Episode #77 The Hidden Truth About Bursitis vs Tendonitis: Recognizing the Signs That Save Treatment Time

Most athletes and active individuals overlook a crucial aspect of injury recovery: understanding the subtle differences between bursitis, tendonitis, and strains. In this episode, renowned sports medicine specialists Dr. Dustin Glass and Pawen Dhokal dive deep into real-world case studies, unraveling how to accurately diagnose common hip and hamstring injuries without immediate imaging. They reveal the life-changing importance of thorough history-taking, masterful palpation, and strategic treatment that can make all the difference in faster recovery and better performance.

You'll discover:

• How to differentiate bursitis from tendonitis based on activity patterns and pain response
• The critical role of palpation and history in uncovering hidden injuries in athletes with multiple past issues
• Practical protocols for managing hamstring and gluteal injuries, including what modalities work and which to avoid
• Key signs that suggest an injury requires imaging versus conservative treatment
• How stress and lifestyle influence muscle and joint health, especially in high-level athletes

This episode is essential listening for sports medicine clinicians, physical therapists, athletic trainers, and athletes eager to deepen their injury assessment skills. Learn how to avoid common pitfalls, tailor your treatments more precisely, and get your patients or yourself back in action—faster and safer.

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Transcript

SPEAKER_00 0:00

And we are back and live, whether we're ready or not. We this is the second opinion with sports medicine podcast. My name is Dr. Doakwell. I'm Dr. Glass. DG, what's happening today? I'm just turning my notifications off, silencing my get interrupted today. But I'm excited to talk today because there's a few patient cases that, well, it might be interesting to listen to for our listeners, but I also selfishly would like to chop it up with you and uh see if I can come to some resolution or conclusion on some of these things that are uh a little bit out of the norm.

SPEAKER_02 0:33

Yeah, for sure. Yeah. Um, do you have any off the top of your head right away? Or I do, but before we get started, how are you, man?

SPEAKER_00 0:41

How's your week?

SPEAKER_02 0:43

Yeah, um, let's see. It's been kind of a roll end of a week. It's only Tuesday, but it seems like the weekend blended in. Yeah, we've been um barbecuing. I I my dad got the Traeger when I was up in Tennessee. My dad uh worked on my Traeger and got it all cleaned up ready for the summer. So we got a tri-tip uh two nights ago and uh had my parents over and had a buddy over, and uh yeah, and the kids were home and so we were out barbecuing and then we were uh had the fire pit going and made s'mores and just felt like summer was beginning and then carried on over to tomorrow uh yesterday. So we were out there last night doing it. They invited friends over to have some s'mores. So it just feels like summer's begun, and uh I'm happy yeah with uh having the kids around.

SPEAKER_00 1:34

No, the weather's nicer, the sun's going down later, and that takes me time's uh you know, it's it's not every day you get to hang like that and just relax. I mean, that's really what life's not about. I mean, although we have jobs where we help each other, and I think there's or help other people, and I think there's you know intrinsic value in that, but in general, life isn't about getting up and grinding all day. It's about spending it with your loved ones, whoever they are, you know, or doing something about. So Yeah, for sure. I'm glad that you got that.

SPEAKER_02 2:02

Yeah, what about what about you? Uh, what'd you do over the last few days, week?

SPEAKER_00 2:06

Man, really just trying to recharge. Um, there were some people sick around me, like my mom was not feeling well, and my dad ended up getting sick, so I was trying to just avoid uh getting under the weather, really. You know, uh Friday was a work day, Saturday was uh I had a little bit of an adventure, which I'll tell you about. But uh Sunday I worked and then yesterday felt like a Thursday, Friday, even though it was a Monday because I kind of worked through the weekend. I'm sure you know how that is. Yeah, that's what I was saying. It was all kind of blending. Yeah, it was meshed together for sure, where I was like, I know it's Monday and people are starting their week, but it really feels like a Friday to me right now. Yeah, well, yeah. So it was a bit interesting. Um, but yeah, overall pretty good.

SPEAKER_02 2:46

Good. Yeah, well, like you said, it blends. I I like you, I work on the week. I work for uh Friday, Saturday, Sunday, and you know, even though it's not as heavy of a load, it's still a load and it still takes away. So yeah, you know, you gotta find those quality times in between. But yeah. So we start Monday all fresh and uh ready to rock and roll with the rest of the world. Um so yeah.

SPEAKER_00 3:08

Sometimes if I can, I'll creep a half day off on a Wednesday morning or a Friday afternoon or something, you know, just try to reset, have some line of delineation between last week and this week, you know, because otherwise I've had uh, you know, 50, 60, 70 days in a row of just nonstop, and it's not really good for your mental, you know, even though sometimes you get it.

SPEAKER_02 3:33

Yeah, right. Well, both of us have a lot of irons in the fire right now, trying to, you know, get things going, create things. You know, we're at that kind of different phase of our career in life right now where we're trying to not reinvent the wheel for sure, but to maximize our um reach and maximize our um you know what we've done over the last 20 plus years and uh capitalize on all that work we've done. So I think it's just kind of for me, and I know we've talked about that, it's just kind of kind of a rebirth, a re rejuvenation. So yeah, it feels like starting over again in a grind, but in a different manner because we have the foundation over already. Whereas before we were building the foundation and trying to make something happen, now the foundation's there. Now we're just trying to kind of fine-tune it, you know.

SPEAKER_00 4:22

Yeah. That's well could it reminds me of something I read last week about uh transition wasn't the word, it was kind of like leveling up. And the conclusion of the author at the end of what I read was essentially when you're leveling up at anything, take high school sports to college, take college to the pros, take you're going from a manager to C level executive or something. That when you're leveling up, there's like a little bit of chaos, you know, it feels unstable, it feels uncertain to this new stuff, it's more on your plate and it might be a little uncomfortable because you're not used to it, you know. And uh what I took away from it was if you feel uncomfortable in the time that you're leveling up or you're trying to achieve something, that's when you're the closest. And I don't know if I necessarily feel that in my heart a hundred percent always, but that's what I read and that's what the conclusion was, and that's it resonated in the sense of like um not everything is instantaneous, right? If I wanted to make a baby today, am I having that baby tomorrow? No matter what I didn't know, that takes nine months, right? There's a process to this thing called uh developing a child, and there's a process to creating things, whether it's uh you know things like podcasts or things like uh educational materials or things like learning a new skill so you can increase your skill set or change your career. And so to everyone listening, I was having this conversation with an athlete who's trying to he excelled in high school and he's trying to excel in college and he's doing well. I think he's doing great. You'd say he's doing great too, but to him, he's like, yo, I'm getting myrt every practice, you know? I'm like, bro, you went from being the king of the jungle in high school to like pushing people 30 yards and throwing them in the end zone and standing over them like Thanos, to now you're a freshman and you're dealing with 24-year-old seniors. Oh, you just turned 18. That were also king of the jungles in their high school. Exactly. He's not going to some you know, shlomo type of college, he's going to big name school. So everyone there is the man. And I said, How are you holding up? And he goes, uh, I'm doing okay. Like, no one's like wrecking me, but like I'm not wrecking anybody. I said, Dude, that's a win. You're coming in the gate holding your own. Like, wait till you're a sophomore, you're a junior, you're a senior, you're gonna be so he was going through this, and I just took a little perspective of like, of course you're gonna hit some speed bugs, of course your speed is gonna be reduced when you have a headwind. And then as I'm telling him this, as I'm sure it happens with you often, I'm like, bro, I need to listen to these same words myself. Yeah, because yeah, uh, you know, if I zoom out in a year from now and be like, whoa, those last six months, we did X, Y, Z, A, B, C, one, two, three. And in the moment, it really feels like, well, none of those seeds are producing fruit yet. But as I look out the window and I see little peach buds on the peach trees, again using the pregnancy example, if I want a peach tomorrow, it's gonna be green kind of. So I gotta wait the three months or two months or eight weeks, six weeks. I'll be bringing one in here and it's gonna be a softball-sized peach, and I'm gonna be like, that was the time it took. And that's how I feel about the stuff that we're doing, you know?

SPEAKER_02 7:46

Yeah, yeah. Not that kids like that was you know, right? Yeah, yeah. No, it just made me remember a conversation I had a kid, because that's a very common thing when the high schoolers go to college, that that freshman year, especially if they were at that level and they were in 10. So I always try to in the past I remember just putting it in perspective for the kid and saying, hey, listen, okay, I want you to take how you're feeling right now and the stage you're in. Now, if you were to talk to a freshman in high school and they were going through the same kind of thing, feeling you know, inferior, having trouble, what kind of advice would you give them, right? Would you tell them that they're no good, or would you say, hey, I've been there, I've seen where you start, I've seen where you finish, trust the process, work through it because guess what? Your senior year is going to be way different than your freshman year. And I try to put it because when they start putting it themselves in a different role versus being the freshman, now they're the mentor versus you see what I'm saying? So they've been through that, and a lot of times it'll flip their um their mindset right there, going, okay, I need to look at it at you know, I'm in my infancy right now, and I will, you know, get there. Um, so yeah. Some sometimes those ballers uh when they're a freshman, so you can't say, remember when you were a freshman, because they're like cleaning house as a freshman. But so I always say, you know, don't think of you, but think of this little freshman that needs mentorship right now. What would you tell them, right?

SPEAKER_00 9:18

And you know that yeah. Before we get into patient kid, just one last thing that I think is important. I was thinking of Tom Brady the other day, just because of his uh, you know, obviously on field success, right? But I was thinking of a couple things he's gone through, like a very public divorce, like losing $300 million in like a crypto Ponzi scheme, you know, uh chairing his ACL after he'd won championships, being traded from the team where he won six championships, right? So even though he's the GOAT and he's the champion, he's won seven Super Bowls, won more Super Bowls than any other team in the NFL, that guy still, in his mind probably started at the bottom several times or had restarts, or maybe he was crushing it in work, but his personal life was in shambles. Or maybe his personal life was great, but they didn't make the playoffs, you know, and so my thought just was, you know, from the outside looking in, it's like, yo, that guy's life's perfect, you know? But knowing athletes and knowing people who are super successful in all fields, they're humans just like us. Like they brush their teeth, they go to the bathroom, they need to shower, they have parents, they have family, they have stressors, they just happen to be famous or have more money than most people. And it made me think, man, if the goat can get traded from the team where he resurrected the whole thing and they're like, we don't want you. And then he had to go to Tampa Bay, who's never ever won before. Well, I don't know, not never, but it's been a long time. They won back in Derek Brooks' days, you know. But like and then he started over and won the chip again. He ran it back, lost 300 and ran it back, and he's you know, art owner of the so I was just thinking, man, even the greatest go through stuff. And so, like, who am I to be whining about going through some stuff? I think that's just a life, you know what I mean? Yeah, it is life. And I'm lucky that I can whine to people like yourself, and I have a couple and I have a dog, and so like the thing that I know from going through other things, and athletes can maybe take something away from this, or people who are sick or injured, that sometimes you're on a path and it's not fun. Like nobody says it has to be fun, in fact. Right. You can say, Man, this isn't fun, but I'm gonna get through this, you know? And you know that's a way better way of looking at it than this sucks, when's this gonna end? I don't know why this happened, like bop, bop, bop, bop. It's just you're not helping yourself with that.

SPEAKER_02 11:45

That's why that famous quote says something about nobody said it was gonna be easy, but they said it'd be worth it, right? It's a great I forget who said it, but it's one of the ones that I constantly remind me or that I get in my head when we're going through things, you know. But yeah, it's a good one. My state championship thing just fall off the Yeah. It happened last episode, too.

SPEAKER_00 12:09

I don't like the way that feels. I was just telling somebody just yesterday, like, hey, we're gonna run this back again. Like nothing win one chance. That thing keeps falling. That's actually kind of like that shit. One thing before uh I want to ask you about a patient thing, just on a side note, um you could move back the camera a little bit, we'd be able to clip it a little bit better, zoom in and stuff. That's why I'm me? Yeah, yeah. She said we were too far up in the we were frame moging, just too too up in it. So she's like, you can move back a bit. Then she can zoom in when needed and zoom out when needed. Tell her to get his big ass head out the screen. That's what she said to me. Direct quote.

SPEAKER_02 12:55

Tell her to mind her own business.

SPEAKER_00 12:57

I'm just kidding.

SPEAKER_02 12:57

See, here's the problem. So, like in my frame right now, my jersey says app. Oh, yeah. So I gotta do this, and then I'm off center. That's all right. So and then I want to get my daughter up there in it, so I gotta and then I gotta get my other daughters in there, see them, and then I got my helmets over here. I I'm just it's just they're not the right studio.

SPEAKER_00 13:18

I'll tell you what, just turn it that way so you're out of the frame and that there you go. Yeah, it's it's perfect.

SPEAKER_02 13:25

That's good right there. Okay, we'll just talk aside.

SPEAKER_00 13:27

Or just have it say ask. Maybe that'll get us some more views. Yeah, there we go. Like, damn, where she's at. That's actually funny. Yeah. Is that good? Yeah, that's great, dude. I think uh I'll ask her. She's the expert. We're just sitting here yapping, it's fine.

SPEAKER_02 13:43

No, appreciate Amy. That's good. We need that. We need her help. So thank you.

SPEAKER_00 13:46

Yeah, shout out to Amy. We appreciate you for sure. So talk to me about uh patient-wise. I know you had somebody that was that you wanted to discuss last week. I do as well, but why don't we start with what was on your mind?

SPEAKER_02 13:57

Yeah, dancer comes in with uh left leg pain in the hip area. Not her first time as a professional dancer, not her first time with this issue. She's had a long history of PRP, all kinds of different injections at different areas. She's had hamstring issues in the same leg. She's had, you know, all kinds of issues that, you know, not really relevant for this case, but just to know that she's a professional athlete, in her mid-20s, dancer with multiple injuries, like a lot of these pros at this level have. It's not, it's it would be very uncommon and unrealistic to think somebody can make it to the professional level without any injuries along the way. So that's just kind of part of it. But yeah, that that leg's had meniscus issues, hamstring tears, labral tears, all the way up. Um, it's been pretty good as of late. Recent competition internationally during one of the practices, rotated a little more, did a little choreography where she had to rotate her leg, kind of whip it around um and bend it at the same time. So it's extension, rotation, and flexion. So extension and rotation of the hip and a flexion of the knee, and then a deduction. So kind of this whipping around motion posterior side. Almost like a field goal kicker um where you what's up.

SPEAKER_00 15:25

Almost like a field goal kicker where the leg comes back and then you're flexing. Yeah.

SPEAKER_02 15:29

So and she's it's a closed contact, so it's on the ground the whole time. So I mean, the first part's in the air, and then she has to contact the ground and whip around, kind of. And so felt a twinge, felt an issue, uh sharp pain in her hip, and then she continued to dance, able to get through it. But as it went on, so got better, pain-wise went down. But the nature of it was when she would get going in the initial phase, it would start to hurt when she started dancing, and then as she warmed up, it would go away and she was fine, and then it would go away. Soon as she finished, soon as it and then towards the end of dance, it would start coming back again. And as she kept dancing, it would start getting tighter and more sore again, and then she would get off of it, rest it, feel better. Soon as she'd get active again, start to hurt, but then it would go away as she loosened it up, and then it was like no problem. She could get through her dance. Then as she would cool down, it would get tight again and then feel better at rest type thing. Does that kind of do very so it was going through this pattern?

SPEAKER_00 16:39

Is it very specific? Like she's like, it's right here on my hip, or it's right here on the hip flexor.

SPEAKER_02 16:43

Yes, it was very, very specific. But this part was more where the hamstring, because she was complaining of the hamstring and kind of the glute area, that was one area, and then the other area was on the side of her hip, kind of. So she was having kind of two areas that were responding the same. So, but not being able to fully reproduce it. So, like when you would test her hamstring, nothing really show up. When you would test the glute, nothing really show up, as far as anything terrible, right? So, yeah, but then when you but if you kept testing it and kept you know moving it around, it would start to get irritated again. So kind of a weird pattern for her. She couldn't really figure it out anyway. Oh, does she like 40 something or like 40 something? Yeah, 20 something in her 20s, mid-20s. Yeah. So um healthy, very healthy, eats clean, you know, just injured, all that kind of stuff, takes care of her body in between things, but has these old residual issues. Anyways, so tested it out. Like I said, initial hamstring, initial glute, nothing, but as we kept testing different things, it would get more and more achy in those areas. So, but then it would calm down. So, anyways, but nothing real pinpoint either. Kind of interesting. So, yeah.

SPEAKER_00 18:08

Would you say would she say I should say uh that it's like a eight, nine, ten out of ten pain, or it's like a low, diffuse three, four, five, but it's she's feeling it, she can still perform, but it's taking part of her attention away, or is it like, man, I'm having to modify my my movements here?

SPEAKER_02 18:26

Yeah, it was it was it was uh seven, eight, nine, uh it would it would change, it would have to it would shut her down once it got to that point. So yeah. So no uh yeah, so no popping, clicking as far as orthopedic tests, everything came out real solid with the hip and everything.

SPEAKER_00 18:46

Any imaging?

SPEAKER_02 18:47

So what's that?

SPEAKER_00 18:48

Sorry, any imaging?

SPEAKER_02 18:51

Nope. Uh because of her past history and because there wasn't any distinct uh slip fall, any kind of trauma, nothing obvious besides that. I mean, I guess you can make an argument about that one particular movement, but in our world, they're making movements like uh all the time, they're feeling things all the time. There was no bruising, there was no deformity. So at this point, we did not do imaging. I told her if it's not responding the way we think it should, we should get another image. She's had multiple images over the years. We know about the labrum, we know about the hamstring tears, so um, and it didn't appear, it was stable, but uh yeah, so yeah, so so the biggest thing was hamstring activation and glute activation would trigger that tube area and um A Bduction on the side of the TFL was tight. So it would not, so yeah, so when you lay on your side, do the orthopedic test, lift it up, let it f settle down knee to knee. It did not drop knee to knee on that side, it was elevated about a fist off the table. So yeah, so that was and then the other side fell straight down, so definitely different. So TFL and glute were tighter, and hamstring activation with reps triggered that tube area. Um so yeah, what would your differentials be? I know what I did, but what would your what would your differentials be? What would your kind of triage of initial care be? What are your thoughts?

SPEAKER_00 20:20

Yeah, so if I distilled it down, I'd say said person needs to see Dr. Glass probably twice a week for like three, four weeks, maybe three times a week for a couple weeks, and then a couple times a week for a couple weeks, and then you do all the things that I'm about to talk about, probably, which you're already doing, and that you know, I think it sounds like a a frequency and like a short duration of treatment type of thing to resolve it. So, no particular order. My thought process leads me to thinking it's like more of a tendon or muscular issue than it is like joint inflammation or ritis or something like that without any imaging and just having you know uh the info that you gave me. The things that jump out to me are the sideline where the leg doesn't go all the way down, so that tension is not good. I'd probably get right into that spot. Is it in the medial glute? Is it in the ball and socket area of the IT band where it kind of goes into that ball and socket? Is it more into the low back? Is it more the hip flexor? I'd probably start in the glute and put them him or her on the side or on the stomach and start getting into glute medius, glute maximus, upper hamstring, like under the fold of the glute, and seeing if there's anything kind of laterally in that area and just feel around. You know, I go by what I feel, just knowing what normal tissue feels like. And so a lot of times, especially lately, I'll do the orthopedic test, but I'll Almost like scan it with my hand first and feel around and be like, oh, this is off. And then do the orthopedic test to confirm. Whereas I don't even know if this is appropriate. I'm just telling you what I do. So hopefully this doesn't like put me on blast. But like I used to do all the orthopedic tests first to determine what's compromised and then go and explore that area first. Now I kind of do it opposite. I mean everybody's like, let me feel, I'm pretty sure it's this. Let me confirm what the orthopedic is. So yeah, it makes me feel like especially with the foot down and that motion of extension hip, flexion knee. It feels to me like it's a very specific, like strange strain based on a very particular movement. So like the flexion of the knee doesn't create it, the flexion of the hip doesn't maybe create it, but this particular movement of extension and rotation that recreates it, right? So yeah, therapy-wise. So what I would do is try to isolate what muscle is tender or tight by palpation. Confirm it with orthopedic tests, make sure nothing's torn, nothing's just given way, which I'm sure you've done. And then honestly, session one, I'd probably just go hands-on, no modalities. I just trust my hands to unwind and loosen and decrease inflammation and flush stuff out. Increase mobility. That'd probably be session one for me. And then how do you feel? Are you sore? Did you feel better? Was it improved for three days and then it came back the first day you danced, all these things? And then I'd add the modalities. I'd probably use something like the ARP wave, or you'd probably use shot wave or something. Um some sort of direct current type of situation. Um that's probably where I'd start, and then pre-competition I'd probably tape if it was possible to tape and reduce the load on said muscle or ligament, or taping helped provide some support either physically or mentally. If it gave her some peace of mind, then I would tape it pre-competition. And yeah, if it was a fill-in-the-blank type situation, I'd probably say it's like a glute medius or some sort of glute strain. I don't think it's necessarily hip flexor related, although that could be secondary. I'd also try really deep into psoas too, lastly, you know, because sometimes I'm at the trochanter of the hip or PSIS, the little hip bone in the back, you know, where people have little dimples for those who are listening. And I've found several times in the last few months where people's psoas muscle is just crunchy and like a piece of beef jerky compared to like a soft fillet. Like I'm going into the abdomen like above the hip flexor, and they're like jumping like it's appendicitis. And so relieving that has helped with stuff down the chain. And lastly, I'll say I know I've been yapping a bit, is uh I check the stress level of the person because if the psoas is involved and they're super stressed, lack of sleep, life is stressful. It might not be the main component, she probably tweaked it through some physical movement, however, that level of stress isn't helping the situation, you know, and it's probably activating the PSOAS, which if that's a secondary or tertiary thing and not the main thing, that's still something that should be addressed. So in a shotgun approach, I hope I hit some of those buttons, but what was you having hands-on? What walk me through what you did and walk me through what I said and what um what was more closer to target and what might be like left field that you didn't think of that's weird or wrong.

SPEAKER_02 25:42

No, you know, no, that's why we like talking about these because it's always different when you get kind of partial history with it, right? That versus being in the mix and doing the flow. So it's a little harder to do a full differential when you're not getting all the pieces to it. But no, I like what you said. I'm I'm with you on I always, I mean 90 plus percent of the time, do uh palpation first and trust my hands, like you were saying before I jump into the orthopedic for a couple reasons too. I want to find it, I want to see is there any temperature change? Is there any kind of uh the the tone of the muscle? What's the tone of the muscle? Is it hot or is it sweaty in that area? You know, is there is there acne in the area? Because a lot of times when there's a nerve neurological component or viral component, there's also some acne in the area, a rash, you know. So I want to be able to check that area. Um, I also want to look for palpable divots in the tissue. Is there some tears that we can actually get our thumb in our fingers inside, yeah, the where the tear is? Um, and I want to know that before I start twisting and turning and tweaking. And uh so I think, yeah, there's been some evolution because in school it's so orthopedic. And I'm sure at some point that if the if our instructors could hear us talking right now, they're like, no, we always said start with palpation for those reasons, but it gets lost because as soon as we get into the orthopedic exams, it's all we want to get into that movement and the tactile so we forget about the palpation, but everything started with palpation in school, right? So yeah, yeah for a student.

SPEAKER_00 27:20

At least the way I felt that I'm curious what you felt. I felt like the orthopedics were very black and white. So, like, let me get the answer. This orthopedic is oh positive, okay. That's what this means. This one this is what this means. And I think I leaned towards that more when I didn't have as much trust in my palpation skills. And as that changed, that's where it changed. You know, so I guess to students or anyone listening, really in any profession, developing those palpation skills is I think priority one, probably. I know I don't know. Um but yeah, I think leaning into that the black and white of the orthopedics is super important, but the palpations are, I think, yield so much different nuanced intrinsic information that like a yes or a no, a positive, a negative just doesn't, you know. So, anyways, I just wanted to say that to anybody listening because I remember being there just trying to memorize a hundred orthopedic tests thinking now I'm a good doctor because I know this is positive, negative, positive, negative. Right in real life practice, that's not that's not how it is. You don't have six and two negatives, and you're like, this is definitely the conclusion, you know? Yeah. I didn't mean to interrupt, but go ahead. What are you saying?

SPEAKER_02 28:32

No, no. So like you said, we use I use the orthos now as a validation. Even from the history, I have 80 to 90 percent of what I kind of think already, and then I go into palpation, gives me that next little percentage, and then the orthos just to confirm or rule out different things. So that's kind of how my I I I take a very heavy history. I love getting into that history with patients because that that divulges a lot of information where I think a lot of people skip that part or kind of brush through that and they miss a lot of part. I'll spend a majority of my first appointment on history before I even touch them. But I explain to them when they first come in why I'm doing that. Because usually when they come in, they just want to get on the table and get started. Yeah, they don't yeah, they don't want to go through that whole history because they've been living at 24-7 for however long. But I remind them this is my first time, you know, experiencing it with you. So I need to get that, I need to get deep into that and figure out. And then after we've talked for you know 30 minutes or so, I have a pretty good understanding of what where's where have you been, what's going on, how's it working, what you know, versus just skipping through where does it hurt, what motions hurt it. And then when we start moving things, they're like, Well, you never asked me about that, and then I just lit them up and I'm like, Oh man, you know, I didn't know you had numbness or tingling. Well, you never asked, you just asked if I hurt. Yeah, I'm like, Well, you should have told me, you know, but if you don't take in a full history or does coughing and sneezing bother it, well, you never ask that. You just ask if it hurts, it hurts, you know. You know, does flex, you know. So, so, anyways, the history for me is really important than the then the palpation. So, from the history, that's where I gain most from this case from her history, because there were so many with her old injuries, and that was kind of the point of this whole whole uh case, because of when you're dealing with somebody that's had so many injuries and so many histories with uh been there, done that tissue damage, PRP, prolo, all these kind of injections, cortisone, everything over the years. A lot of times you get false positives with your palpation and with your ortho exam. So when you're getting a bunch of false positives, nothing's really adding up. You have to go back to your history. So, from her history, the knowledge that at one with the location she kept pointing to, there's two locations, one on the ischial glute area and one on the hip side. From those two areas, then I want to know when does it bother you? So, how often, how frequent, um, and how painful and how fast does it go away? So, in her history, she was telling me that you know during rest and uh normal activity, no pain. There's zero pain with normal activity, going up and down the stairs, getting in and out of the car, getting in and out of bed, no issues. Um, it's only when she starts warming it up and getting or starts activity, it starts coming back. But then, so okay, it starts hurting with activity. That's one indicator. But then the next hit part of the history was yeah, but after about 15, 20, 30 minutes, it actually goes away. Okay, so that's a very interesting part of the history because, and we'll get into why, but then then it goes away. But then when it hits the fatigue factor and then comes back again, then it hurts again. But then when she sits down, rests 20 minutes by the time she gets home, no problem again. So there's so again, so from her, if I didn't ask her all about the history of all that, and I just went on pain and just went on some of those tests, uh, could have missed a lot. So from her history, it it steered me more toward the differentials, would be a some kind of sprain strain, okay. Because of the mechanism, that would make sense, a sprain strain in one of those areas because it was that whipping motion and she felt something happen, okay. So a sprain strain would be a differential. Um, a tendonitis might be thrown out there because of her workload, okay, in that area. So she could have some tendinitis, and then the third one, so in that area, um, could have some kind of bony stuff going on, but very unlikely. And then the other one would be a bursa. So sprain strain, um, tendonitis or bursitis, something like that. So, how do those all differ? So, sprain strain typically sprain strain is basically, or in this case, more of a strain of a muscle. That typically indicates some kind of tissue damage, grade one, two, or three. Grade one, basically the tissues, and I'm showing for those that can't see my fingers interlace, and basically we're pulling just out a little. That'd be a grade one. Everything's intact, just separated a little. So we tweak it a little. That's where we call. I tweaked it a little. It hurts, but just pulled farther than its physiological end range. Grade two will be you get that separation a little, but then you actually tear a few of those fibers a little more, you actually get some light bruising or a lot of bruising. So grade three is would would be a complete tear separation. That's a very obvious one. So, with that kind of tissue, that even a grade one, if it's a sprain or uh a strain, typically, no matter what you do, activity-wise, will start bot, it will bother it because it's a it's a it's been structurally damaged to some degree. So any kind of activity would bother it, it would not get better with movement, it would continually typically stay more painful. Yeah, because it because basically your brain's like, I don't want you to continue, so I'm gonna stay painful because if you keep going, you might fully tear me or something like that. So that's kind of how the body works. So we can kind of rule out the strain part in with that history. The next part would be a tendonitis. Well, tendinitis, yeah, in that area where the hamstring attaches onto that glute or on the ischium, the tuberosity, that you could have some tendinitis, you can have some hip tendonitis, you can have you know psoas tendinitis. So, but then again, the presentation's a little different. It doesn't get better with rest. Tendinitis typically it will feel a little better, but then it will, and then it I mean, it will feel better with rest, but then it will completely go away. So if you took your time and you rested a week or two, it would go away because that the inflammation around that tendon has gone away. There's no mechanical issue, it was just kind of an overuse issue. So, but because it goes away completely with normal activity, then we kind of rule that out and then it comes right back. So the third one would be that bursitis, where that does follow that pattern where at rest, when the muscles are calm, the the bursa is at rest. As soon as you activate that muscle and the tendon slams down on the bone, the bursa will swell a little or try to get the pressure off that tendon, then you'll feel things. Then as soon as you rest, it goes away. So you can rest for two, three years and feel fine. But as soon as you start active again, because it's more of a mechanical issue with bursitis, it will come right back. And that was kind of the pattern we were seeing with what she was going on. So that's what geared me towards more of that. It was more based on her history, not so much her exam. So the ischiogluteal bursitis fit with everything, and then um, and then definitely that TFL area, so trochanteric bursitis fit that mechanism. So, so my treatment plan was to then okay, we got to get the tension off the glute, get the tension off the hamstring, get the tension off the TFL to allow that bursa to stop being activated. Because the bursa is always there. Bursa is always lay anywhere where you have a tendon to bone insertion, you have a bursa naturally for people listening. So, but you never know they're there unless something happens, either fall impact, or overuse or a strain that started the mechanism or an infection or something like that. So, anyway, so long story short, that's gonna that was the thought process on that. And the whole point of why I wanted to talk about this was to remind our listeners, really think about that history taking and really pay attention because uh you could miss, you could start working on the wrong things. Because if I were to work on really scraping out at that insertion site at the issual tube at the pain level, it will piss it off, right? You just indicated, yeah, no good, right? If it's a bursa, you'll piss it off and it will just prolong it. And that's what I see. Both of us have seen that a lot, where somebody's like, Man, I've been going to therapy and it's not getting any better. And then you're like, Okay, well, let's take a look at it. And then me and you have talked about bursides in the past. Yeah, we then we say, Okay, well, stop touching that area because you're pissing it off. Let's work above and below. And sure enough, now that you've gotten the tension off the bursa, it goes away. I call a so for me, we've said this in the past, but I try to explain to my patients like if you've ever seen a puffer fish, a puffer fish is very small and thin, right? When it's not activated. But if you get too close or you upset it, it swells up. And basically that's what I picture a bursa. But as soon as you the thread is gone, the puffer fish goes back to being a thin little fish again. So I talk about my I basically tell my patients that their bursa is like a pissed-off puffer fish. So you just gotta remove the threat and it will go back down to how it wants to be.

SPEAKER_00 37:59

I have a few questions and some I know the answer to, but just I want to talk it out for those who are listening. And also, there is a little bit of like fogginess in this case that I want to just clear out a little bit. Um so first thought as a new doc or a student or a PT, you don't even have to be a Cairo, somebody who's uh assessing this person, MD, whatever. I could see how your one stop process could be any of those three, like you said, a sprain strain, a bursitis issue, um tendon issue, right? So those are pretty easy to be like a multiple choice test, what could it be? I think the distinction is between the tendon issue and the bursitis to me, you know, because sprain strain is usually you can determine that through palpation if there's tissue damage, like you said. The pain pre-activity, the pain going away during activity, and then returning post-activity makes me lean. Oh, that's like a tendonitis issue. That's like a hooper who has a sprained ankle, it's stiff, doc, my ankle's stiff, it hurts to walk, I'm limping. We warm it up, we tape it up, they get move in, and now during the game, they're hooping, they're doing their thing. But post-game it tightens back up, right? So one of my questions to you is why did you lean more bursitis versus tendinitis? Um I just want you to go just a depth a level deeper on that because I think I know your ABC to that, but I don't know if it was at least I didn't catch the clarity in that. Um and then secondarily for someone treating, you don't always have to know exactly what it is. I mean, obviously you want to know what it is not to make it worse. But if you start with the theory or the mindset of, well, above all, do no harm, then you can do some palpation, get some feedback. Oh, that irritated it. Okay, we're not doing that anymore. Now let me work on this or that. Um and so I could see if you weren't 100% sure if it's a sprain strain, a tendonitis issue, or a bursa issue, you might do some of those treatment things that are the same no matter which one of those three things it is. Now there's certain things you do for bursitis that you wouldn't do for sprain strain or vice versa. But as a clinician, I would eliminate those. I'd say, okay, we're not doing these things that are good for one thing but bad for the other thing. But I know this, this, and this is good no matter what it is, right? And so as a rookie doc, that's where I would have started. I would have been like, okay, well, let me get the hamstring looser, let me work the glute, let me work the IT band, let me get the psoas, let me get the hip flexor, let me get everything around that because whatever the issue is at the epicenter at the bullseye, the concentric circles of supporting musculature and stuff is also going to be affected. So that to me is like low-hanging fruit. Let me clean up all this other outside stuff and then see how it affects the bullseye. If I didn't know what the heck I was doing, that's where I would start and be like, how much did that improve? Five percent? And I'm like, okay, that's not enough. It improved 50%, but then it came back. Okay, I'm on to something. Let me try to figure it out, you know? So what was your like it's definitely brusitis and it's definitely not tendinitis? What was your and then my one more question? I haven't seen too much too frequently I haven't seen brusitis in the issue of tuberosity, right? Some people want that. They pay for like a BBL, they go for that brusitis swelling. Like, what made you jokes aside, what made you determine that she had bursitis there? Because to me, that's a little bit of an unusual spot to have bursitis for at least the demographic that I see. Do you see that often?

SPEAKER_02 41:56

Yeah, so let me go. I'm trying to remember all the little questions, but I want to go back to the student thing. I think you're absolutely 100% right as a student. Yeah, you got to start somewhere, right? And you just gotta start working on stuff. And a lot of times in the beginning, and you know, both of us have been instructors in the past, and we would tell our students, hey, just get your hands dirty, get get in there and figure out above above all else, do no harm. So as long as you're not putting somebody at risk, don't be afraid to start somewhere. If it's a good educated guest, go into it confident, be happy with your choice, and you're you're probably gonna make it better to some degree. And then once the dust settles, figure out how much more you have to work or figure something else out. So you're absolutely right. In our world, in the professional setting of having to work with these pro athletes, pro-entertainers, where time is money, and they we we have to be as precise as possible. That's where we come up with our differentials and have to be as accurate as possible because being as accurate as possible saves time, right? So, so for us, it's a little different. So our both of our brains just go to that differential and try to be as specific as possible. But as a student, that comes with time, and that, you know, yeah, you're absolutely right. I like that you brought that up because that's important, right? Don't be so so scared that you have to be perfect and right, you know, yeah.

SPEAKER_00 43:23

These thoughts that's not reality. 20 years in practice, you know, and 26 years in like studying this stuff, and even longer, you know. Like my intention when I started college was sports medicine. So was I very good back then? No, I don't think I think I was kind of barely getting through my undergrad. And that's what I told somebody else who's struggling in college. I said, dude, I think I was a straight A student. I don't want to like blow anyone's mind. Like I think I had counselors tell me I should become a farmer, like, drop the bro. I think you should join the family business, you know? And so like it just does come with time, you know. It it's it's no different than if you're an athlete, if you're in any profession, like you're not gonna be a great lawyer year one, even if you were great in school. And so to somebody who is struggling in college, I spoke with this week, it's like you're gonna be a better student as a senior than you are as a freshman, bro. That's just yeah, you're gonna learn how you study. I didn't figure out how I studied and how I learned until I was in grad school. It took me five years to do undergrad. So my first year in grad school, my sixth year in college or fifth year in college, maybe, I was like, oh, this is how I really actually learn art stuff. Yeah.

SPEAKER_02 44:38

Let's table that, let's table this conversation because this is a great podcast episode. I think me and you, because both of us have very similar stories on academics was not my thing either. And it were it took a while. But yeah, well, yeah, because you saw me on the later part, but that's why I think we should share some stories to our you know uh listeners, because it is a good story for both of ours, you know. Because yeah, people from the outside would look in and say, Oh man, they've always been like this. And if people really knew, like you said, like I don't tell people very often, but I want to be real with everybody and kind of let them know better because if it helps somebody, yeah. So, anyways, let's table that, let's write that down as uh I'd love to talk about that one. That'd be a good idea. But back to real quick on the so a couple things. I think two one, what one do I see it very often, and two, like what made me think about the bursitis versus a tendonitis or something like that? So the the mechanism of hamstring and glute, so ischial gluteal bursitis, so the so where the glute fold comes across that ischial tuberosity and the hamstring insertion. So if the glute gets tight, slams down, or the hamstring gets tight, slams down. So in my with working with a lot of dancers, I see it a lot. So it is something we see a lot, and I only started recognizing a long time ago when I was sending in for MRIs, thinking it was a uh tendinitis or a tear, and it always come back as bursitis. So that's the only way I learned how common it actually is. So uh it'd be interesting a lot of the cases that you might think are tendinitis or a strain, just like I did, a high ham hole, a whole high hamstring, because it's way up there. Almost uh so many of my high hamstrings in the beginning were all bursitis, not strains. That's the different treatmentality. That's so important. Totally, totally, because because but they presented just like to your point, they present just like a tendonitis or a strain, but the the MRI kept coming back. No, this big old inflamed bursitis. I'm like, it's not you can't, it's not like an elbow that blows up or a knee that blows up from falling on it, right? Those are the ones we always think of the bursitis where we landed on our elbow, it swells up. Like on my Instagram page, I got this great one of this guy's elbow, and it's literally like just it's gross looking, like you could put your whole hand around it, but uh yeah, or a knee, you land on it. So it's not like those, it's underneath, you don't see it as often, you know.

SPEAKER_00 47:14

So alpha as much.

SPEAKER_02 47:17

Yeah, so yeah, so it's uh the the history it the history for the bursitis, so so that gets me into the next point. So one, I had to learn through imaging what the difference looked like, okay. And so, so real quick, so once I understood that a lot of these cases were bursitis, I then had to figure out, well, how do I make the differentiation? Well, it was in the history, and you mentioned so typically, and this is this is not everything, but typically a tendonitis with activity does not typically get much better. Couldn't like we can we can get things loose for game time, like you said, tape it up, wrap it up, but it's still pretty sore, but they can still play, but it's sore the whole time. A bursitis is different like that. It once it warms up, there's zero pain, it goes away. It's it's totally different. At rest, no pain, or warmed up, no pain at all. Like it, there's no pain. Whereas a tendonitis, we can go from eight out of ten, I'll come in limping, we loosen up the calf, get the pressure off, tape you up, and now it's a four or five. But I can play with that because does that make sense? So that's where I see the differentiation when I see that the pain goes away completely with either warming it up or at rest completely. Because even a tendonitis at rest, you can be at home chilling, not doing anything. But when you go to the bathroom, you go to something, the pain is there. You're limping, you're like hesitant, bursitis, no pain. So that's how I make that the differentiation.

SPEAKER_00 48:48

That's a gem for anyone listening who's a student or a doctor, or even a patient, you know, who's going through some pain, that's helpful. And I always tell patients to um, you know, everyone's Googling things and looking stuff up, chat GPT or whatever, trying to differentially diagnose. But if you're an athlete or you're interested in your health, like I really, in fact, I tell my high school kids who are now in college, bro, by the time you finish college, I don't care that you're a business major. If you know me, you're gonna have an associate, it's an anatomy, or you're gonna have an associate, it's in physiology, you're trying to be a pro athlete. I got my hands on you as a high school kid or a college kid, you're entering the pros with like a bachelor's level of knowledge on your body. Because if you don't know about your health and you don't know about finances, you're just gonna be a broke, hurt athlete at the end of it. Is it three years? Is it four years? Is it five years? You're gonna be not as healthy and not as rich, you know? So those two things I think are super important. And that was the gem, dude. Bersitis and tendonitis, it's a big deal.

SPEAKER_02 49:48

Yeah. I wanna I want to leave one last thing on that because we were talking about one that gets missed all the time, and we're seeing a lot of it, is Achilles bursitis. Oh, yeah. I'm telling you, because everybody's coming in with Achilles issue, and it's right down there where the tendon meets onto the bone, and you palpate it, it feels like a strained Achilles. It feels like Achilles tendonitis right at the heel. So you first have to rule out either the uh the peronial tendon or the posterior tip tendon right next to the Achilles to make sure those aren't tendonitis, Achilles tendonitis squeeze tests, you know, see if there's any spare. But again, then the last part, ask yourself about the history. If the history doesn't match up with tendinitis, then it's probably that bursitis. So start working those muscles above and below on the foot to get the tension off that bursa, and you'll clear it out way quicker than treating for tendinitis.

SPEAKER_00 50:44

One last thought. Yes or no? Yeah. You have a pain point wherever on the line, pain's here. Don't you feel like a lot of times you go above and below or left and right, you go around the bullseye, like I was saying, and address that tissue and just massage the sister and the brother and the uncle and the aunt and all the surrounding family members of the issue, it makes that main issue a little bit better. It takes that tension off, like especially in the bursitis case, like you were saying. And so just going back to sometimes you don't always need to hit the nail on the bullseye to make an improvement. When somebody comes in with a lot of pain, if you want them leaving feeling better, even if you don't know a hundred percent what the diagnosis is because you need imaging or you need time or you need to see how things respond, that doesn't mean the person can't leave feeling better. You don't always need to necessarily have all the answers to make someone leave feeling better, I guess is what I'm trying to say. And do you find that yes?

SPEAKER_02 51:51

You ask yes or no, yes. Yeah, knowing your origins and assertions as a student will be a game changer. Just know those forward, backward origin, origin, assertion, actions. I know those are tedious and annoying, but master them and it'll it'll make you a better clinician and diagnostician.

SPEAKER_00 52:09

Yeah, and along those lines, yeah, I know it's supposed to be the medial superior part of the trochanter of the elbow condyle. You know what? That's not what we're talking about. You just need to know that it inserts right here on this part of the elbow area.

SPEAKER_02 52:25

Then you see, yeah, I'm glad you clarified that. Yeah, we come from more we come from a different thought process on that.

SPEAKER_00 52:31

Yeah, I don't care about which the words are important for the exams, right? But you want to be able to know where to go. This is where it connects, this is where it connects. Yeah, you know, and it doesn't have to be perfect, you just got to know kind of where it's at. So Dustin, that was very informative, at least for me too. You know, like um, it's good to kind of dust those things off. And when we talk about these things, it always seems to be fortuitous because inevitably I'll have somebody come through, I'll have some conversation where I'm like, yo, we just talked about that. You know, so yeah, right. I appreciate that, yeah, for sure. Um to wrap up here if uh you have any last thoughts.

SPEAKER_02 53:11

No, I just want to go over your case study. Um maybe next Epi we can do that.

SPEAKER_00 53:16

Absolutely, no doubt, no doubt. Um I'm glad we went over this case though. So Rositis versus tendinitis versus sprain strain, tissue tuberosity, high hamstring, low glute, or hip kind of uh ball and socket joint area. And yeah, I learned a little something today. I hope our listeners picked up a little tidbit. Guys, girls, if you have any questions regarding this, leave it in the comments. We read those and we will address those.

SPEAKER_02 53:44

So uh also if you disagree, if you disagree, that's how we all learn, right?

SPEAKER_00 53:49

Let's have a yeah, look, you're a good conversation. That's a great point. If you're a medical professional of some other sort and you have an opinion, you want to hop on, let's have a professional discussion, you know. Or if you're that's how we learn, or if you're a patient who's gone through this and you had a different experience and you want to come on, let's have a conversation, you know. We are all about talking to people, getting to know them, getting to know their stories and their experiences, and trying to disseminate some helpful information to everyone listening. We don't know everything, we have a little bit of experience and a lot of passion, but we're always of the mindset that we can learn from other people. So yeah, leave your questions and comments. We're all ears. We'd love to hear from you and uh continue this discussion.

SPEAKER_02 54:32

Any last thoughts, Dustin, before I sign off? Nobody, just have a good rest of the day, good week ahead.

SPEAKER_00 54:39

Yeah, you're also in a short sleeves. You're looking like it's summertime over. You're in a beanie and a I just want to see SoCal versus Narcal right here. It was like I don't I don't said 60 miles. It was so windy that our palm trees that are 20 feet apart were swaying and the tops of the trees are hitting each other. And like we have a big tree that's in the backyard, and I was walking the dog last night, and it was like squeaking. And I was like, is that a squeak right before something breaks, or is that just like an old tree, you know?

unknown 55:08

Yeah.

SPEAKER_00 55:09

So it was super windy. I went outside and I'm like, yo, it's a beanie and like a long sleeve day today. Yeah. So I like it. Anyways, well, thanks for the time today, Dustin. I know you got a busy day to all our listeners. We always appreciate you. Uh please share this, please share this with uh somebody else who might be interested in some sports med talk or an athlete who wants to increase their knowledge. And uh as always, guys, be safe, be healthy. If you have any questions health-wise, please send those in. We will uh look those over and address those. And everybody be safe out there. We appreciate you listening and uh participating. Thank you for your time as well. And we'll be back with you next week. Our episodes drop every Monday now. We're on a cadence, so um you can tap in and check those out, and we will be back with you soon. All right, guys, thank you for listening. Thank you for participating. This is uh Dr. Dogel with the Second Opinion Force Medicine Podcast, and we will see you soon. Take care, guys, be safe, and we'll chat with you guys soon. Okay, good night.