165. Busting hip pain myths with Mehmet Gem

you're listening to the Physio Edge Podcast episode 165 with David Pope. Hey you and welcome to the Physio Edge Podcast. I'm your host David Pope and Australian Sports and Musculoskeletal Physio and on the Physio Edge Podcast I talk to the leaders in musculoskeletal and sports injuries and dive into their expertise and give you lots of practical take-home tips, techniques, strategies that you can use with your patients to get great results. And on today's podcast I'm talking to Memet Jim, who's also known as the Hip Physio, Memet's a Physio based in Devon in the UK. He started out with a Bachelor of Sports and Exercise Science, then went on to do his Masters of Science at the University of Essex and then a postgrade diploma in advance, Euro Musculoskeletal Physio at the University of Hartfordshire. Memet's had a special interest in hip and groin injuries for the last 12 years and teaches a course for Physios called Simplifying the Hip. He's got a lot of experience treating hip and groin pain and he's looking forward to sharing all that with us on the podcast today. We're going to be diving into all things related to the hip and busting a lot of myths around glutes and hip flexors where the patients should be doing hip mobility exercises. We're going to be talking about FAI. How you can differentiate hip joint pain from greater trochanteric pains in drone or lateral hip pain and Memet's favourite glute exercises. Lots of great stuff in today's podcast. I think you're going to really enjoy it. We've got a few great free resources to go along with the podcast and the first one is a series of infographics on tricky tendons. Now, if you treat tendon opities, you'll know some patients respond quickly. They get great results and other patients that are respond as quickly and it can be a bit harder or sometimes you get tendon opities that are in areas that you're less familiar with to help you out with all that. We've got a free infographic series and you can get your free access to that infographic series over at clinicledge.co/tricky tendons. The second resource we've got for you is your clinicledge trial membership. Now, clinicledge membership is designed to give you all the skills that you need to treat all your musculoskeletal and sports injury patients. We've had some fantastic presentations recently on low back pain that are going to take you through how to assess and identify what's causing your patient's low back pain and then how to go about treating it. So you can get your access to that with a free trial clinicledge membership and dive straight into and start improving your results with your patients. And now, let's get into this podcast with Memet gem. Hey, Memet, how are you? Very good, very good. Thank you for having me and I appreciate the invite. Great to have you on the podcast. I'm looking forward to diving into hips and growing pain and busting some myths and misconceptions. Yeah, thank you, mate. It's nice to meet my debut on the podcast and I hope if you would enjoy it, we'll try and jump back in as much as possible and hope if you people find it useful. Absolutely. So first off, where are you based? Yes, I live in Devon now. So it's like Southwest Coast of England. I have done it for the last few years. I grew up, though, my whole life I was crazy and lived and worked my whole life in London. The last five years have been a bit of a change. So I've gone from a city life to raising kids and living with kids and wife down in the South Coast in a rural area now which is quite nice. I've been a physiotherapist for about 15 years now and specialised in hip, groin type physiospeciality. Probably for about 10 of those. So I knew I wanted to do pretty early on. I had a really, really distinct insight and extent from my own experiences. I had a AI which was at the point of when I was qualifying and I didn't know anything about that. I had surgery, didn't work out too well. And then basically at that point, I was really keen to learn, just become a physiotherapist thinking, "I want to know what's going on with my hip." And on the other hand, I was wanting to use all the opportunity I had for like in service training, CPD development to just correlate with what I was trying to understand about my hip. And that took a while and then obviously what happens is as the years go on and then I was doing like post-grad masters, again, anytime I had to do any kind of research or review, whatever it was all hip related, years went on. And then I basically spent all my time trying to learn about hips pretty much from the day dot. Don't get me wrong in the beginning. You don't really know anything. Do you? I was just winging it for the first two years. But pretty much that stemmed in interest and in after a few years, I realised actually, I know what I'll give it. I know I have a passion for when it was hips, pretty much from an early period of time. My hips fine now, so it was all sorted out. And that's what led me to doing pretty much what I do now, really, which I'm very grateful for. It's funny how those experiences shape you and it can be sometimes injuries you experience yourself or different patients you see that sort of shape the direction that you go in. So it sounds like it was a bit of a journey of self discovery at the same time as you were looking into how to treat hips and getting a real interest in it at the same time. Yeah, definitely, I'm pretty happy with how things transpire and how I've got to this point now. That wouldn't say necessarily everyone who's a hip specialist or shoulder specialist or knee specialist has to go and have an ACL reconstruction or a shoulder replacement just to get some sort of like inciter empathy. But it's useful. It certainly helps shape my perception and awareness and more importantly the passion. And I love it now. Just huge, like, have such a huge passion for hips and share some like decent information. I think that's what I'm most passionate about. It's quite a complicated area. I just want to share as much good information because unfortunately because it is quite a difficult area. Sometimes misinformation could be rife, especially online outlets and social media and stuff like that. There seems to be lots of myths and misconceptions. And glutes seems to be one of the big ones where there's a lot of myths or any glutes. Tell us a little bit about some of the myths that occur around glutes particularly to start with. The amount of traction that some of these myths get. Fascinating. It could always like the more obscure, random and simple like these myths are, the more people were concerned. But I get it because ultimately, who's the audience? The audience is someone who's in hip pain. And realistically, someone who's in hip pain. They just want to quick fix. Because I'm in it, you're in pain. You just want to resolve it. Something that was so common was this glute annesia situation that come up with the actual term amnesia and glute together doesn't make sense. It's like saying like happy teapot. Like those things don't come hand in hand. Glutes and weak glutes have inherently been blamed for everything that's wrong with the world. But for people who have hip pain, it's such an oversimplified approach to take one person's one muscular weakness and strength deficit. One is not going to correlate with their pain, but it certainly isn't going to be singular blame for someone's experience. But trying to explain what I've just said isn't as sexy as a term, but a glute annesia that seems really straightforward and that you could fix by doing this exercise that you'll find on this person's Instagram page or this person's YouTube channel. So unfortunately, those are one of the things that have probably come across. And I get like how sometimes it is explained to try and simplify what's going on. But also, you don't want to be giving patients information that's flawed just with the hope of that's easier for them to understand, because that's not the case. And you've got to make sure that we're giving them right information. But equally you don't want to bombard them with science either, but it doesn't mean that you lie to them and just say things like you glutes to switch stuff because they aren't, if you're walking about and you're sitting in your standing up and you're putting your shoes on and you're going outside or upstairs, they are wrong. It's impossible for it to just like all these other muscles are working but one of them's just asleep or switched off. And that's all but bear of mind. Can glutes get switched off or get amnesia? No. I think no. I think there's some glutes that any muscle could certainly become deficit in their strength or kind of functionality. But ultimately, if you have motor loss of a muscle, which is the fact that the muscle is not firing because there is some sort of like input that is inhibiting its function. That's a quite unique and significant scenario. So in regards to the common theme that we see with these patients and often when people are being told this, that's not what's happening. Actually, to be honest, I would hazard, I guess, the majority of the time. The glute strength probably hasn't even been tested to then be able to say it's switched off. So at that point, I'd say, like for me, glute will amnesia is a term that's been made up that doesn't have any kind of like decent clinical validity or applicability. I'm quite lucky to be at the cold face of like hip physio. I probably should also point out that my opinions are try to base them on evidence-based background and research and understanding. I appreciate not everyone's going to agree with me. I'll talk to someone like, look, I'll tell you, I'll be open, I'll be transparent, I'll be pragmatic. I'll tell you what I know as it is, but also understand that there's, I don't know, everything. And none of us know everything. There's going to be like limitations and levels of ambiguity to all that is stuff. But if I feel a little bit more certain on something, I'll be a little bit more assertive with those thoughts. And this is probably one of those, where I'm saying switched off glutes or glute will amnesia. I think there's something we probably need to just stare away from a little bit. Have you had a patient come in and say to you that they've got their glute switched off or their glute to? They've forgotten how to fire or they've got glute to your amnesia? What's the first thing someone does that go on Google? They'll type in what is my hip pain? How do I get rid of hip pain? Why does my side of my hip hurt? Whatever. And they might come across that, and then they come to see a physio. And that physio is sitting in front of them thinking, "I've just listened to mever talk. I've just gone on this course." Blah, blah, blah, blah. I know that this thing isn't even really valid. But the patient comes in and they say to me, "Am I in my clinic?" And they say, "Oh, mever, you know what? I've got a problem here. My glutes are switched off. Or I went and saw someone and they told me that I've got glute to amnesia. And I've still got this hip pain." And I know that from talking to them, And that hit pain is. probably going to be a little bit more complicated. It might be hip joint pathology, gluteal tendinopathy, deep gluteal pain, whatever. What you don't do at that point is then just absolutely slightly other clinician has told them, slightly other physio or disregard on that patient is telling you. I think that's a really important thing to, for any clinician to understand is just, you've got to show a level of respect and professionalism across the board, even if they're telling me stuff. And I think, geez, that's honestly bonkers, like whatever you've been told makes no sense. But you don't want to confuse the patient, you don't want to make them leave thinking, okay, I've had now two quack conflicting bits of information. You have to put yourself in their shoes and think, how can they leave understanding better what it is I need to do? And like that comes out to saying, I understand a thought process, I understand what you've been told. There might be some glute involvement. What we could do is probably try and refute that through your assessment or even if there's involvement we can integrate that into your plan. But also, if you've been doing stuff and it's not got any better up until now, there might be something that's been missed. So we'll go through that with your assessment and see if that's relevant or not. And just try to educate the patient, but like bit by bit. And you want to gradually challenge some of these beliefs, particularly if they're a little bit, maybe wild beliefs, but you're also not looking to stray away just hit them with that's absolutely not the right way to think about this. We figured out glutes are getting switched off or getting amnesia. When and how do you test glutes strength? - I think any hip strength testing is quite vital, but I think it will be relative to the individual in front of you. I think one of the pitfalls that often clinicians, they associate contractile muscle testing with strength testing. Like those things are really quite different. If you're pushing someone's hip against resistance or abduction or hip extension with your hand and you're just resisting a resistance, that's not really strength testing. You're just like testing the fact that that muscle can do something that is active, that it can resist resistance from a contractile perspective. That doesn't give you any data. Like just ranking something full out of five or five out of five. But it doesn't tell me anything. It doesn't tell me if it is weak, how weak it is. It doesn't tell me what plane of movement is a problem. It doesn't tell me really from a rehab perspective where to focus, right? So if you're testing someone's glute strength and you've been using handheld dynamometry, if you've got them prone, if you've got them upright, if you've got them supine, whatever kind of like hip type strength test that you're doing to elicit some sort of response if you do like maximal voluntary isometric contractions and you're trying to get some data, then I'll have that discussion. Like if it is weak, how weak is it in comparison from left to right? What's the asymmetry? Is there an asymmetry? Because the thing is as well, they like that's going to help guide your rehab. Like this is a thing that I tell all clinicians whenever I'm teaching is that you got to answer me why? Like you have to answer my why question. Let me ask you this. For someone who's got like weak glutes, what was your comment as an exercise given for someone who runs for glutes that we all know, hip thrusts are a pretty common one. And he used loads and what I'm talking to physio is I'm like, let's talk about rehab and they're giving a hip thrust. Why are you giving that to that patient? Because you're giving it to that patient for their glutes. Or if you're looking at like EMG recording data studies and you're saying, I know that step ups are great for glute max. I know that side planks are great for glute need or whatever. Why are you giving it to bicep curls are great for bicep? And like why does that bicep need to be work? If you're telling me though that you're looking at the data and there is a deficiency or a real notable deficiency and you feel like that may be playing a role in that symptom, that patient's presentation, then great, then we can funnel that from their assessment into their treatment. And then you're selecting exercises based around that. But also loads of things will contribute to that weakness. One exercise that focuses on one muscle isn't going to be the answer. They're all these muscles do slightly different things. They all work, you have synergists as well. They work in different planes and movements and angles. That's where rehab for me gets quite exciting. And often patients recover better if your exercise prescription is really clinically reasoned. So in around about answer to your question, manual testing is useful to see if there is an inhibition or an inability to resist manual resistance or gravity or whatever. But actually getting some tangible data is what will then help you. Now you don't necessarily need to do that for everyone because if you've got an athletic individual who has hit pain and on the other hand you have less active patient who may be just has some, let's say, gluteal tendon operative. The five-year-old patient gluteus is turning up. He isn't really that active but has a high level of pain. That kind of, you start to create the question, is it worthwhile your time trying to do a full kind of hip screen? So that, but then again, and it's as almost like a paradox is I'm like contradicting myself. But on purpose, he's just trying to demonstrate the level of this situation where it might not be relevant for everyone. So again, you'd be able to answer why though. Plus it's you why you'd be able to add that argument. The handheld dynamic momentary sounds like it's a pretty common you use that a fair bit within your clinical practice. Any other sort of test that you'll tend to do when it comes to testing gluteal functions, strength, that sort of thing? We have a lot of normal data for crafts, for example, singular carp raises to failure, relative to age, and engender. We don't really have that for the hip, to be honest. There's some more data coming out, but it's very specific. It's almost asymptomatic, high-level female footballers. That's the most recent one, but we don't have it as generalised for the other stuff. But we still get information. For example, if we're looking at glutes in isolation, well, you could get them to do power through us, but some people will struggle with that if I had hip pain anyway, or they might be able to do too many feet to get a good insight. So you could say, if you've got a chair, you could do single leg high-box stepups to failure. See how many of those that they can do, if they can, and if they can't. And also just trying to understand that, you're just trying to understand how many that they can do, but also the quality of their movement. And then it's using that same principle for other things. The doctors, you could do a straight-long lever, Copenhagen, single-hold to failure, symmetric-hold. You could do the same with a lateral plank, side plank, on one leg, maximum-hold, endurance test. So with the hamstrings, single-leg hamstring, bridge on the chair, 90 degrees at the hip, 90 degrees at your knee, to failure. But there's loads of opportunities for you to get. It might not be as accurate, but it's still you're getting some information. I love a single exit to stand from a chair. I think loads of people can't do it. If you get people with hip pain that are still training in the gym, I'm like, great, you're still training it, and you're still doing your compound lifts or whatever. But you can't do a single exit to stand from a chair, but you can do it on the other leg for 20. What's going on in the gym when you're lifting and doing heavy deadlift still now? If you can't do one leg raise from a chair. So I think that starts to paint a bit of a picture. Did you mention this in really nice ways to test it when you don't have a handheld dyno? You can use some of those functional sort of tests and check what the time to failure is or how many reps they can do when you're comparing side to side. If you've identified some deficits, tell us a little bit about some of your favourite exercises that you tend to use if you identify that they've got a deficit. You know, where do you tend to go? How do you tend to structure someone's rehab? Rehab is easy to get right if you just have the right principles for what you're trying to do. But those principles will start from not necessarily the best or the sexiest exercise. It's some of my most effective exercises like the most boring things in the world. But there's an important element to that that we need to make it not boring for the patient. So I think rehab is really important from the perspective of making sure that the patients are adherent to it, right? So it doesn't matter how much information that you know, how much knowledge, how much information you've gathered from in service, trainings, or see if your patient doesn't do the rehab. Nothing happens. The hip's not going to get better on its own. To get that output, you need to dose it perfect. You need to make sure that it doesn't irritate the pain too much. If it does, you've educate the patient on how to manage it themselves, how to regress, how to within that week, just tailor it a little bit. You need to make it fun. No one, I can't be asked to do rehab if it's boring. So if you just have someone has a sheet of 10 exercises that they could have got off the internet, it's boring. All right, I was going to do that for four weeks if you're asking them to do it. So the length of the rehab set or session is really key here. So sometimes I would probably pick four, is my sweet spot, four exercises. Even that can be a bit boring. I say, look, this is what I need from you. 20 to 30 minutes, three times a week. That's what I need from you to start with. That's what works like an hour and a half of your life a week for the next few weeks for us to start to see some sort of change. And they say, okay, fine, I can do that. My job then at that point is in those 20 to 30 minutes to make it effective, clinically reasoned and fun. But also, the fun comes with a lot of my patients want to exercise. They want to feel like they're endorphin here. They want to feel like they're training. So I find circuits work quite well. So I can normally say, look, you've got four exercises. You do one, two, three, four, have a little rest. Time your rest, two minutes, three minutes, do it again. We do that two or three, four times. And I want you done in half an hour max. If it's taking any longer, let me know. Drop it that, whatever. And what that does is it facilitates like positive reaffirmation in the sense that they get to the end of week one, week two, week three. And they've done it. They've done one, they choose their Wednesday. That's so much more apparent for a patient who has hit poem, then the complete antifesis. that which is I've got an hour of exercises that I've been told to do every week. I've got to end of week one. I've done 50% of it. I've got to week two. I've done 50% of it. I've got to week three. I've missed the other two weeks. I was probably not going to get any better. I'm already struggling. What's the point? I'll leave it. And then they move on to the next thing. And I think that comes down to us as our responsibility to just understand that person and that individual so that we keep them adhering to it. Now, the other thing as well, you said that what's your favourite exercises? Things that are boring and simple, sometimes the most effective. But we also can't do them forever. The step ups, the side step ups, the single leg box squats, the single leg RDLs, they're all great. Many patients benefit from challenging lower limb strengthening exercises. And I find that for my total of patients I work with, were often a lot more active, benefit better than the lower level bed-based like Pilates, clamshells, pelvic bridges and stuff like that. For some, that's great. They're great. There are some patients that are too irritable, too painful, that's a limb is great. But also, we need to elicit a response. And to elicit a response, you need to do stuff that is going to be effective. So although some of the boring stuff at the beginning works quite well, you also need to change it and adapt it. And that's when the assessment findings come into play. And the selection of exercise for me also comes down to thinking, these are the things I need to work on. These are the exercises, but also understanding that these exercises we can tweak and change with angles, weight, dynamic movements, to then take it to the next level. So it doesn't get stagnant enough. That's quite important. Say we're going to look at a gluteal tendonopathy. What's the sort of exercise that you tend to avoid or that you tend to include with those sort of patients? Yeah, glute tendonopathy is surprisingly quite a challenging condition to manage. On paper, you think it's just a tendon. We pretty, we're pretty good at tend and self care practitioners. We know a lot more about we know how to manage it, but GCPS, a great internet painting, which is the umbrella, so eight to nine times that tendonopathy is the main culprit, to be honest. It's a challenging cohort in a sense that there are not the most simple, directed tendon risk factors at play. We've got other factors in trinsic as well, so things like people who have got like systemic, inflammatory hormonal changes that might have cut them at risk or playing the role in their symptoms in particular, but also a patient cycle that not all the time, but sometimes maybe are less active, maybe are a bit more sedentary, and don't do exercises in comparison to the FAIs and the hip displations of the world. It does mean that where you have someone who has a high level of pain, high level of irritability, and a duration of symptoms that are probably persisted for months and months, you do have to tailor it because actually the way that we manage GCPS in particular is twofold. You could give someone, in this patient group, the absolute cremdala crem exercise rehab plan that you think should work within six to eight weeks. But the important thing here is if you're not also educating the patients and some of the things that will provoke it, and behaviors that might not allow them to recover as well, I don't think it works as well, like when you look at the key paper, the leap trial that was published years ago, that was like a great demonstration of how well physio can work to manage people with GCPS. It's this free group, so I was waiting to see steroids and I love the physio group. It isn't just physio exercises for eight weeks, it was a program on load management, education, and exercise, and that education, the reason it works so well is because consistently, you're educating, they need almost two sessions a week for two months, almost, you think if you're telling the patient and educating them that much, they'll remember it, remember I said before, like normally in that first session, they forget most of it, if you're telling them again in three days and then again in four days and again in three days, they probably are going to retain it, and I think that education piece is really important. So, although it's got exercises that we would use, yeah, they probably would fall into the category that I said before, lower level, maybe bed-based, a lot just general activity, getting someone walking a bit more, just trying to functionally get them moving, but also on the other hand, we've got to educate them on some of the stuff that might provoke it, which unfortunately is the first thing that they would do because they would go and Google and they would start, I said search for something, and they end up coming in telling you that they're doing foam roller, tennis ball release, trying to stretch their IT band, or doing like absolute savage glue stretches, because that's what they've seen or someone's told them to do, and then we're thinking actually like that glue stretch that you're doing is also the same as a diagnostic test that I've just done to elicit your pain. It doesn't really make sense because I'm trying to get your hip to her, but you're doing it as a treatment, it's not their fault, it's just what they've picked up, so you're trying to un-pick that, and those things from a management perspective have to come hand in hand, you can't do one without the other, and that's why it's quite a difficult patient group, because we're trying to progressively load a tendon at the same time with a patient who probably doesn't want to, not all the time, and not all the time, but like majority of the time, and that challenge, but I find it a good challenge. I enjoy it. Now education piece plays such a large part, I've had patients come and say, "Oh, yeah, you're asking me, do you do any stretches?" No, then you find out a little bit down the track, and they say, "Oh, I normally sit at night, and just in front of the tally, and I'll just sit with my legs crossed like this and pull my knee across," and you're like, "Okay, these are some of the things that we need to explore, and you start to find out some of the things that are actually contributing," or like you say, they've done some research, and they're just, yeah, they love to stretch, or they've picked up some exercise, someone said, "Do you need to do this periform or stretch," or whatever it might be that they then go and aggravate their lateral hip tendon uply with. Yeah, and the thing is with this, and I think it's worthwhile just one of the, I try not to get into debates online and stuff like that, but I see it happening, but one of the only debates probably I've had is this concern about educating patients on things maybe to avoid. Now, I get that everyone should be able to do everything. Yeah, compressive load is normal. Yeah, it should be able to tolerate it. I get it, but also if you're with a patient who can't tolerate a compressive load like with the stretches that you mentioned there, it doesn't make sense to just hammer a knock on the door of pain all the time because it doesn't help, it will increase their sensitivity, it will reduce their mood, it will reduce their compliet, loads of knock on effects and that stuff. But it's an understanding of the patient that you're not going to avoid it forever, I'm not telling you not to stretch, it's just now for a few weeks, just let's see if it makes a difference. The interesting thing is what you said before, some patients do stuff that you think shouldn't help and it does. An archive patient has come in and they say, "That's the only thing that gives me some pain relief." I don't think that's the only thing I probably don't want you to be doing. At that point, I don't turn around and say to them, but you know what? Actually, when you're doing that, the excess compressive load of your tendon insertions is probably going to exhaustive it. They don't care about that, they're just like, it feels nice. I'm like, "Okay, continue to do it, but do my stuff as well." And if you're not getting any better, because ultimately you're here with me now and it's not better, so whatever you've done hasn't been enough, but if you love that exercise, do it, but do my stuff as well. And if you're not getting any better by, and then I'll set a date, I'll say, give it five, six weeks. If you're not even a little bit better, and I'll refer to it as like a net gain of rehab, because this isn't going to resolve in six weeks. I'll just say, if you have a some net gain in rehab by six weeks, then we'll have to probably drop that one thing that I think might inhibit our progress. And if you're not and you're progressing, then we'll keep it. And I think that's really important to consider, but it comes back down to the thing that I said before about people are sometimes doing stuff that you think, well, I wouldn't otherwise that, but they love it and they're saying it helps. Who am I to tell them to stop? We've talked a little bit about glutes and you've mentioned their stretching and those sort of things. Now, hip mobility exercises on social media, there's lots of people demonstrating all sorts of different hip mobility exercises as such. Tell us your thoughts on hip mobility and whether patients should be doing different hip mobility stretches in some of Europe, the misconceptions around that mobility for the general population who just have a bit of a tight stiff hip but aren't in the ability to take in pain is fine for actually doing it the great. There's no problem at all. For some, they love it. For someone who's got hip pain and they've got hip joint pain that is specific to a hip joint pathology, that is presenting with a stiff hip, which is often when this is used because no one's going to go and look for the reduced improvement of their hip mobility unless they think my hip mobility is diminished and often that is a cobalt of patients that fall into like hip impingement or femoral as subliminal impingement syndrome, their FAA syndrome, because with FAA syndrome, often those patients are the one that do have a stiffness of the hip either into deep reflection or into a rotation at 90 degrees or even into excellent rotation as well. So they have that stiffness. Now, is that stiffness because someone has the morphology of the hip of FAA, this restricted area of movement, does that someone, does that individual have a version or an acetabular version of a hip profile? So you've got obviously ball and socket and then there are very different versions to how that socket may sit and also the profile of that hip in regards to how much it rotates. So if you have like a retroverted profile, your hip will rotate less into internal rotation anyway and it got an antiverted profile at the vice versa, but it equally if you have someone who has a cam related FAA syndrome, they'd have lost of internal rotation too. So you think what you're trying to gain there, you're trying to push against a structural problem. restriction like a bony restriction that actually will probably precipitate more problems later down the line on the general kind of what I've just said there like when you're searching people search for stuff and hit mobility whatever like none of this stuff would get mentioned it's not sexy and someone who isn't necessarily aware of that when they're giving that also to the patient might not be aware that that restriction might not just be a soft tissue stiffness that they've got actually what you're doing there is probably just jarring the hit with that unfortunately what I could lead to is things like joint infusion or even in some extreme cases like hygienic instability of the capsule because it's actually you're stretching it past its capacity to tolerate that range of movement and I think that's where my limitation to it is I think I'm not against it but I rarely use it and where I would use it is if I have an athlete who requires these real extreme ranges of movement for the sporting performance that they're trying to do and they've possibly recovering from surgery then over to that point utilize it or if I'm utilizing it conservatively trying to get as best because it is a challenge clinically but getting as best an idea into what their profile is and working within those means rather than trying to find the end point restriction and then pushing past it so if the patient comes in and you're testing them and they have got restricted say internal rotation at 90 degrees and what's your thoughts here on him on trying to improve that is that something that you work on if it's just the person's coming because they might have some hip pain or some hip stiffness and probably a combination or something like that or maybe they've come in with low back pain and they've also said oh my hips are pretty stiff tell us a little bit about he might approach that range of movement movements and things that you might avoid and things that you might include yeah I definitely wouldn't focus too much on the avoidance perspective but it's going to be really hard to refute that there isn't these morphological causes that are restricting the range of movement and that's the same for me as well like there's a degree of I'm not really too sure why that's restricted and I think that's not the only reason why it's not my top priority but also there's many situations where if it was a hip condition like the butt throws up if I are like I mentioned the patients who do well from it that you manage conservatively have to have an understanding that we have to work within the means of what the hip allows us to do condition it strengthen it throughout whatever planes and angles of movement that you have access to but also just be mindful that it might still be a bit stiff afterwards but you might have no pain you might still be able to play sport you might have no pain you might have full function but you might just have less internal rotation still on that side that might just be normal for you and I think they need to appreciate that when trying to manage it that doesn't mean you avoid moving into those angles and positions actively but you probably would avoid someone sitting on the edge of a bed holding their thigh and just doing loads of internal rotations repeatedly because it doesn't increase it you might increase it transiently like for a few hours but I suspect that's probably not actually like the morphology of the hip that you're addressing so for my perspective it's not my priority which is surprising to people because I think someone who specialises in hip should be obsessed with like mobility and range and majority of the time well I'm not I'm like I just want to get people physically more robust and actually making someone emotionally and psychologically resilient is on par with getting them physically robust for me like those two things come hand in hand everything that I do with patients from a physioperspective when it comes exercise and rehab I'm doing not just to make them physically stronger but I want it to have a knock on effect I'm trying to make them life psychologically more like resilient to like the tasks that they want to do and that kind of comes with obviously with that shouldn't pain as well. Keep mobility exercises as such they're not tend to be something that you'll include too much in someone's program for instance you mentioned they're not just sitting at the edge of the bed doing internal rotation on their leg to try and improve that so someone has maybe it's a bit of hip joint irritation or their hip joints involved in their pain have you found anything that does help to improve it obviously we can't change morphology but are there any is there anything strengthening or manual therapy any of that sort of stuff that you found actually can help to improve someone's comfort with their and potentially their range of movement. Yeah to be honest like that's a kind of a very common approach we know when we've got someone young adult population yeah if I hit this pleasure who do have although it will be it from two very different structural drivers to their symptoms do have a structural driver to them ultimately if you've got one that's got instability from lack of coverage and one that's probably got either too much coverage for a pincer or this kind of cam morphology we have a joint condition a common question that patient might ask you is how are you going to get my pain better if the cam is still there how are you going to get my pain better if the pincer is still there because they're I'm like educating them on morphology and then they're asking you like how the hell are you going to make that better for exercise same with the hip expenditure educated them explaining it to them as a possibility not a definitiveness because it is hard clinically to diagnose these things but there might be an instability a lack of coverage and then they say how are you going to manage that because if there's a shallow socket then house exercise going to address that and the argument is like none of this stuff has just happened your cam has been there probably for two decades your pincer has been there since the same time when you've developed in adolescence same with the hip displacement like I happen to infancy or you know secondary acidification during adolescence development if you're presenting with sentence when you're 25 30 like there'd been there a while like you're just getting symptoms in last six months 10 or 12 months whatever but those things have been there which means it for a significant amount of time your hip has tolerated it managed it and been absolutely fine what we need to do is create a program that allows your hip to do that again all right and create a program that allows it to have the strength and the conditioning and the stability and whatever it might be to allow you to get back to where you were before and I think that's really important because often patients they might come to you with an x-ray or an MRI scan and it might say label to it might say cam it might say pincer whatever and then they don't know that sometimes it's just normal people just have those things it doesn't equate to pain so then your program has a little bit more like back into it because then you're like look what we're going to try and do now is focus on trying to build just strength tolerance whatever it is physical function tolerance whatever it is that we're trying to address but also be mindful that there are circumstances where it's fine don't worry you're not going to need surgery like I think that's what patients really get concerned about is that like when they hear structure and morphology the only way to fix that is to go in and shave it and repair it but they're just educating them on the fact that loads of people have these things and have no pain and may never have any pain don't worry let's just focus on this first and then normally that helps but again that's why it comes back down to education I'd say some of the most valuable outcomes I get from patients is when we have a really successful session on like education and reassurance I think those are like the most powerful they're not like the sexiest things in the world and everyone goes on a course about how to build rapport and how to communicate and I'd say those are probably our strongest skill sets anyone can learn to do an exercise anyone can read a sheet or go on an app or whatever like the ability to really communicate listen articulate your thoughts and just treat someone with genuine respect and like care is so powerful there's those people who have hip dysplasia FAI ankle sprains knee miniscus tears like they don't go to a clinician they just carry on with it so we're seeing a group of people that might not have any history of anxiety stress depression whatever but they are bothered about I'm lucky to not have those things but I know when I've had an injury I have got worried about it I thought oh jeez I'm not going to be able to work I'm able to do this so there is that underlying level of new anxiety that we have to respect and address and a lot of that comes out to just education reassurance and that's really quite vital and it's easier to do with rapport definitely is it's a major part of what we do and you mentioned there that education part that's come through pretty strongly a few times it's helping patients understand what's going on with their body and that even if there is that morphology like you describe that whether it's a chem pincer you know antiverted retroverted here whatever it might be that that doesn't necessarily mean that they're going to need surgery but you're going to help to work to settle it down and you can help patients improve their thoughts and their attitude towards it as their pain improves as well and that's all going to be a big part of the treatment yeah for sure I agree and I think as soon as they're on board and it might take a little bit time to get them on board but as soon as they are and they understand that I think you can have real good outcomes definitely all right let's have we've had a chat about gritties now we've talked a little bit about the hip they want to chat to about hip flexors in a minute too but while we're talking about hip mobility and range of movement internal external rotation testing and range of movement testing around the hip obviously it sounds like people come to you they often think that you're the hip guy you're going to help you're going to be really interested in their hip range of movement when do you test hip range of movement and when do you find that's actually relevant to what's going on yeah I would test it for all I'd say even though I might not necessarily give individual exercises specifically to a range of movement deficit like the things we mentioned I would assess hip range of movement for every patient that presents in whatever capacity I think it's really quite valuable I think there's ways to do it that are probably better than others and we spend a bit of time and I'm doing this on my course just to explain to clinicians the reasons as to why I do it in certain ways. I think patients can present with levels of irritability that kind of can tarnish the insight that you're getting. So I think that's really important. But I certainly would assess it. The reason for that is it helps you build that clinical picture. If you're having someone that presents, let's compare those two patients, right? So we had the active young adult and we mentioned earlier the gluteal patient. So we had young active, very fit healthy adult and then we had maybe more sedentary less active gluteal ten of the patient decades apart. I'd still want to understand their hip range of movement. On one hand, I'm trying to understand, is there a hip morphology that would correlate with a potential hypothesis like the things we discussed, this pleasure, F.A.I. And on the other hand, I'm trying to understand that the other patient is there another underlying hypothesis differential, like for example, an arthritic hip that might be coexisted with a gluteanopathy or actually, did they even have a gluteanopathy? Is it an arthritic hip, this man at masquerading or presenting like that, or are there two things coexisting? And I think that starts to give you a little bit more. So I look at all of it to help my high poth, what I call a hypothesis, raw rumble, right? Because when you're talking to a patient, you think it could be about 10 things. I've got 10 differentials in the ring. I've got to try and barge out a few of them by doing my assessment. And that's what your assessment should be. Assessment is trying to understand what I don't think it is to see what's left. Because it's hard in clinic to diagnose stuff. If you're seeing someone for the first time, clinical tests are real, they're limited. We have loads of restrictions and limitations. So that's not to say that when the patient's there, you think you say to them, oh, I can't tell you what's going on because none of these clinical tests have a high specificity or likelihood ratio. You just say to me, I think it could be this or this. And that's in your head. Then you've got to that point by another final as much as possible. And a lot of that comes when you mentioned about hip range of moving. That will support that rationale and thought process. You brought up a good point there. So oftentimes patients come in, they might have a couple of conditions going on or they might suspect that they've got their hip jointes involved. And actually it's their they've got GTPS or vice versa. Or maybe they've got a combination of that. So tell us a little bit about some of the clues. So if clinicians are listening and they've got a patient coming in with hip pain, what are some of the clues that are going to help them to identify whether their patient has got GTPS or whether the hip joint's involved in how they can go about differentiating that. First and foremost, the subjective is key. Subjective is absolute paramount because not only does the narrative and the story paint a bit of a picture, the patient has all the answers. You shouldn't be jumping to getting them on the bed and doing clinical tests and trying to dive, no, something. You should have a real strong suspicion as well as going on before you even start like touching them. But with that in patient in particular, it can be challenging. So for example, if you've got those two hypothesis, OA, osteoporias, the hip and GTPS, a glute tendonopathy, you could argue and say, well, for OA, we have real obvious textbook signs and symptoms. In the sense of you've got an age and a demographic that increases your suspicion, you've got the time frame, which is usually a bit slow and progressive, which increases your awareness of it. You've got the standard difficulty put in shoes and socks on, get difficulty washing legs at the bottom, difficulty walking, difficulty getting in out of the car. You've got real normal, obvious OA signs and aggravating factors. And then with your GTPS patient who has symptoms, probably in a different place, lateral hip, but also that lateral hip might be so sensitized that they've got symptoms, then going into the batter or into the thigh, you think actually the OA hip could also present with the symptoms there. So all of a sudden, you think the locality of symptoms now is off. Now I can't use that to differentiate because it could be both. And then the GTPS patient saying to you, as you are a couple of shoes and socks on, I can't reach down all my shoes and socks on a couple of toe nails because they can't rotate the hip because it hurts. They've got a contractile or compressive intolerance of the tendon, which means they can't do it. So, no, you think, can you not do it because the joint is stiff or restricted or can you not do it because the tendon is so painful that it stops you doing it. And that's why passively looking at the range will help you with that. Anything, I think, fine, can you lay on that side? No, it hurts. You know, on the other side, no, that also hurts. And then you have to dive into that. I think, are you unable to lie on that side in bed because of a contractile or compressive intolerance of the tendon? Or is it just because the joint is painful? But it starts to paint a bit more of a picture because it's unusual for the joint to be painful if you're laying on the good side. Because really, if you need it together, the hip isn't going to be that provocative. You'd be like unlucky if the joint was that irritable. But this time the patient's telling you distinctly, I've got pain here on the side of my hip when I'm laying on the good side and when I'm laying on it, it's distinctly painful on that part of your cancer. So then you're starting to subjectively separate these two things out a little bit. And that's when the kind of thought process of trying to understand a bit more about the patient with regards to GTPS is fairly pertinent because we've got some key factors and risk factors that we mentioned. I think the menopausal status of a patient is fairly pertinent to understand the fact that those hormones of changes may have a catabolic effect on tendon health is imperative to understand but also highlights the needs to have good rapport for patients as old because it's a sensitive topic to discuss. You know, I'd get a black eye if I just asked someone if they're a menopausal 20 minutes into appointment when they're coming with hip pain, they're not going to understand it. But I would explain why, you know, why I'm asking it, why I was being quite thorough with it. So those things are quite important and it'll start to lead your full process. Now, it may well be that subjectively you're finding it hard to differentiate between two. It may be that then clinically, you also will struggle to differentiate between a two because again, they could coexist, they commonly do coexist. So it's a challenge at that point. And what you do there is embrace the ambiguity. I think it takes a good clinician to understand that working in that gray area was really quite a skill to explain to the patient that again, because they don't care too much, they just want to get better. You stay like there's a couple of things that could be going on. We're going to address it by considering all of those factors. Then you carry on. All right. And I think that's a real, real important lesson. I think sometimes physios are just so keen to have to just be one thing. It has to be, it's not. Sometimes there's a bit of both. There's a bit of both. And that's really, really cool. So you pick up the clues from the history, like you would with all things, then you're going into that objective, going, okay, maybe we have both things going on or you're still a little bit unsure because they're getting pain when they're lying on their side, they're getting pain, putting their shoes on, like you mentioned, bending over to put their socks and shoes on or getting dressed. So what are some of the tests that you then like to use to help to identify which of those might be involved or if there is both? When you've got someone who has a hip joint pathology specifically, but away, you're not necessarily going to have the degree of specificity that you would do when you're testing for the glute tendons. If you don't have a cluster of tests for the glute tendons, things like single-leg stance, palpation, fader resistance test, sideline, hip aptuction of resistance, they're all looking at the compressive and contractile tolerance levels. So whether you can stretch it and it hurts, whether you can contract it in its most stretched position and it hurts or in a range resistance. And if it hurts, you wouldn't necessarily elicit that level of distinct response in a local area when you were thinking if it was just the hip joint. So then you'll start in a clinically to be able to separate these two things out a little bit. But the difficult years, when you're doing a fader resistance test is my favorite one, because it's one of the rare tests that we have that has a high level of specificity, meaning that is specific to this. You bring the hip into full flexion, adduction, external rotation fully. So you basically do like a glute stretch, like piriformis touch stretch, right, fully rotated the hip. And then you would get the patient to resist back into their starting position, which is obviously mainly going first into internal rotation, extension and aptuction. So when you're doing those tests, are you trying to refute away? What are you thinking? Is your away hip going to let you come into full flexion, adduction and external rotation? Probably not. Which means you're going to struggle. And then you're thinking, actually, there's a passive inability to do that from the hip itself. It's not an intolerance from the glute tendon. Do you see what I mean? So that starts when it starts to paint you a little bit more of a creature specifically. The cluster of tests, though, are great. The grandmother tests, I think, are really useful to consider. And from the away perspective, I think looking at quadrant restrictions and range of the only things that really have been able to give you a good indication if that loss of range is there as a result of an arthritic hip. So you tend to use those tests from Alton Grimoli. And it's good to dive into some of those because we've got people that might be familiar with them. Maybe they're not super familiar with the cluster of tests, but you mentioned there some really nice ones that you might not expect the patient to have pain if they just have hip away. And so if they have GTPS but not hip away, you might expect it with that pain on single legs standing. There's that kind of landing on one leg for 80 seconds to see if they can tolerate that level of position. So you'd see that was painful. That's quite a good sensitive test, which means that if it's pain free, you can't 100% roll it out, but it starts to paint a picture that you might be able to roll it out. Now, palpate in the side of the great trochanter, which often patients get told that it's bursitis commonly. It's not, I'd say bursitis is there a very minority of the time. Certainly in isolation, very minority of the time, say nine times that, 10 is the tendon, pain around the area, and then bringing the fade of resistance test, which is the one that I see. is when you're bringing a hip to your chest, the cross your body and rotating it like how you do a blue stretch, puts the blue mead. So a group mead, which is the most commonly impacted tendon muscle with this. When you're bringing the hip into full flexion, adduction, and exonerotation, it becomes the most stretched position of it. And this is kind of an interesting thing to people for people to consider, especially when they're doing like clam shell exercises, which commonly get prescribed. When you do a clam shell, you're on your side, your hips are flexed, feet and knees together, right? And then you bring your knees apart. So you're basically in hip flexion, and you're going into hip exonerotation. But when you're testing the fader a test, the reason why it's so specific is because it's specific to that muscle intending, because that's the thing that we're dealing with. So if you're in a flexed, glute stretch type position, and you're having to resist internal rotation, and that elicits the pain, and it's a specific test, that just reinforces, biomechanically, what the glute mead does in hip flexion, it does intenderotation. So if you're doing a clam shell, you're putting it under compressive load repeatedly, which is why often patients find it painful to do, because it looks like it should work the glutes, but it doesn't. If anything, it would irritate it. So that's again, a demonstration of just flowing your assessment into your management choices from a rehab prescription. And those are kind of the first three. And the last one would be like the side lying hip abduction. So just the same laying inside, bringing your leg up, seeing if you can do that, and often I would do that passively first and getting the patient to just withstand that leg hold in mid range. No one can effectively resist when the leg is halfway up. You're real, like you've got to be able to just like hold it and then resist it at that point. But again, it just gives you a little bit more understanding in regards to those lateral structures and what they can withstand. We've actually got a great question from Tom Goome that I want to just run past. You get your thoughts on and Tom asked, what's your thoughts on returning to running with hip dysplasia? Runners tend to get a lot of conflicting advice. So it'd be great to hear you or take on this. I think if we're talking about someone managing it conservatively, I'm the biggest optimist. I think until someone or there is a real obvious reason why someone can't get back to the stuff that they love doing, I'm all for them doing it. Hip dysplasia is no different. Like I said, people who have hip dysplasia would have had that level of hip morphology throughout their life, not just happened. So we have to consider two facts. Is there such a deterioration in hip health that has caused them to have that level of pain that is inhibiting and getting back to their sport? And have they done enough rehab to get back to running? Okay. What we can't do is focus on someone having significant hip pain as a result of hip dysplasia, have low quality rehab and then just try and get back to running themselves. Often what we would have to do is consider, let's try and gradually progressively get them to that tolerance that they can withstand running. And if they can, then that's absolutely fine. People have characteristics and levels of hip dysplasia and have no problems. And that's really important to consider. Unfortunately, there's still that misconception that running is bad for joints. Impact is bad. But we're greater adapting and tolerating these things. This is no different scenario. But I guess if you've got an individual who has to significant pain is rehabbing quite well, but really struggling to get to the point of where they can tolerate running consistently without the risk of their symptoms flaring up again. I think that's when you just have to be a bit more pragmatic and say, if we're going to manage it conservatively, that's the only thing that we're struggling to get you back to. But that's not us telling them to stop. That's just their lack of mobility to tolerate what you're doing. What I wouldn't want someone to say is you have x, you can't do y. I think like it takes a lot to be that descriptive and decisive with that. And you look, you could argue, you could listen to this and say, yeah, but memory, you just said about clamshells. Don't do this if you've got this and then it should complete contradiction. But again, if someone could do clamshells, whilst they have GTS, crack on, whilst the GEC pairs his fix, they can go back to doing clamshells much like the same with this. If they have this major, you manage it, they get back to running. And that's absolutely fine. Well, I see a lot with the hip replacements as well. Don't run. If you run, it's fine. Last too short, let's just go on with it. It's fine. Just manage it. Make sure that individual can tolerate it and help them get back to that point. But there's still a lot of information out there. If you've got a hip replacement, don't do this, don't do that. You can't physically, you can't. There is evidence to tell us country and there is an evidence yet at all that shows that it will have a negative influence in the long term. Until there is, then I think last too short, these people have been in pain. They're not having these treatments to live with more dysfunction or limitation. Let's have a chat finally about hip flexors. They cop a lot of bad press. There's lots of stuff that they get blamed for. Everything from back pain, knee pain and everything else. Tell us is, why do hip flexors cop such a bad rap? For some reason, hip flexors just get blamed for a lot. Mainly just, I think, location of where the symptoms are. Then, on the other hand, they do become irritable with other conditions. If you have a FAI, if you have hip dysflasia, you can get irritability of the area. So it's tendon and other hip flexors. But that's not the main problem. That's a symptom. Same with patients who have femoral neck stress fractures or bone stress injuries. Get blamed for hip flexors just because it's there. There's just a locality of symptoms and where anatomically this muscle group is, I'd say it's getting up there with the weak glutes. That someone walks in and they say, oh, I've got tight hip flexors or my tight hip flexors. I just feel it's probably the joint. Even if it is painful at your hip flexors, probably something else is causing it or it's not the hip flexor. As my good mate James likes would say, it's never the hip flexor. But sometimes it might be in some uniques. Everyone thinks I've got tight hip flexors, always blames the fact that I sit a lot. So my hip flexors got really tight from all the sitting. What's your thoughts on that? I think it comes back down to the fact that things will feel stiff if you don't move. So it could be the jointness stiff. It could be the hip flexors. Yeah, sure, muscles will get tight if you don't move. No one complains about, oh, I've been sitting too much. My Achilles feel really tight. My anterior ankle feels quite stiff when I've got out from more. No one really says that stuff. It's just normal. Things get stiff if you don't move. It doesn't have to be pathologized. It is just normal. What isn't going to happen is if you're seeing that you're best that your hip flexors are going to shorten and become, you get like some sort of contracture. I think people think not like we're way more fragile than we are. But it's the perception. If you're stiff, you get up, if it's tight, you think it's short. It probably hasn't, it probably hasn't. And we certainly are not going to get like contractures of the hip flexors just because people work off his jobs. When patients come in and they say, I've got tight hip flexors, or if you suspect that there's hip flexors involved in their pain, what sort of test do you tend to do? If I think that they've got it earlier, so it's tight growing pain, I would probably do two things. I think, and it falls again, because if we're dealing with a muscle or muscular tendon, a muscle tendon dysfunction, I've want to do similar to what we've said before. Some of the key things, especially with those who have instability, who have secondary Iliosalus pain, are quite like doing a plank and a three-point plank at that as well. So the Iliosalus acts as an anterior femoral head stabilizer, especially in the first 15 degrees of hip flexion. So often people who have instability, and this is, and I need to caveat this heavily with, this is probably the only time that I would, this is more my opinion and approach. This isn't based on evidence, but often when you have someone who has an instability of the hip, they have an intolerance to do that, three-point plank, and certainly as you go from a plank into a pike where you increase the hip flexion through a trunk or pelvic flexion or rotation, often they struggle or are intolerant to do that. So that just gives me a little bit of insight into resisted anterior load or those structures with hip flexion to see if they can tolerate it and often they can't. So it just gives me a little bit of information there to then help with my rehab further down the line. Looking at range of movement, Thomas tests a great, but Thomas says has to be done really well for it to be effective. So this is one where you're sitting off the edge of the bed, hugging the knee and the other leg is dropping down. That hugging was the knee, that restricts and limits the pelvic position is what the test lives and dies by. Like it has to be in that position for it to be effective if it is, then it gives you a little bit of specificity into that flexibility of the anterior structures, but again at that point, I'm not overly stressed about trying to do some sort of like passive treatment to loosen it up. I would just maybe encompass that with some of the exercise that I choose. And also in that fully stretched position, I would often get into resist as well. So I can get some insight into the contractile tolerance in a fully stretched position, in that Thomas test position also. You could probably gauge from the prone hip extension, but difficulty looking at that, it's not going to give you much to play with anyway for most people. So I want to look at those two things. And then I will just go a little bit further to assessing the contractile intolerance when they're on their back with sure and long levers. Mainly for me to just figure out like how reasonable it is. So then when I'm picking exercises, I'm picking the ones that are pitched at the right point. I'm not so much to think, from a diagnosis, we've got as much as we're going to get if it's painful to contract it, find it's painful to stretch it, like we're getting some insight. That's not the diagnosis. That's just like part of a clinical, the main diagnosis is the joint. This is just like something else that's going on that we have to just still encompass within our rehab, but not put just all the focus on it. You mentioned there a three point playing can move you into a park. just clarify that a little bit about how you might get a patient to do that. So you get someone in a plank, right, normal plank position on their elbows, on their toes like good form on two legs and they say to you yeah I can do that it's not too bad. Let's see their right hip is the painful one and you say okay cool can you lift your right leg up so you extend the right leg so you basically doing a plank but just with the left leg and they say yeah that's the right the right one's a little bit stiff to hold up but I can do it fine and then you say stop around and then you get and stop around and what often will happen is they just can't do it they can't lift the left leg up because it's too painful when they can't withstand that force and load going through the hip on that right hand side so they normally just can't do it they can't lift the left leg up don't think that's quite a big difference from left to right person foremost. Now it doesn't just give that stability in neutral it goes as you go through flexion so what I would normally get them to do let's say they could lift the left leg up the right one is a bit painful but they can do it then I would progress it to start to lift their butt up into the air so you keep your legs straight and then you just start lifting your butt up so into the plank position but not too much and then dropping it back down to neutral and even just slightly past as well to see if it causes pain like if they can or can't tolerate it's just trying to paint a bit of a picture in regards to what's going on especially in those like first degrees of flexion and just being mindful that's in a long lever so then when I get them on their back and I'm doing other tests for the hip flexes and shortly like I said I'm just trying to figure out where they level their reactability possibly would be. Yeah so you're getting them to lift one leg off the ground so they've got three points of contact on the ground instead of four and then within that three point contact you then going into a pike position so they might have one leg still off the ground then moving towards a bit of a pike position coming up a bit and then coming back the end to neutral or maybe a bit past you mentioned there. Yeah just to see how it responds to it and but I would say often if it is irritable like that first hold is normally a big problem and unfortunately like it's not a standard as clinical test it's not I've based this around like anatomically what's has a high prevalence and Elyosos tendonopathy and overactivity are those structures especially for hip dysplasia is quite commonly correlated and there is a causal relationship between that as well and equally biomechanically that's what these things do so I'll just try to merge them together and these are one of the things that often you can pick up that's not to say if they can do it there's no hip dysplasia that's just I'm just trying to my main focus on that is if they can do it that I know I can use that within their plant because I know that's still helping with the stability that means I can still use that as an exercise potentially. So if they can't you're maybe suspecting that there might be this what some hip flexor involved but there may be some hip dysplasia in what's going on. I would want to know if there is I want to look into that yeah and I'll just be mindful of that or if not I would just say well it's unusual to get that level of hip Elyosos irritability just randomly as a primary diagnosis unless you're like a sprinter had a long jump whatever like someone doing explosive or a dancer where they're kicking their leg at the top of range every repeatedly for like three hours on end like most people aren't doing that so it's unusual for a primary diagnosis so that then does raise my index or of suspicion at that point then I'm thinking okay we will use that as part of our rehab journey for that individual at whatever level that we think that they can tolerate it and it might be the they can't do that at all you might give them a dead bug you might go from short to long lever and just use the weight of the leg to start to load it if so we're not doing it it gets resistance we're just using gravity and the lengthening of the leg and the weight of the leg essentially to just gradually load it from that eccentric property of the muscle. Nice you mentioned there it's a really nice starting exercise for instance if they can't cope with a long lever stuff that dead bug might be a nice place to start to help to get some e-centric strength there what are some of the other exercise you like to work through or progress through when it comes to hip flexors ilia so is related groin pain. One of the irritability it has settles so we've gone progress a little bit some of my favorite things are using that kind of plank position so sliders are used quite frequently so like double or single leg sliders into full pikes or if people don't have that they can use a swiss ball exercise ball and if the pike is too difficult doing things like knee tucks also are really useful to do because they can like do a short lever for me I find that really beneficial as things are then continuing to increase and improve I try with all my rehab to start doing two or three for ones the two for one is like I've got I'm doing two good movements in one exercise so for example you could do like a so as much so if you lay on your back right lay on your back knees aflex or hips aflex to 90 degrees and you've got a band around your feet right so so as much it'd be like you push one leg all the way down bring it back up and then straighten all the way down the other leg and bring it back up and basically as you're moving one leg the other one is so rigid that it's you're holding it against the resistance of the band now I my two for one with that would be to get them to do a hamstring bridge so lay on your back heels on a bench or a box 1990 lift them up so purely isolated hamstring bridge and then do the service march at the top of that so you work in your hamstrings because they're statically having to hold you in that position and then you're doing the hip flex the march with the band as well so you didn't do one that's tough but just an example of where I was sometimes trying to I guess like multiple things at one it's quite intense quite hard work another example would be if you've got someone completely supine on their back and you've been doing the leg raises that's easy right so if you put a medicine ball between their legs or a swiss ball you do an isometric adduction squeeze and then do the hip flexion raises with two legs that's quite tough you get a hanging from a bar and doing toe tap toe raises just imagine someone hanging swinging and I've got the swiss ball between their ankles and you're squashing the ball and then you're doing straight leg raises then you've got abdominals adductors hip flexes so three for ones two for ones I'm being quite hard to this imaginary patient but you get the point of try to make definitely working through from short lever to long lever then incorporating like different muscle groups at the same time so you can actually get a little bit more bang for your back or intensity I think that's a really nice place to wrap it up we've covered a lot of great topics there's a lot of myths and misconceptions and we've explored a lot of those and how he physios out there can share accurate information with their patients and take an evidence-based approach to you know assessing and treating the hip so really appreciate you coming on and sharing all that with us today amendment yeah thank you for having me on a big great and I really enjoyed it and hopefully people listen and find it useful and you've got any questions just feel free to reach out where can people find your amendment what's the best place to get in contact with you all to see what you're doing and you've got going on okay patients I would say my website which is just the hipphysio.com and in my main social media platforms are Instagram YouTube and X or Twitter if you search for the hipphysio you'll find them my main one is Instagram and at the moment on YouTube I'm starting to create a lot of patient-centric videos because I get a lot of referrals from physios and what I want them to have is like a place where patients can cover just learn a bit more about their problem how to manage it and just to cut out all the BS and then I find out online yeah that's something that's developing and that's growing perfect so check it out on Instagram and Twitter or X and YouTube as well hey we'll have links to all those in the show notes thanks buddy thanks a lot yeah thanks for your time and great questions thanks having me thanks for coming on amendment and sharing all that with everybody we appreciate it thanks amendment hope you enjoyed that podcast I'm on Twitter or X at David K Pope on Instagram at clinicaledge and also on Facebook at clinicaledge if you enjoyed the podcast love to get you to write a review for us on iTunes Spotify wherever you're listening to this podcast leave us a review and let us know what you enjoyed about this podcast to have a great week and I'll catch you on the next physio hedge podcast see ya