he does his own procedure. He has access to the inguinal and lacunar ligament and what he does he check for inflammation, little tests, um and he will clean all that. Uh he will check them and then he will release the bacterial ligament if this is under tension. He says that uh there is a tension uh and uh this can cause um pain. So again, um right. Uh so this is the um the, the he says that um he is happy, obviously some procedure, he will apply the mesh and he will ask them to stretch in 24 hours and um they're coming back to their activities for a week, you know, and I've seen this but also, as I said, I've seen disasters as well. Um So this is the Los procedure, how he does um the operation, she has the axis with the scope and then problems in the, in uh in the inguinal lacunar ligaments and he will check if there is inflammation test there and then he will release the pectinal uh ligament and then he will apply this big mass, ask them to stretch in 40 24 hours and they can return to play in um um in, in a week time. Um Another procedure I work a lot with professor A and if you remember the first talk I did today is uh el the um the growing cons back in 2014, the inguinal disruption, this is how she calls it. Um So the MCR is the Manchester Growing repair technique again, is something that he created. But he has a lot of evidence for this and he has a lot of procedures. He has a lot of, uh.