Ortho on the go
Ortho on the go
All things Hip
Use Left/Right to seek, Home/End to jump to start or end. Hold shift to jump forward or backward.
Welcome to the Ortho on the Go podcast. My name is Chuck Dowell, host of the podcast. This is an educational orthopedic podcast focused on discussing both clinical and functional orthopedics. We will discuss a variety of topics within the field of orthopedics, including reviewing interesting cases, hearing from different professionals throughout the orthopedic profession, and discussing common musculoskeletal injuries and complaints. This podcast is meant for anyone that wants a better understanding of orthopedics, including all levels of practitioners, coaches, parents, and athletes themselves.
SPEAKER_01So welcome back to the Ortho on the Go podcast. I'm here with Tessa. You want to introduce yourself?
SPEAKER_02Sure. I'm Tessa Cothy and I'm a physical therapist at Summit Physio and Performance here in Colorado Springs.
SPEAKER_03And I'm also my name is Kat Kui. I'm from Summit Physio as well. And I've been here in the Colorado Springs area as a PT for like the last four years now.
SPEAKER_01And we we uh see patients quite a bit. I know often we exchange patients back and forth. And hip problems is a common thing that we see. And so we thought it'd be good to do a podcast or discussion regarding hip problems. So we were kind of talking before we started this. Let's start with what when you see somebody that comes in with hip complaints, what have kind of what's kind of your first process as far as evaluating them? Do you decipher it based upon age and activity level, or how how do you go through that process?
SPEAKER_03Uh totally. Um so really, yeah, I definitely look at like area pain, like the incidence of pain or potential injury as well, whether or not it's acute or chronic. And that kind of points me in the right direction of which areas to look at. But most of the time, we uh that's typically how I practice is I look at, you know, if it's super pain dominant or a little bit more stiffness dominant, or if I see any sort of like weakness kind of happening up in the hip, then I kind of dial in on where potentially those areas are to focus.
SPEAKER_02And I think too, like we always are mapping out people's symptoms on a body chart. So we're always asking about do you also have any low back pain? Because that's something we'll see happen with the hip a lot, and we see that get missed sometimes. Um, and then we'll ask too from down the chain, we'll look at is there any history of knee pain or ankle foot pain? Because often um things at the hip can be related to knee or foot ankle as well. So kind of looking like all the all the lower chain and um at the back too, because they can be impacted.
SPEAKER_01Yeah, I think one that's one of the things that's often missed, and people don't necessarily understand is how much lack of mobility or lack of function of one joint can affect the joints above and joints below. And that's what you guys do a great job of. And I I think one of the reasons we always send patients to physical therapies because you guys can do that full-body evaluation, which we can't do necessarily in clinic. But as you said, I mean, oftentimes people will come back and point to like the posteriogluteal area and say, I have hip pain, and that could be necessarily referred as high or low back pain and not specifically coming from the hip. So the location of pain is is definitely a component of if it's hip dominant or where it's coming from. And we discuss so mobility. Um, do you check often mobility? What are the more common things you see as far as a lack of mobility and or a lack of uh strength uh that causes hip pain?
SPEAKER_02Yeah, so I would say uh typically for mobility in the hip, we're looking at almost all ranges. So hip flexion, hip internal and external rotation, and hip extension, um, and then abduction. So um I would say the biggest common things we see as far as mobility are limited um like adductor mobility is a big one, and then hip extension is probably the second biggest one with a lot of tightness and hip flexors. Um and then from a weakness perspective, um, I'm typically seeing actually quite a bit of hip flexion weakness. Um, people that are tight are often also weak there. Um, but then mostly the lateral hip is a big one. Um, probably the first two things come to mind, and then um hip extension, probably being third.
SPEAKER_03Yeah. I would echo that as well, too. Like almost everyone who comes in uh that I see that's complaining of like hip pain or even like low back and knee usually has some limitations in terms of like weakness, strength, or activation in like the lateral hip, like hip external rotation, hip abduction as well. But um, yeah, I would agree with Tessa 2 hip flexion is also something that I see pretty commonly with low back and like most hip issues as well.
SPEAKER_01Yeah, and I mean we all sit a lot, right? For work and or for outside of work, we sit a lot. And so there's tends to be a lot of hip extension, like tightness, because we're in that seated position, and there tends to be a lot of hip flexion weakness because of that tightness, and maybe those muscles are getting their natural stretch response. Um, they're not getting to full elongation to cause activation of the muscles, and that potentially then leads to some deactivation, right? So we talked about glute weakness, and we blame a lot of things on the glutes and the gluten meads, which necessarily doesn't have to be the case. It's not always gluten mead weakness, but it is true, right? Sometimes the glutes can be shut off and it can be hard to turn them back on because that neuromuscular activation is not working. Um, when you guys see that, what what's kind of your first process as far as improving the you know the patient's symptoms? So they come in with some tightness and some poor and weakness in their hip. What what's the first process you you do as far as a therapy component?
SPEAKER_03Well, maybe basically I'll basically assess like which motions, like which functional motions are giving them the most issue, and then I'll kind of consider like how that uh muscle actually plays a part in that. So, like, say for instance, like squatting as well, I'll look at whether or not they have pain like in the hip hinge as well, or even coming out the bottom of the squat or on the distinction, and that kind of helps me dial into like which particular muscles uh maybe need a little bit more work or like activation, because most of the time some people feel that they're weak or maybe they're not activating uh similar the the way they that that they should. And actually it's the vice versa aspect of it where they could just use a little bit more um just like like okay, let's turn this, let's turn the glute on during coming out of the bottom of the squat, or like, hey, we actually do need strengthening through this area. So it really just depends on a case-by-case basis what I'm looking for in that particular functional, functional motion.
SPEAKER_02And two, I would say like the biggest thing we do is like first we try to put the fire out, is calm down the pain, is like locally treat the areas of concern that we're finding that pop up on our exam that are like really tender or really weak, and we need to get them functioning better. And then we're going to dial in with specific exercises to load and strengthen that and have them start working on supporting uh their areas of concern. If it's some someone that's like super high irritable levels, then we'll give them lower level uh exercises that are gonna just be for calming down pain, but it depends on what level of um pain people have and how difficult of an exercise we can give for them. So it's always very specific to the patient's impairments and how irritable their uh condition is.
SPEAKER_03Yeah, I'd say it's hard to generate force when you're like five, seven out of ten pain levels. So that's usually step number one as well.
SPEAKER_01Yeah, and that's uh I remember during Tesla, during our low back conversation, we had that discussion. I think a lot of patients that I see in clinic, they're always hesitant to start physical therapy because they're acutely in so much pain. Their first thought is, oh my gosh, I'm gonna go out there and do a lot of exercise, and that's just gonna flare things up. And I always, as a practitioner, try to explain to them, no, the first process they're gonna do is calm things down, get you out of that acute inflammatory phase, and then they're gonna kind of try to try to correct the underlying problems to reduce this from coming back and becoming a chronic issue for you. And I think that's something that a lot of uh people don't understand as far as the physical therapy process is your first thing you're gonna do with most patients is calm their symptoms down. And I think therapy can be quite quite helpful. You guys have a lot of modalities you can use to calm down acute symptoms. We've talked about it, but you know, dry needling, you have a lot of utilizations of that. You can use manual therapy. Um, I you you guys know better than me. I'm not a therapist, but what other like modalities could you use to calm acute symptoms down?
SPEAKER_02Um actually cup therapy and doing biofash deprecation has been a really great adjunct to um additional manual therapy we can do because it can actually help improve mobility and bring blood flow. And that can calm down pain quite a bit in like an acute situation. Um, but gentle like mobilizations to grade one, two are going to be our go-to like pain-relieving things uh for joints. And then even like uh manipulation, depending on if they fit our um prediction rule for like low back pain or neck pain, if that's appropriate, like that can really help patients if you can get that at the right time timing. So lots of things we can do.
SPEAKER_03Yeah, I'd say too, like, I definitely echo Tessa's statement there. And also most of the time I'll try and send them home with like a self mo or like a self-traction, something that they can do, or even like a neuroglide, something that they can physically do at home, especially if their pain levels start kind of inching back up to where they were as well.
SPEAKER_02And isometrics too are very good at analgesic effect. Um, so we'll dial in that too, if that's appropriate. Um, we you we get a lot of good effects with um dosing that out appropriately.
SPEAKER_01Yeah, I mean, I found in a lot of patients that come in and see me, they want some type of pharmacological treatment for their pain. And I I don't like to give pharmacological treatment. I I prefer to try to send them to you guys because I think the manual therapy works better than the pharmacological therapy. Yes, we can adjunctively use ibuprofen and medrop dose packs and stuff to calm some acute inflammatory stuff down, but ideally the hands-on stuff, I think you guys would agree, tends to work better. And I for cupping, which is interesting you mentioned that, and even maybe dry needling. Do you guys find that patients will get some kind of inflammatory flare the next day? I've had a few patients come back and say, hey, I'm a little bit more sore today than I was the day before, but that's part of the process, right? That's the intention of the, you know, uh the modality.
SPEAKER_02Yeah, I would say maybe from cupping slightly more than dry needling, people will report more muscle soreness because you almost get like a bruise effect there. Um so you're gonna have like tenderness likely where those cuffs were, but it should not be like that really high pain, like really tender before as before it should feel more like bruise. So um I think any with any like deep, soft tissue work, I think you can be more sore, but I personally don't feel a lot of um soreness from drenuling, especially if we're doing it with eSTEM and not doing a ton of pistoning. Certain areas like the hand um or the foot maybe can be a little bit more sore even in the wrist. But um, what do you think, Kat?
SPEAKER_03Yeah, I would I would agree as well. I think it's definitely different on like a case-by-case basis. I've seen folks that just respond a little bit better and are less sore with dry needling, or vice versa, with like cupping as well. And some people can tolerate both. And usually they end up there is I usually tell folks like, yeah, there is a period where you're gonna experience some soreness, but you know, that should calm down with like, you know, the type of like Eastern that we use with dry needling is specifically designed so that they aren't super sore for like a good four or five days afterwards, and they can experience those effects where the pain levels just kind of come down as well.
SPEAKER_01Yeah, I mean, I even see that you mentioned manipulation, but you know, we see a lot of patients post-chiropractic work who kind of have some acute inflammatory symptoms for a day or two afterwards, and they'll come in and see me and say, hey, why is this flared up? And sometimes it's just a conversation to say that's a normal reaction, actually. What we're trying to do, right? Sometimes we're stuck in that proliferative phase of the inflammatory cycle and we're trying to reset that inflammatory cycle to kind of get the healing in there, and it just, you know, requires a conversation to encourage them that this is normal and this will get better.
SPEAKER_03Yeah. I think I was gonna say, I feel like some people um miss out that inflammate inflammation is actually a normal part of the healing process for depending on what kind of injury you're coming in with, it's just when inflammator inflammation when the inflammation process starts getting out of control. That's usually when that's I dial in into like the whole like this uh dry needling that we get. But yeah, most of the time I I just have to tell folks like, hey, this is actually a normal part of the healing process. It shouldn't stick around for uh too long as well.
SPEAKER_02And um too, what I'm finding is the more we can educate our patients and just the general public too, of like when you are getting soft tissue work or treatment, like you need to follow those things up with your specific rehab program because that's gonna help everything stick and then stabilize after we like increase all this motion. You need to um do things that are gonna then support your joints and the muscles, you know, that we are specifically working with you. So sometimes I'll just be like, you know, people will be like, well, after the session I was more flared up. Like, well, did you do your rehab like after it? Like we discussed, and like maybe that compliance wasn't there. Um, but like sometimes people just need a little bit more stabilization, like after doing like tissue work and needling and cuffing. Um really improving range of motion and things and trying to learn how to use that range of motion again.
SPEAKER_03Yeah, I would say like the rehab exercises are like the meat and potatoes of really rehab, because like the dry needling and cupping um really again brings your pain levels down so you can appropriately load and work the body parts that you're having issues with, and that would that's actually what makes the mobility and like um strength stick around more is the rehab exercises after we put pain levels down to like lower level, lower, more acceptable levels.
SPEAKER_01Yeah, because I mean, even if you're sore the next day, the the movement and the muscle activation will help to flush a lot of those inflammatory things that are going on. Um, and so, you know, I mean, you do a hard workout, right? You ride the exercise bike the next day and it'll kind of help flush the lactic acid, your legs, your delayed onset muscle soreness and things like that. So, as you said, sometimes just reiterating, you know, movement will actually help. So that kind of leads into the next thought process that I had. And I get you guys probably get this question just as much as I do, heat or ice. So, you know, somebody comes in and kind of says, Hey, I have this acute, you know, pain, it's always do I heat, do I ice? It's a very controversial topic. I mean, you guys probably would say every therapist you ask will tell you a different answer, right?
SPEAKER_02Yeah.
SPEAKER_01Every practitioner you asked will tell you a different answer too. Like, what do you guys thought process, heat or ice?
SPEAKER_02I'm probably a bit more biased towards heat. Um, just there's some new literature coming out that, you know, we we want to actually avoid icing with an acute injury. I think it depends on the timing of the injury. Um, but like, especially in acute situations, there's kind of some new literature that's showing we actually don't want to ice right away. We want to um move and find specific exercises and move within our tolerable levels of pain um and not blunt that inflammatory process. But so I think if it's more of a chronic chronic issue, I'm more okay with like people using ice or heat. But I think it's if it's an acute situation, um the the literature is coming around where like we want to maybe not ice right away. I don't know what you think, Pat.
SPEAKER_03Yeah, I think I remember reading the same literature as well. So I'm not really like acute, like chronic issues. I'm like, hey, it's really whatever you feel a little bit more comfortable with. But I remember reading too, like literature about how you're not supposed to cold plunge like directly after like really hard exercise. And I wonder if that follows like the same pro thought process of like letting the muscle fibers like um like you know, regenerate, heal, kind of deal, because you don't want to you don't want to dampen that response too quickly after an injury or like soreness as well. So I'm kind of either or depending on the patient or the person in question.
SPEAKER_01Yeah, and I think you mentioned it right. So inflammation is actually a good thing, not necessarily a bad thing. And so that's the thought process behind ice and the vasoconstriction, reducing inflammation, is you're actually maybe bringing away some of the you know healing uh you know things, you know, cytokines and things like that that can kind of improve the patient's symptoms. And so yeah, I mean it it's a controversial topic. I I think it's up in the air. Um, you know, I I I recommend the same thing. Most of the time with chronic injuries, whatever helps, whatever you feel like helps the best. A cute injuries, you can go back and forth, whether you're ice or heat right away.
SPEAKER_02I think if someone's like choosing, like, am I gonna take uh anti-inflammatory or I'm gonna ice, I'm gonna probably say, let's ice and see how we do instead of having to take a medication. I agree. Um, so I'm gonna usually bias the like niece um impactful thing for someone.
SPEAKER_01I would agree. I mean, obviously, if we can avoid the systemic side effects of anti-inflammatory medications, I do think they have the uses, and I do definitely use them in a lot of patients. And it's definitely one of the questions I ask when somebody comes to clinic is did you try medications? And we're all resilient to take medications because of the side effects, but they can be useful in certain situations. And maybe those are the times to consult the therapist or you know, whoever you're working with to see if it would be appropriate at that time. Um, so okay, patients come in, we've calmed the acute inflammatory symptoms down, we've done our functional evaluations and we've seen whether they're having some limitations in motions or maybe some poor muscular strength. Uh, you you know, we mentioned on the chart that you guys had pulled up. How do I now delineate whether this is an in-articular or extra articular pathology? What do you guys use as far as your exam skills and the patient's presentations to kind of figure out which one of those we're dealing with?
SPEAKER_03I feel more if we're talking about specific like assessment, I'll really check end ranges as well, too, for like any sort of like joint dysfunction or pain at end ranges, and then kind of see what the appropriate mobilization is there. If someone's pretty good in like their full range of motion, like I'm pushing them all the way in the available range of motion, they're not really getting much pain, then that kind of dials uh that kind of puts me in the direction of a little bit more extra articular versus intra-articular as well. And that's after screening for um other joints, so like screening out low back, screening out knee, and it's solely a hip-focused um injury, that's typically how I bias it as well.
SPEAKER_02Yeah, I think um always looking at active range of motion, then uh overpressure with passive range of motion really cues you into um is there something like going on internally or more uh muscular base externally? Um and I will use some special tests with the hip that work pretty well too, looking at a fadier or faber test, um, some compression tests and things like that, that also will help rule in if we think it's more of like a um FAI issue or a laboral issue, even just we can do some different tests that will like potentially provoke like clicking or catching. And so that'll kind of cue me in on is there something internally going on, or um, you know, we look at our palpation exam too, and that can cue us into a lot of external structures as well. So um, and what is popping up with when we manual muscle test them? Is it painful? You know, when we're stressing the uh direction of pain, that'll cue us in of like maybe those muscles are also not doing well from a strength or um pain perspective there.
SPEAKER_03Yeah. And whether or not the pain is the pain replicated is the pain that they're coming in with is also something I'll pay attention to because something can be, you know, uncomfortable or painful, but not quite what they're coming in for injury-wise.
SPEAKER_01Yeah, I mean, I think it's, you know, we talked about this again during the the low back talk. I think sometimes when people come in and acutely painful, we'll get a lot of false positive tests with some of these impingement maneuvers, you know, and these faders and favor type maneuvers because they're gonna have so much inflammatory pain around their hip. Um, is that really truly what the underlying problem is, or are we getting a false positive test for that? So, as you said, you know, are we reproducing the pain that they're coming in with? Are they acutely inflammatory, painful, and is that truly a positive test? Um, you know, testing active versus passive range of motion, you know, their passive motion if they're painful. I tend to think more underlying structural pathologies versus active motion, painful. Um I don't know if you guys have ever done the hip impingement test on yourself, like a fader test on yourself, but I feel like that test is always painful.
SPEAKER_02Yeah, I was gonna say, like, I usually tell people like this test honestly sucks for most people, even people without hip issues. So I'm like, but is this your similar pain? And like kind of dally against the questioning, and then I always will compare it to the other side because if if that feels different than the other side, then that will cue me in of me that it's a positive test versus not.
SPEAKER_03Everyone's baseline is different too. So usually I just check their unaffected side for what is considered quote unquote normal for them.
SPEAKER_01Yeah, and I I that's what yeah, uh you said exactly what I. Was going to say, I think you have to check the opposite side to see if they have similar pain on the opposite side with that impingement maneuver. But every time I do fader on myself, it always hurts. Um, you know, so and I I think some of that can be underlying structural FAI type pathology. So we talk about FAI, that's the CAM deformities and/or the pincer deformities and/or combined deformities with the hip. And at some points, um, you have to consider maybe their limitations in the range of motion is not necessarily a soft tissue limitation, but more of a structural limitation secondary to this CAM deformity. So when, from a therapist standpoint, if somebody comes in and they're complaining of acute and you know hip symptoms, would you send them and/or consider getting further imaging to see if they're maybe having some underlying structural limitations and maybe more motions, not necessarily the answer for that patient because you're not going to get that because it's it's more structural.
SPEAKER_02Yeah, I personally would refer would um send for imaging if we've given PT like a very good shot with really good dialed-in high quality care with compliance of recap programming and things are not improving at any capacity. Um, they're still very limited and we're not making progress to goals. Um, that'd be my biggest factor because um it's very common to have like these deformities on asymptomatic hips. And so just rushing into image imaging just for hip pain is not my first go-to because we see so many of these uh asymptomatic hips having all of these deformities. So it's a big education thing I'll do with people as well of like we don't need to rush into an image here unless things are really not progressing how we want them to.
SPEAKER_03Yeah. I'll kind of look at like have we made any measurable change at all in like range of motion, like pain, quality of life, or like for um the patient population that we see, like their performance in like their sport of choosing. And sometimes like if there's no progression whatsoever and they're still noticing the same issues, then that's probably when I again, after a fair amount of education, like send them in for like an image to see if there's anything underlying that we've uh we've missed or haven't been able to address with therapy.
SPEAKER_01Yeah, I mean, it's interesting. I talk more patients out of imaging than I do into imaging for that same exact reason. You know, we know the literature shows that, you know, 40 to 60 percent of athletic individuals will have underlying label tears but be asymptomatic, you know, and over 30 to 40 percent will have CAM deformities and be asymptomatic. And so we're gonna find those on the MRIs. Is that the source of your pain or is it not the source of your pain is the difficult part? And sometimes once you get that MRI and it shows that that's the case, whether it be psychologically or whatever it may be, they're then focused on that. And, you know, I've seen patients not improve with surgical intervention regarding that because that wasn't the underlying source of their pain. And so sometimes I don't like to open Pandora's box and get the images because that can then change kind of how they're gonna do from a treatment perspective. Um, and so yeah, I agree with you completely on that standpoint. And um, you know, I I agree. I think, you know, I like to try to have them fail a good course of physical therapy first before even considering the imaging because of the the you know, the no the knowledge of knowing that a lot of these patients are gonna be asymptomatic and still have these underlying pathologies, but also because it's gonna help them postoperatively. We know that a good pre-operative physical therapy program, if they do end up having some kind of laboral pathology or CAM deformity, will significantly improve them post-operatively. So we're not really losing anything by that. And the majority of those patients will get better as well.
SPEAKER_02Yeah. What are your thoughts on um your perspective? Because you do perform and assist with these surgeries of like um arthroscopies, procedures in the hip, and laboral repairs on the success rates of those and just efficacy of the procedure. Um, I had a client recently like inquiring about this. And, you know, I know I've read even studies that are like if you look at a two-year follow-up, there's not necessarily a huge difference. Um, so I'm just interested in your perspective on that.
SPEAKER_01Yeah, so that goes back to exactly what we're talking about. I think, you know, the hip arthroscopy field is such a new, evolving field. There's a lot of literature that's going into it, but we're also finding, as you said, sometimes we're chasing the rabbit down the hole with these positive MRI findings that wasn't necessarily the underlying reason of why they're having hip pain. So I think it's successful surgery in patients that get it for the right reason. Um, cam deformities tend to do better than pencer deformities. Cam deformities we're more worried about because you're getting that grinding on that laboral kind of articular cartilage junction, and those are gonna progress to more arthritic changes. And so, from a surgical standpoint, we are a little bit more aggressive with CAM deformities because we know that's gonna progress the patient to developing problems in the future. Versus pencil deformities, you know, those we tend to find more often in females than we do in males. Cam deformities are more often in males, and we think that's because of the rotational force on the physis when they're young causes overgrowth of that physis, and that's what creates the cam deformities to happen. We noticed that females tend to have pencil deformities were in their mid-30s to 40s. They were athletic, they were so strong, and they had so much dynamic stability within their hips that they were able to compensate well for it. But then when they start to become a little bit unathletic and that dynamic stability is not there, that that deformity starts to become more painful. And so maybe it's not necessarily going in there and taking their labrum down and fixing the pencer and/or fixing the labrum. Maybe it's getting it back into that stabilization that they had before. And so that's why we say, hey, let's do the physical therapy program. You didn't have pain for 30, 40 years, but you had this deformity the whole time. Maybe if we can get you back into that, your hip back into that shape that it was, you know, and and how important is neuromuscular kind of facilitation. So, you know, we improve the mobilization, but we talked about load, the importance of load, the importance of muscle activation. And I think that plays a huge role in a lot of hip problems. So uh hip arthroscopy gets a lot of negative reviews in some patients, but I think you have to do it for the appropriate reasons. We use interarticular hip injections for that reason a lot of the times. That helps us to delineate extra or interarticular problems. So if we give somebody an interarticular hip injection and they get almost complete resolution of their symptoms, we know it's an inarticular hip problem. And so then we know that's maybe something we can fix. And maybe the labrum that we're seeing around the MRI is the source of their pain and it's not a soft tissue injury extra articular. But if we give them the injection and they get no resolution of their symptoms, then they're probably not going to do well with surgery. Does that make sense? So I think from my perspective, those are my thought processes behind it, and that's why I talk a lot of people out of it slash delay the surgery, don't rush into it. But for CAM deformities, and maybe if I've had an injection improve my symptoms, maybe then yes, the surgery would be helpful for you.
SPEAKER_02Do you have an age that you find is more successful with those procedures than others?
SPEAKER_01I think for the CAM deformities, we want to get some early because we know they'll lead to progressive arthritis. So we want to try to fix those in their early 30s to 40s. We know that the literature shows anybody after the age of 45, and I'm 46, so I'm not knocking on anybody. I'm I'm in this age range. Anybody after that age group tends to not do as well with the surgeries because they already have some underlying genome changes within their hip, and maybe their success rate's not as high. So I think you have to be much more selective in that patient population. Um, you know, I used to do a lot of joint replacements, and I'd see those patients who were probably in their mid-50s get the laboral surgeries, and then within two years, we would then be doing a joint replacement on them. Yep. And maybe we didn't necessarily do that for the right reasons. It's kind of the same reason we don't scope arthritic knees with meniscaltin because we learned that that maybe didn't provide as much success. And if not, we made some of those patients worse.
SPEAKER_02Yeah.
SPEAKER_01Um, so yeah, I think the younger the better. Um, if we could find that a form is younger, definitely better. Um, when we get up into the 45 to 50, 55 range, we got to be very selective on if we're doing it and maybe more push towards the therapy on those patients.
SPEAKER_03Yeah, yeah, it seems so too.
SPEAKER_01Um, so let's say that we see all these patients, last thing, and we're kind of we're we're recommending load. We're saying, and I know this is a this is a loaded question, it's a difficult question, but somebody's at home and they just want to start doing something on their own. What are like three, four simple exercises, and we'll maybe add a video to the end of this, that you would advise them to do as far as improving the the kind of neuromuscular facilitation, the adductor strength, the abductor strength within the hip? What are your go-to kind of core exercises? I know, loaded, right? That is super slow.
SPEAKER_03Yeah, so I it's it's always that answer. It depends. Yeah.
SPEAKER_01Well, I feel like isn't there like one exercise you do on most patients or a couple exercises you're like, these are my go-to's on most patients?
SPEAKER_03If we're talking the oh man, if we're talking adductor strength, like a Copenhagen is almost always my go-to. Like Copenhagen for adductor is amazing.
SPEAKER_01So, what's a copening? I'm not familiar with that.
SPEAKER_02So you are going to be on your side, and one of your legs is gonna be up on a bench, your top leg, and then your bottom leg is gonna be under your and typically we'll start with the bent knee position, but that is like money for inner thigh, yeah, strength and stability.
SPEAKER_03Groin issues, too. I would say that's a big one I'll give for that, just because we like we talked about isometrics are so beneficial too for like pain relief as well. Try to think of a good glute.
SPEAKER_02Um, I'm a big fan of the standing clamshell exercise uh with a band because we're getting that close chain and open chain action, and it's in a single leg version, and you can do with or without like wall support with that. Um, I find that that is very um, very good. Or like a side plank clamshell also is really good for getting that close chain stability.
SPEAKER_03Um I was gonna say too, I've been reaching for more of like a split squat kind of situation, like a Bulgarian kind of deal, just because you can vary it to a little bit more quad dominance or like hip dominance, depending on what you need in an individual. But I like I kind of like the single leg, I like the single leg focus a lot. That way it forces uh the person to isolate one side versus the other versus using both sides um to compensate as well.
SPEAKER_02Um, and I think uh maybe for a mobility uh thought process, I'm always kind of leaning towards like eccentric loading um over just giving people stretches. And if I give people stretches, they're more of like a loaded mobilization, maybe even with a banded hip distraction. Um, but like let's say for the hip flexors, like I'm really liking like a laying on your back, you're hugging one knee to your chest, and you're doing like a uh kettlebell raise with the other legs. So we're like eccentrically loading into uh hip extension and opening up the hips, so we're strengthening and lengthening at the same time. So um, those are some of my go-tos.
SPEAKER_03Yeah, I was gonna say I've definitely been noticing people kind of progressing along quicker with like more active eutentric loading. So, like for going off that sort of hip plugs for like hip um extension as well. I'll actually look at like a single leg RDL if they could if they have the form for that, or even like a normal like Romanian deadlift just for that um eccentric lengthening of the hamstrings. But yeah, I really find that's been sticking a lot more with my clientele.
SPEAKER_01I feel like that dynamic mobility uh significantly you get better results out of that than you do just the static stretching. Like, you know, a lot of patients have static stretches they do at home, but I you guys probably would say the dynamic, kind of loaded mobility stuff patients tend to do a lot better with. What are your guys' thoughts as far as core strain? So we talked about sometimes, you know, we have FAI, we have core muscle kind of athletic pubalgia that we'll see in some young patients, but there's a huge problem in the NFL. We see a lot of NFL players kind of out because of this athletic pubalgia, which is, you know, inflammatory changes at the insertion of that rectus femoris and that adductor aponeurosis on that pubic symphysis. And we think some of that's related to poor strength and mobility within the hip, but also poor core strength. So, do you guys do a lot of like um you know planks and kind of core strengthening? You do a lot of like um abnormal lifting. What's what's the appropriate terminology for like what tanning or walking with like different loads in your hands, like front squat, you know, load one hand?
SPEAKER_03Yeah, go you can go. I was gonna say, I do a lot of like, well, first I check to see if they're able to brace and activate their brain properly, because there's a lot of mis uh common misconceptions with like bracing in general. And then also like for me personally, I train core in a lot of different in like all planes. So like instead of just like frontal or like sagittal, I also train like in the rotational plane, so like rotational motions, like anti-rotation as well. So yeah, I would definitely say yes, we do a lot of like um core training and loading.
SPEAKER_02Yeah, I think you know, starting out depends on how acute someone is, but like starting out with like either, you know, anti-rotation, anti-siden, anti-extension or flexion, either whatever direction, you know, and then progressing to like loading through ranges is important and multi-directional. Um, you know, some people are if you kind of ask them like what they're doing for their workouts and you find that they're really not moving out of the sagittal plane, then you know, getting them in other directions is huge. So uh kind of depends on what they're doing already outside of also their PT stuff, too.
unknownYeah.
SPEAKER_03It's kind of interesting to see how strong someone is in like sagittal plane, but then like you check out rotation, it's actually, you know, could use could use a fair amount of work as well. But I'd say honestly, I go over bracing a lot because we treat so many like weightlifters as well. Cause yeah, I'd I'd say that's the most common thing I go over. And then yeah, depending on the person's presentation, it just depends and kind of progresses through there.
SPEAKER_01I mean, it's always funny how somebody can like do a hundred sit-ups without a problem, but you ask them to do a side plank and they like completely fail because they have this single planer strength. And we know just from research, even you know, overhead throwing athletes, single planar, you know, kind of strength significantly predisposes you to injuries because you're it's not a functional strength for you. So I think the functional core strengthening exercises are so much better than anything else. And Kat, yes, fantastic. As you mentioned, like the core bracing, right? So, you know, if somebody's doing a squat and they're not bracing their core appropriately, how much load is that gonna put across their other tissues? You know, how much then load are they gonna put across their S-side joint, their hip, their knee, their ankle because of their improper, you know, bracing, and that's then gonna predispose them to injuries there, and maybe that's even causing the pain that they're having in that area. So I think appropriately bracing, and you can do a whole 30-minute podcast with that um is is definitely helpful. So, so yeah, I I think, you know, um, as we talked about, you know, I therapy from my perspective, from the hip perspective and a low back perspective, I think is um underutilized, but probably the mainstay of treatment for a lot of these things because not necessarily surgeries or injections are are the the case there. And even we didn't even discuss, you know, gritter terrochoteric syndrome and you know the inflammatory changes you can get there. But you know, I I think therapy is so important for from that aspect. Any anything we missed? Anything you wanted to talk about that we didn't talk about?
SPEAKER_03I feel like we covered a lot of things. So fair amount of core, we got into like we assess. There's other like hot topics we could go over, but that you're right, that'd be like a 30-minute topic.
SPEAKER_01We could have a 30-minute topic on every part of the clip. So that's the funny part.
SPEAKER_02Yeah, I'd say bursitis. Bursitis is probably that that might open a can of worms longer than a 30-minute podcast.
SPEAKER_01We don't call it bursitis anymore, we call it radotrochetoric syndrome and change the name because yeah, there's so many other tissues within that area that cause this. Yeah, I think that's a different topic as well. I'm not huge on injections for that area. I think oftentimes, you know, we miss some partial injuries to the gluten mead gluten insertion there, and so the injections are just kind of mimicking or masking um that necessarily. So um, I I definitely think those are you know therapy slash, you know, uh is is helpful for that as well. Yeah, yeah.
SPEAKER_02Yeah, I've had a lot actually, like a few people ask me recently, like, well, can PT help bursitis? And I'm like, uh yes, absolutely. And let's see if that's even that, you know.
SPEAKER_01Yeah, correct.
SPEAKER_02Let's uh assess this.
SPEAKER_00Well, I hope you enjoyed this episode. I think this was a good discussion regarding the hip and how the interplay between uh physical therapy and clinical medicine uh can evaluate the hip itself. Um, Kat and Tessa have both provided some videos regarding bracing uh during exercise activities and some stretches and strengthening activities you could do for the hip. So if you tune into the YouTube video page at the end of the uh recording, uh I will include these videos and then I will try to include a link to these videos um on the recording itself. Uh again, please follow us on social media or throw on the go podcast on both Instagram and Facebook, and please reach out regarding any topics you'd like to hear covered. Thank you.