[Expert Physio Q&A] Lateral hip pain: clinical reasoning beyond the diagnosis with Mehmet Gem

This episode with hip physiotherapist Mehmet Gem is a snippet taken from his Assessment of Lateral Hip Pain Practical live Q&A session. Held monthly, these sessions give Practicals members the chance to ask their clinical questions and get direct answers from expert presenters.

In this episode, Mehmet discusses:

• Differential diagnosis in lateral hip pain
• Interpretation of symptoms and clinical tests
• The role of imaging in assessment
• When to reassess and adapt your approach

👉 Learn more about Physio Network’s Practicals here: https://physio.network/practicals-gem

Mehmet Gem is a specialist hip physiotherapist based in Exeter, UK. He holds a BSc (Hons) in Sport and Exercise Science, an MSc in Physiotherapy, and a PGDip in Advanced Neuromusculoskeletal Physiotherapy. He has over 16 years of experience in musculoskeletal physiotherapy, with the past 12 years focused on hip and groin conditions, including FAI syndrome. Mehmet now runs a specialist hip pain clinic and teaches healthcare professionals through hip-specific professional development.

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Transcript

SPEAKER_01 0:05

Be flexible, be pragmatic with your approach, don't be too rigid, but also just like use every bit of that information that you get from the assessment to kind of feed into what you're gonna do. Equally, to caveat that, maybe something else does come back from the imaging. Something that you think, actually, that's not relevant. But I'm helping them understand the lack of relevance to that. You know, then being told, oh, you've got a mildly arthritic hip. Irrelevant because it's mild or it just might be the precursors to arthritis. Us feeding that back to them is different to a doctor saying you've got an arthritic hip because we're giving them context to that. So I think like depends on the scenario of who's going to control that level of content.

SPEAKER_02 0:45

Welcome to another expert QA episode. In this episode, we're sharing a highlight from a recent session with Mehmet Gem where we dive into the assessment of lateral hip pain. Lateral hip pain can be challenging to assess, from navigating differential diagnosis to knowing how to track a patient's progress. Mehmet breaks down his practical approach to assessment and explains how to adapt when presented with a more complex case. Remember, practical subscribers get exclusive access to these live QA sessions with the opportunity to ask their own questions directly to experts. We hope you enjoy the episode.

SPEAKER_00 1:26

So, first things first, hello to everyone. My name is Sean, and I help run the QA's for Physio Network. I'd like to start by welcoming Mehmet, who is here today to answer some of the questions today on the assessment of lateral hip pain. Thanks, mate. I appreciate that.

SPEAKER_01 1:41

And yeah, thanks everyone for jumping on. I appreciate you kind of taking uh the time to attend. So, what are your thoughts on having imaging done to confirm a diagnosis of hip conditions like GTPS, FAI or OA, especially if the patient is pushing for one? Okay, there's this is this is quite useful actually. So let's let's break this down first and foremost into kind of like two different parts of the question. One is imaging to confirm the diagnosis, which this individual's asked in regards to kind of GTPS or joint related. And then the second part of it is if the patient is pushing for one. First and foremost, like the whole point of having a robust clinical assessment is to be able to do your subjective questioning and do your physical examination and by the end of it have a fairly good hypothesis, right? I don't think we're in a position as physios when you have nothing to back up your assessment to confidently say 100% this is my diagnosis, because like it's a challenge because a lot of the clinical tools and tests and things that we have are not 100%. You know, you ought to think even MRIs aren't even 100%. So it'd be really remiss of us to assess someone and say this is my definitive diagnosis. But you have to have a strong hypothesis. And my thought of this is is fairly dislike the same, really, across the board when it comes to these kind of hip conditions, and that is that realistically, we could get to the end of the assessment and you could have one strong hypothesis, you can have four, you could have three things that you think actually maybe there's a bit of both, like maybe there's all of these things coexisting. Well, that's all right, that's very common. But the question is like, at what point do we need to be more definitive? And that's a really critical thing to be aware of. And what I mean by that is with your appointment with that patient, who's coming to see you, who is saying to you, right, you know what, like I I want to go and get a scat, I've come to see you. Ultimately, if you can explain to the patient a strategy of what we're going to do to manage this, that already starts to set the precedent. And what I mean by that is if I've got by the end of my assessment, I've assessed the patient, I think, right, think it could be this, I think it could be this, I think it could be this. I'll explain to them and say, look, okay, well, for starters, my thought process is these are the things that could be involved with your symptoms. This is how we manage it. If we're going to get a successful outcome, often the timelines and how these things develop demonstrate some sort of outcome over this time frame. But what I'll say to the patient is we need to put a timestamp on what we need to see as a change. So if we get to like three months in and nothing has changed, like you're getting worse, you're in like a net loss from your rehab. Everything that we're doing is having to be regressed. Everything that we're trying to do, we can't progress with, and we're seeing nothing at all. And you're diligent, and you're a good patient, and you know that they're a good patient. That's when you'll say, right, well, we can try and prove our hypothesis with a diagnosis, and to do that, we can maybe utilize imaging, but explain to them the limitations of imaging, explain to them that it doesn't always correlate with symptoms. Explain to them that it might not change what we're going to do, but it might reassure them. I notice here on the question, the patient the question says also or OA. I think the difference with that is if you're if you have a hip that you think is coexisting both of an arthritic intra-articular component to it and GTPS or lateral hip pain, and the primary driving force is maybe the arthritic hip, it might be that arthritic hip is limiting what you can do to load that tendon up sufficiently to get the changes that you want because we've got a cause here that is overriding you trying to treat the effect of the tendon as well. So at that point, maybe you need to consider well, look, do we need to know that this kind of causative factor from the joint is going to be too much of an issue to hinder their recovery? So, yeah, so that's kind of my thoughts, but on that one.

SPEAKER_00 5:37

I wonder your opinion on using not using imaging solely for reassurance purposes, because I think we should be able to do that through our conversations and education as you've you've just been going into in lovely detail. But if you get any patients who maybe really, really are so focused on a scan or an image of some sort, so much that until they they feel like they've had that that solid piece of information that says there's nothing major going on, it is safe to load it, for example, use it. Does it ever become a tool that you would use in that sort of sense where where maybe an x-ray to just tell them what it isn't, for example, may may give them that reassurance to help them get that buy-in, which then kick starts the process?

SPEAKER_01 6:21

Like like I said, never say never, right? I thought I'm too old on the tooth to say never say never. I think in some scenarios that will be beneficial. Imaging isn't bad, right? Imaging is about imaging in the wrong hands and fed back to the patient in the wrong way is the issue, not the actual imaging, right? So I think that that isn't a problem. So one of them says to diagnose TFL in surgery on tendnopathy, is palpation a main diagnosis? And in the one underneath, it says, what is the benefit of doing an external derotation test over a straightforward resisted abduction palpation and single leg stance? And actually, these two things will come hand in hand. So I'm going to kind of answer these two things together in one, mainly because this is the exact reason why you would do a derotation test. Let's kind of start off with this kind of proximal IT band issue type, TFL type issue first, because it is quite hard to kind of come up with all of these different tests that are very, very specific, because a lot of them aren't, except for this derotation test, which I'll explain shortly. With that more, I guess lateral hip but pelvic type presentation. I'd want to understand if that individual one, their location of palpation pain is obviously going to be in a different area. We're not bang over the greater drachanta at this point. We're talking about more sensitivity, especially around kind of iliac crest type region. So we want to understand that for one location of symptoms. Where is that? How does that feel? Often they might also respond with pain that is irritable, not just with abduction, because we'll have that crossover with the lateral hip, but kind of like side flexion, so side bending, side flexion of lumbar spine might provoke it if you have like a lateral shift in that area as well. But it's quite challenging because some of that stuff will provoke the lateral hip and the glutenopathy patient. But that's why we need to be a bit more specific. It really easy thing with this patient cobalt is you've got to consistently ask them like where it hurts. And I know it sounds really obvious, but when you're thinking about so many different things from your assessment, like where I'm palpating and the clinical tests and the position and their mechanics and what they can and can't do, actually just reinforcing like where are your symptoms when you're doing something gives you quite a lot of information. You know, someone giving you pain and real notable discomfort around the iliac crest versus someone who's saying, actually, it's distinctly over my greater trichanto is you know, anatomically quite notably different. And in the hip that is quite complicated, whether you've got a younger individual with labral tear or FAI syndrome or hip dysplasia and lateral hip pain, whether you've got an older person with like an arthritic hip and lateral hip pain, we need to try and discriminate like our symptoms coming from an intra-articular component or contractile load. That's why you're asking them where their symptoms are, by the way, is also critical. Because if we're doing this fader resistance or derotation test and someone's saying to you it's painful, like where does it hurt? Like, are you getting pain in your groin when I'm rotating your hip? Or are you getting a lateral hip pain stretch when I'm stretching it? Are you getting pain when we're resisting the movement? And if so, where? And if they can't even do that because the joint is provoking them and the joint is stopping them doing it, well, your gluten mead as it acts as an internal rotator. The more that you flex the hip, the greater the leverage as an internal rotator for the glute mead. So you don't even need to bring the hip into adduction technically to really test that contractile load force of it. Because getting them to resist internal rotation, even at 90 degrees flexion, if it's reproducing their lateral hip pain, that is a contractile component that is driving their symptoms. Something that we need to consider that we need to probably improve upon when we're managing it as well. So there's a lot of, and partly why this is a quite specific test, right? Specific to this pathology and specific for what we're trying to look at. But it gives a lot more understanding in regards to what it can and can't tolerate. The useful thing for me as well is mainly the joint. So, like, are we getting kind of irritability from that actual load or are we getting any irritability from that compressive load? And it starts to paint a picture, and also it's something that you can reassess and re-evaluate.

SPEAKER_02 10:23

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SPEAKER_01 10:48

So let me move on. Do you have any specific assessments for the lateral hip pain in runners? This is a good one actually, because this is where we have to be a little bit more we have to do a little bit more detective work with this one. If I have to summarise that, I'll break it down. So look at their running, look at their running gait, try and adapt it and modify it and see if it makes any difference plus or minus to their symptoms or if it's the same. Look at single leg endurance control, look at dynamic single leg land control in multiple planes of movement, and then also identify their ability to do functional tests to then load the tendon and structures that we discussed to see if that provokes pain. You know, so can they do things like you know, curtsy lunges, curtsy sliders, like really trying to put that tendon under load significantly as well? That might not necessarily be distinctly what they're doing running, but understanding that tendon's ability to tolerate that same kind of like stress essentially. And then the basics, you know, they're a lot of the time people who develop this stuff who love running love running, but also they end up only running. So it's understanding training areas like are they doing too much of the same thing? Are they only running? Are they not doing any strength stuff? Sometimes the things you start to discuss with them, they've never done, and they've just started just to keep running and running and running, and they've adapted and developed these negative behaviours because they are runners, and runners, I don't know who's on the call now, but you know, some runners only run, they love running. Um, and then you've got to throw in a mix, actually now you've got to do split squats and a step up and a lunge, and all of a sudden it becomes less fun because you're taking time away from them running. So it's just understanding some of those training errors that's that sometimes can contribute towards it as well. So, is there anything else you do to rule out or rule in the joint, particularly if it's articulate or laboral? And if someone's restricted in range, but due to pain, do you just wait until that settles to assess the full range, for example, to determine if it's OA or FAI, versus compresively intolerant? So that's quite useful. I don't think we would necessarily have to have to wait because, like we said earlier, like some people might have an inability to rotate. So, like you know, if you have just textbook FAI syndrome, the loss of range of movement will be, you know, if we if we're looking at the general population, normally fairly distinct, you know, they're at 90 degrees, they've got a loss of internal rotation, they might have a more greater ability to do the flexion and external rotation for that derotation, and it might not necessarily hinder them doing the abduction resistance and the palpation and the single leg stance. So you could still get quite a good insight with that. But in the case of someone who maybe has more of an arthritic hit, like the the restriction might not be just from pain. And if it is, I guess my question would be: what would restrict someone's pain to that extent that you can't passively do it? Well, you could be in a flare-up, but technically, even if you had an acute flare-up of a labral tail, you'd you'd still be able to rotate the hip passively, it'd still be painful nonetheless, anyway. So I think the restriction issue is mainly if it's restricted from the joint, the morphology, the adaptation from the pathology within the joint that's inhibiting the ability to rotate it or move it. But you can still, like I said, you can still get so much information because ultimately, like if you're passively moving the joint, whether you're testing the joint and you're bringing it into flexure and an abduction and doing like the classic kind of you know, fabres and fidus tests, and you're seeing some sort of reproduction of symptoms. Firstly, like I said, where is the pain? Show me where the pain is. But is it when I'm passively moving it? Is it when I'm passively stretching the tendon that's causing the symptom? You know, that's what I want to understand. Is it worse when you're starting to resist it? Like there's a lot that you can identify, and if that restriction is there from the joint, I don't necessarily think we have to we have to wait. What happens if we can't confidently get to a diagnosis? How would we manage that with the patient? So it's good of you to say that, Owen. It's fine to have that level of ambiguity in your mind, okay? It's fine even to explain to the patient that there might be a couple of hypotheses. What you don't want to do is articulate that in a way to the patient where you're saying, I don't know what's going on. It could be loads of these things, and making them think actually they haven't got a clue what they're talking about. It takes confidence to be able to really articulate and say, look, I'm being really critical. I think it could be two or three things. What we're gonna do is treat your symptoms as they are. We're gonna I I can see that I'm not able to give a definitive diagnosis and say it's definitely this that's causing this, because there's a couple of things that are going on. But what I do know is we need to get you to be able to walk better, we need to get you to be able to load this hip better based on what I've seen from your assessment. We need to be able to modify what you're doing exercise-wise, because I think you're, you know, if it is the joint that's driving, I can see the joint has some restriction, but also your tendon doesn't like this kind of movement from your from my assessment. So we start by treating as is with the patient in front of you, setting some clear objectives for what that patient is in regards to their goals and what we're trying to get from it. And then if you're worried that you're even thinking, like, is it even the hip at that point? As in, and I'm talking like, is it the joint? Is it outside the joint? And actually, nothing makes sense. I think that's a different scenario. But that's why you have to be able to look at this as a complete picture. And one of the things when I teach on my courses, I say to pay, I say to physios, look, imagine that you go into that appointment, and in your in your mind, you've got literally every diagnosis it could be, right? Not just hip. Literally, it could be like visceral infection, cancer, red flags, lamb spine, it could be anything. What you have to do is try and nullify as much as you can, right? Just get rid of it from your differential list, get rid of everything that you know it definitely isn't. Get rid of all the ones that you're really confident and you think I'm really sure it isn't that, and try and funnel down your thought process. If you're confident that what you're left with isn't anything sinister, like urgent, life-threatening, worrying, or anything like that at all. And you're thinking you're thinking actually, okay, look, it could be two or three of these things. Treat the patient as they are, symptom-wise.

SPEAKER_00 17:13

Meme, I think I can speak for everyone who's attended this morning and saying thank you. I think that was super, super detailed, but a really nice, I say broad overview in it in a in a in a polite way, in the sense that all bases were covered and we've dove into each question in some real good depth there. I think everyone will take away lots to to stew over and sort of hopefully guide their practice moving forwards a little bit more. Hopefully, yeah.

SPEAKER_01 17:40

Yeah, thank you for jumping on, everyone. If you need me, you know where to find me. My website's fairly easy to find, just the hitfysian.com. So if you want to reach out or find me, just direct yourself to there and you'll find me somewhere.

SPEAKER_02 17:53

We hope you found this episode helpful. Keep in mind this was just a short snippet from a much more in-depth QA session. As a practical subscriber, you'll also access live sessions like this every month where you can learn directly from leading experts and your own clinical questions answered. If you'd like to be part of these sessions and explore our full practicals library, you can start your free seven day trial via the link in the show notes or by visiting physionetwork.com. Thanks for listening and we'll see you next time.