Thank you.
SPEAKER_02:Increasingly, my diagnosis tells me less and less about the individual athlete's needs. So rather than rehabbing hip, you're looking to ultimately rehab the athlete. And if you have four or five hip pain athletes in front of you, they all have very different strengths and weaknesses. And historically, when I look back at those that have got better and those that have got better slowly or maybe not got better at all, is it because their anatomy was the problem or is it because I was applying the one solution to them all rather than giving them their individual needs?
UNKNOWN:you
SPEAKER_01:Hip and groin pain is a common presentation in athletic populations, but can be tricky to unpick. In today's episode, we explore how well we can diagnose hip and groin pain, how important and just how accurate our diagnosis is, and we discuss how our diagnosis influences the rehab journey. To unpick this topic, we are joined by Enda King, who is a sports physiotherapist, strength and conditioning coach, researcher and educator who works with elite athletes and teams across a spectrum of sports. It's currently working as head of elite performance and development in Asparta, Doha, Qatar. Enda gives us some really interesting perspectives on this topic and some clear takeaways that will no doubt help you with your assessment and rehab of the sporting hip. My name is James Armstrong and this is Physio Explained. Thank you very much for coming on today. It's great to have you finally on the podcast.
SPEAKER_02:My pleasure. Thank you very much for the invitation.
SPEAKER_01:Wonderful. So we are going to dive straight in today, giving the listeners some key clinical pearls around the sporting hip. We're going to dive straight into the diagnosis and then we're going to talk a little bit about how important diagnosis is and also how that might influence the rehab that we prescribe for our athletes and patients alike. So we're going to get straight in with it and we're going to talk about pain provocation tests and how important they are and when a test is positive, does that really tell us where the pain is coming from and is that important when we're looking at the sport in here. So, Enda, I'm going to go straight over to you. Let's talk about pain provocation tests.
SPEAKER_02:Yeah, I think when you have an anti-athlete coming to you, I mean, your number one thing is where is the pain coming from, your differential diagnosis, and then using that differential diagnosis to decide their management strategy, whether that's onward referral or something that you're going to take in under your rehab wing, so to speak. So when it comes to producing pain in the hip, the pain provocation tests at the hip are well documented in terms of faber and fader and hip internal rotation. The challenge with nearly all of those tests, and there's a very nice systematic review by Mike Raymond on this, is they're all quite sensitive but not specific. So in other words, if you're positive in a fader test or hip internal rotation test, I have no idea where the pain is coming from. If you have no pain on these tests, there's a good chance that you have no hip problems. So they're very good clearance tests, but they're not necessarily good tests for identifying or confirming if the pain is coming from the hip joint. So obviously you would be using your subjective with it, but in and of itself, the subjective for pain in the hip joint can often be very similar to the groin or to the lateral hip as well. So it can be very difficult. So our pain provocation tests are very good clearance tests. If you have no pain in them, there's a very good chance that your symptoms are not coming from the hip joint. However, if you have pain from them, a more detailed examination may identify other structures, especially if there's injury or spasm or tone that muscle can very often be irritable in those fader tests as well as other structures around the front of the hip. So in reality, the only way to truly confirm and the Warwick consensus would have reaffirmed this, the only way to truly confirm if you have pain coming from the hip joint is that you have some symptoms. So clicking or giving way or some reporting some symptoms, you have positive pain provocation tests and your pain is resolved by an interarticular injection. So the only way we can actually truly be sure that the pain is coming from within the hip joint is with an interarticular injection, which can be part diagnostic, part therapeutic. It may help to settle symptoms down a little while you address the reasons that you became symptomatic in the first place. But ultimately, as I said, having a positive fader test, especially when you get into your 30s and beyond, as unfortunately I find myself in now, the fader test probably hasn't been comfortable for about 10 years. So it doesn't necessarily mean that you do or don't have trouble. The difficulty with the radiology side complementing the pain provocation test is there's so many false positives in radiology, especially of the athletic hip. There are a number of research papers that show that the presence of camorphology is much higher in athletic populations, partly because of the extra loading that you would have in an athletic population versus a recreational population, and also because of When you play pivoting sports and you're involved in lots of change direction, which is abduction and external rotation of the hip, that will load the epithelial plate when open during adolescence. And very often it's that additional loading and mechanics will lead to the development of CAM lesions over time. So when you MRI an athletic hip, CAM lesions are much more common than uncommon and labral tears are present in about 80% of the asymptomatic population. So the great difficulty for us is Someone does a fader test, they say, oh, that's your hip joint. You go for a scan, you say, oh, there's a labral tear. And then all of a sudden you develop a hip pathology where perhaps many of the findings that are there are unrelated to your symptoms. So I think having clarity of what the tests do and don't tell us what's normal and what's abnormal and ultimately understanding that an interarticular injection is the only true way to be confirming that symptoms are coming from the hip keeps us on a very even keel and avoids us going down management pathways that perhaps we don't need to.
SPEAKER_01:And I'm assuming really that interarticular injection, although being diagnostically maybe important, it's not something you're just going to automatically dive straight to in order to get a clear diagnosis?
SPEAKER_02:Not at all. I mean, lots of athletes will present with pain coming from the hip joint that don't necessarily need that. Yeah, your initial difference diagnosis is always around pain. Is this for rehab or is it for something else? Okay, whether that's sports medicine injections, whether that's an orthopedic opinion, etc. The reality is, especially given the high prevalence of normal pathological findings on MRIs, that conservative management is nearly always, especially in the absence of big trauma or marked pathology on scan or x-ray, is always going to be the first port of call. The exceptions to that, obviously, are stress reactions around the neck of the femur, maybe the inferior pubic ramus. they're quite important to pick up early and avoid prolonged rehabilitation periods that are ultimately will end in failure and may end up in more serious injuries off the back of that. But once you've decided that the pain is coming from the hip joint, they need to go and do your rehab assessment, which should be trying to identify why that athlete has become symptomatic in their hip. And there'll always be a load component to this because very few people develop pain in their hip sitting around. It's always after sport or always after. So there'll be an athletic and loading component to that. But under that, there will be their motor control, their strength, and then how they express those mechanics during running and change direction, etc., which are the most common provoking activities. And so the research would say, on average, you lose your hip range of motion when you have a hip problem. On average, you have a weak hip musculature in every direction. But that's on average. That's when you group everyone together. In reality or in clinical practice, every hip will have slightly different strengths and weaknesses. And it's about trying to identify the smaller musculature, the control around the hip, whether that's iliopsoas, the front, the deep rotators, the back, glute min at the side. what kind of strength is wrapped around that in terms of your more superficial hip flexors, your big lateral hip muscles, so glute med, upper glute max, then posterior glute max or lower glute max. And then how obviously you express that strength around the hip in terms of your lumbopelvic control, your jumping and landing, et cetera. So every one of those things can contribute to how you load around the hip and therefore by extension, in addition to your training load, how easy it is or otherwise to aggravate your hip. And even then, you'd have some people who describe their hip is aggravated during change directions or during sidestepping maneuvers. You'll have some who say they have no pain when they're running, but when they're walking and taking long strides, they're getting that irritation at the front of the hip as it gets. So again, the subjective will often begin to narrow in your focus on A, obviously where the pain is coming from, but B, if I'm having pain when I'm walking, especially taking long strides, how much of that is my ability to control hip extension? or not, as the case may be, and what are the structures and components that I might need to address in my rehab in order to settle that area down and then obviously to avoid re-irritation in the future.
SPEAKER_00:Thank you. Thank you.
SPEAKER_01:Brilliantly now, you've led us on really nicely to once we've got that diagnosis, what are their rehabilitation needs and how you've talked really well already on how we could go around that diagnosis and how that diagnosis is going to lead into some rehab. So let's dive in a little bit more now on that, if we can, in terms of once you've got that diagnosis, how would you use that to inform your rehab needs and how do you tend to find that plays out with the sporting hip?
SPEAKER_02:Increasingly, my diagnosis tells me less and less about the individual athlete's needs. So rather than rehabbing hip, you're looking to ultimately rehab the athlete. And if you have four or five hip pain athletes in front of you, They're all of very different strengths and weaknesses. And historically, when I look back at those that have got better and those that have got better slowly or maybe not got better at all, is it because their anatomy was the problem or is it because I was applying the one solution to them all rather than giving them their individual needs? And increasingly, it's always been the latter. I went to the program that worked for somebody else or my assessment was not comprehensive enough to identify all the factors that were contributing to their issues and or my rehab program Even though I eventified all the deficits, it wasn't effective at getting change in those deficits. And that's where the biomechanics lab has been really useful. Previously, where I worked in Dublin, and now currently in Aspatar, because you hear lots of people failing rehab. What does it mean to fail rehab? And did rehab fail you? So ultimately, why does one person get better than the other? Well, obviously, there's a load management component to it. You need to progress that accordingly and make sure that your hip is responding. But ultimately... If you lack that motor control around the front of the hip, just as an example, whether that's your hip, your iliopsoas, your obliques, just as a broad component. If whatever I'm doing is not affecting change, I could do it for six weeks or six months. It doesn't really make a difference. I'm highly unlikely to get the symptom released that that athlete is looking for. Time and again, you'll find that athletes with anti-inflammatories and rest, they feel better and then they go back to activities and they feel sore again. And they go round and round and round and round until eventually the anatomy gets the blame. And therefore we need to go in and do something with the anatomy rather than step back and see how do they address that. So to answer your question in a less roundabout way, how does my diagnosis influence my rehab? My diagnosis really says, is this something for rehab or is it not? Or at least not immediately. Once it goes to rehab, I then need to start from scratch and say, right, look at this. How does this athlete move? Maybe they have a history of chronic ankle sprains, previous issues, and that's affecting their motor control the entire way it's trying to connect chain. So if you have a hip problem and the only thing you look at is the hip joint, how much am I missing the opportunity approximately and distally to address deficits that are contributing to why they become symptomatic in the area? So again, there's where you're sore and why you're sore. Okay, we've identified where you're sore. We've decided you're for conservative management. Now we're going to look holistically at how you move, especially with the stories that you've told me. You'll have told me what your main pain-propagating activities are. So if your pain is during running, well, surely I need to have a look at your running mechanics along with your strength and along with everything else. Well, this is where you are now. How can I build you back up to that being a pain-free activity? Like most injuries, if you leave it long enough, the symptoms will settle. But ultimately, if you don't address the underlying reasons when the training load comes back up again, you may be susceptible to redeveloping symptoms.
SPEAKER_01:Yeah. That underlying cause rather than just what you're assessing, because I know obviously you could address a strength deficit that you found on assessment with a patient who's got pain, but that strength deficit isn't necessarily the thing that is the underlying cause of that pain necessarily at that time.
SPEAKER_02:Especially in a patient with a hip, it can be difficult to see the wound from the trees. what was here before the injury came and what is here now afterwards. And in the reality, especially the more chronic presentations, it really doesn't matter because some people settle and get better with any intervention. It's just an acute flare up and away you go. What is it about those that become more chronic as time progresses? A bit not dissimilar to anterior knee pain. You get a bit sore, your quads get weaker, you load your knee differently, you get a bit sore on round week go. And so while your quads might not even start your knee pain, the reduction in quad strength is now contributing to the ongoing irritation in the area. So while your lateral hip, just as an example, may not have been the primary reason for lateral hip function now may be contributing to the ongoing irritation in the area. And this is particularly relevant in those that have gone on for hip arthroscopy. whereby the anatomy is going to be either revised by paring back the CAM lesion or repaired the labor. But if I'm not addressing the underlying reasons why that area is becoming mechanically impinged in the first place, it's going to be very difficult to stop the provocation and ongoing irritation in the area. So again, a lot of what is described as pathology is normal. But if someone did go to have intervention in that area orthopedically, well, at the very least, surely I want to give that procedure the best opportunity to be a success. And similarly, you have any surgery, you have any ACL reconstruction, you're going to have weakness and inhibition that's as a result of the surgery that may or may not have been there. So you need to restore that and put that back as well. So it's the same with the hip joint. The hip joints are difficult at the best of times, but where I feel why I've become more consistent is in rehabilitating the athletes, not rehabilitating the hip and taking a step back. Every time you have someone who's a little bit slower to get better, is it because you've missed something in their diagnosis or is it because you've missed something in your rehab assessment? And invariably, my assessment has got broader. You almost create the outliers. You have a way that you approach an athlete. It works for a while. And then there'll be someone where it doesn't work or gets arrogant. And so at that point, you can say, well, they failed rehab. If you go to someone else or you can look back in yourself and say, actually, am I missing something here in the deficits I've identified or in my ability to address those deficits? If you've addressed all your deficits and you still have symptoms, well, that's a different proposition.
SPEAKER_01:That's fantastic. I must admit, before we started this podcast, I looked at the breadth of what we were got to challenge ourselves to cover and i think we've covered it fantastically ender thank you so much for your time i think one of the key things that's come out of this is looking at the athlete as an athlete rather than as a joint that's really key and then also as you said that multifactorial rehab looking at rehab as a broad sense and also i think not being afraid to stop and take another step back and look again during that rehab cycle so i think that's been absolutely brilliant really really useful and i can't believe we covered diagnostics and in a bit of rehab as well in one podcast episode in the time that we've perfectly finished on and i'm sure we will definitely be looking to get you back on with some more specifics but in the meantime thank you so much for your time today
SPEAKER_02:my pleasure thank you james
SPEAKER_01:for everyone listening again if you found to this episode useful which i'm sure you have we'd really appreciate you to hit that subscribe button and share the podcast far and wide to get into as many years across the globe as possible Thank you very much.