Latest / The STA Clinician Podcast / Ep199: 'Understanding Tendinopathies Of The Hip & Pelvis' with special guest Dr Alison Grimaldi

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Ep199: 'Understanding Tendinopathies Of The Hip & Pelvis' with special guest Dr Alison Grimaldi · The STA Clinician Podcast

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  You're listening to the Sports Therapy Association podcast, putting evidence
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  back into soft tissue therapy.
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  Music.
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  Welcome to the Sports Therapy Association podcast, episode 199.
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  My name is Matt Phillips, creativerunchatlife.com. And as always,
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  this episode of the Sports Therapy Association podcast is being recorded live
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  on the Sports Therapy Association YouTube channel.
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  And also for those of you who prefer it on Facebook, it's normally recorded live at eight o'clock.
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  But because this episode, like last week, is going out at nine o'clock,
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  basically, because my guests, it seems like the experts of tendinopathy all
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  live in Australia for some reason, which we might pick up again tonight.
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  So it's kind of a bit kinder to do this at nine o'clock BST because that's six o'clock over there.
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  So, if you have joined us live, then thank you very much. You're welcome to
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  ask questions as always.
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  If you're listening to the podcast and you want to join us live,
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  then next week, just put this out there now so you know, those of you who are
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  listening to the first part of the podcast, next week there won't be anything happening.
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  But the week after, part three of this Tendon special with Dr.
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  Ebony Rio will be happening at nine o'clock BST as well.
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  Okay, so do join us then if you fancy being able to ask the guest questions
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  directly and hang out with people in the live lounge.
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  So yes as i've already said this is part two
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  of a three parts tendon special in part one
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  last week i had the pleasure of spending time with
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  dr a professor sorry doctor hush my mouth
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  professor peter maliaris and let's just bring
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  those of you who listen to podcasts you can't see the screen i'm going
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  to put some nice screenshots up here so yeah it was with professor pete
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  maliaris has been on the show before who like all of my guests is a
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  hugely prominent and internationally respected tendon researcher and educator co-author of
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  over 100 peer review publications peter is
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  also creator of the internationally acclaimed mastering lower limb tendinopathy
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  online and face-to-face course now in its seventh edition
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  details of which can be heard in episode 198 of the sports therapy association
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  podcast available as always on all popular podcasts players and youtube so a
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  huge thank you to professor peter maliaris for opening our tendon special last week so tonight in part
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  two, which is entitled Understanding Tendinopathies of the Hip and Pelvis.
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  My guest coming up shortly is the one and only Dr. Alison Brumaldi.
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  And then, like I say, in two weeks' time, on June the 4th, in episode 200.
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  200. Isn't that fantastic? The topic will be managing tendon pain with special guest Dr. Ebony Rio.
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  Right then, back to my guest tonight. It really doesn't get much bigger than
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  this, people. I'm so excited and rightfully so. People have been messaging me all day.
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  Dr. Alison Rowdy has got over 30 years of clinical experience with particular
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  expertise in the management of hip, groin and lumbopelvic pain dysfunction.
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  She's also a fellow of the Australian College of Physiotherapists, Principal
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  Physiotherapist at PhysioTech and an Adjunct senior
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  research fellow at the university of queensland so
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  as always this is a huge opportunity for people who have joined us live
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  and if you listen to the podcast i really do encourage you next in two
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  weeks time to join us live as well because you don't really these opportunities
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  don't come along all the time to ask questions live direct to guests of this
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  caliber so i do encourage you if you've if you've got um some time free then
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  do join us in a couple of weeks time so anyway i'm babbling on without further
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  ado let's bring up dr allison grimaldi.
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  Music.
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  Stick to the sports therapy association podcast evidence back soft tissue therapy,
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  how you doing good thanks matt i'm sorry i started babbling then because i'm
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  so keen for people to actually join this i feel quite guilty that i'm not like
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  there's not hundreds of people joining now but it's hey that's education we
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  want to reach people who don't know you don't we Otherwise, it's just an echo chamber. That's right.
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  So thank you very much. I do appreciate it, especially since it's like six in
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  the morning, isn't it, where you are in not-so-sunny Brisbane, I hear?
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  It's beautiful. Actually, the weather's been lovely. Just a little cool,
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  but only 10 degrees, so it's not sort of like… 10 degrees. Wow, you guys are suffering.
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  Anyway, great to join you today. I really appreciate it.
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  People are joining us now. That's good. People are coming through the door.
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  Let's just bring some people up. Like I say, if you have joined us live,
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  then do ask questions away.
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  And if you do ask questions, I'll bring your lovely logo or photo up onto the screen.
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  Cecily Hislock says, evening. I have another. No, I'm not having another joke,
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  Cecily Hislock. I'm just going to hide it now.
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  I just listened back to the way I started Peter's podcast last week.
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  No, Cecily, I banned you. Forget it.
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  Let's just move on. Fine. Thanks for joining us, people who are live.
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  All focus has got to be on Dr. Grimaldi, I'm afraid. So, Dr.
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  Kamaldi, fantastic to have you here.
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  It's a huge topic. We talked about understanding tendinopathies of the hip and
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  pelvis, and we're not going to get through all of that tonight.
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  But I'm wondering, just for listeners who aren't aware, what would the kind
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  of most common tendinopathies of that region be if we were going to dip into
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  a few of them tonight? Dr. Kamaldi,
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  The most common ones would be gluteal tendinopathy and proximal hamstring tendinopathy.
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  Then we can have some other tendon problems that might occur.
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  Sometimes with adductor-related groin pain, you may get the tendon involved.
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  So we can have adductor tendinopathy.
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  Rectus femoris tendinopathy, we can get sort of at the front of the hip there.
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  And then we can even get other tendons involved, often associated with osteoarthritis.
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  So, for example, at the back of the hip, the obturator internus tendon that
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  runs right across the back of the hip there can get tendinopathy as well.
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  But the most common ones that we see are going to be gluteal tendinopathy at
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  the lateral hip and proximal hamstring tendinopathy at the ischium.
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  Fantastic. Yeah. So we haven't got time.
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  It would do a massive discredit to you and everything if we tried going into all of those areas.
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  But I'm wondering as an opening question, in the topic of tendinopathy in general,
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  are there some common themes, do you think, in treating those areas?
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  Although obviously, there's going to be distinctions.
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  Do you think there are some areas which are responsible for mismanagement of
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  tendinopathy of the hip and pelvis, things that aren't quite trickling through to the clinic floor?
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  I guess one of the common things is that a lot of the tendinopathies around
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  the hip and pelvis are insertional tendinopathies, which just means that the
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  the tendon sort of wraps around a bone for it sort of inserts into that bone.
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  And so there's opportunity for compression of the tendon.
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  And so compression is a really important factor in the development,
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  we think, certainly in the management of tendinopathy.
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  It's something that we tend to reduce to try to reduce pain.
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  But I guess in terms of mismanagement, I think one of the things that's often
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  prescribed for tendinopathies is stretching.
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  And so particularly with gluteal tendinopathy, which has previously been diagnosed
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  as trochanteric bursitis.
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  And one of the really strong beliefs around trochanteric bursitis was around,
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  it's all about tightness of the ITB.
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  And so there was lots of, you know, one of the main treatment approaches was
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  stretching of the ITB or trying to mechanically lengthen the ITB and eventually
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  surgically lengthen the ITB.
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  Similar with proximal hamstring tendinopathy that a lot of patients will try
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  to stretch and stretch and stretch.
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  But for both of those situations, stretching isn't terribly helpful and might
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  be provocative because you're actually exposing that insertional tendon to more compressive load.
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  And with gluteal tendinopathy, particularly tendinopathy,
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  That population is actually really short in their lateral soft tissue structures,
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  even though that's still the common belief, even though now we've sort of moved
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  towards, you know, gluteal tendinopathy is our understanding of the primary
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  condition, but we might also have bursal change there.
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  But there's still this sort of belief that the
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  ITB must be tight and so there's
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  still some stretching going on out there perhaps but when we actually assess
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  these people in clinic they're actually really tight and they're much more likely
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  to be long in that lateral stability mechanism and that's because that population
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  tends to sit with their knees crossed in adduction,
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  stand and hang on one hip in adduction,
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  walk with excessive adduction, you know, in their normal everyday gait patterns.
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  And so they spend a lot of time in adduction in a lengthened position.
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  And so they do actually tend to be longer rather than shorter in their ITB and hip abductors.
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  And so stretching is not going to be useful and it's just going to be provocative.
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  We do see a subgroups that are tight, more commonly males that stand with wide
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  legs, sit with wide legs, but they're the much smaller population.
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  But stretching won't help them either because it'll just cause that compression.
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  Massage can be useful, but the massage is not about lengthening the ITB.
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  What we see in those with gluteal tendinopathy is they often get tender and
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  a bit overactive, if you like, in the vastus lateralis, so in the lateral part of that quads.
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  But that's simply because that muscle is part of the more superficial stability
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  system for the pelvis in the lateral lateralis.
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  Lateral stability mechanism. And so when the vastus lateralis contracts,
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  it pumps out the ITB and so that helps the ITB in the upper glute max.
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  So if you're weak in the deeper abductors, glute min and glute med,
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  then you need to use more of the superficial abductors and that includes vastus lateralis.
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  So I think, you know, a lot of that tightness and tenderness that we feel down
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  the side of the thigh there is about vastus lateralis trying so hard to,
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  you know, help the lateral hip.
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  Actually, a couple of weeks ago, I saw a patient who was so weak and she had a large BMI.
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  So there was a big physical mismatch between her ability to load bear and she
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  would get this massive cramp in her vastus lateralis just trying to weight bear
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  because she had a lot of atrophy and just was not strong enough to weight bear
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  with the weakness that she had and the body weight that she had,
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  but she'd been through all of these investigations trying to,
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  you know, figure out what this problem was in her thigh.
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  Well, I can explain what the problem is in the thigh. It's a,
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  you know, an enormous overload on your vastus lateralis.
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  So massage can be really useful to help sort of, you know, reduce pain and,
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  but it will only be a very temporary.
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  You know solution because we have to get to
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  the the root of the cause which is which which is up
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  at the hip there very long answer no that's
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  just i should really just stop the episode there because there's
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  enough there to keep our listeners going on for a good couple of hours
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  i'm like it's just it's everything it's just
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  ticking all my boxes it's fantastic i mean it's recently
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  i gave a webinar for physique management on proximal hamstring tendinopathy
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  and i i say on that guys i'm just a conduit people
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  maybe like the way i give the information but this information is
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  coming from experts like yourself like peter maliaris in
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  particular the paper he did with tom goom on that and other
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  people as well so to hear you can to hear
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  it from i hate especially from the horse's mouth always seems so disrespectful
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  but hearing it from from you saying things like it's you know it's not always
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  a stretchy tight issue okay just because it hurts doesn't mean it needs to be
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  stretched and a lot of cases when it comes to insertional tendinopathy the research kind
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  of suggests that maybe that that extra tensile could cause some compression, et cetera, et cetera.
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  So it's really refreshing to hear this message kind of said,
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  because unfortunately, especially with soft tissue therapists,
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  massage therapists, sports massage therapists.
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  Most of the principles taught are about increasing range of movement,
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  because we know that laying hands and massaging can increase,
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  even though it's kind of not for very long.
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  It's temporary we can increase visible flexibility and
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  range of movement but because of that all the
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  techniques people use is to kind of stretch and increase but so
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  when it comes to conditions where it's not lack of range of mobility isn't the
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  issue here it's actually the opposite it's actually need to put some stiffness
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  in it sounds like a foreign entity so now it's great thank you so much for mentioning
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  that because it's it really does help therapists think oh god maybe i better
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  I better crack on with this because if Dr.
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  Alison Grimaldi is saying it's not always a stretching issue,
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  then it must be true. So that's really good. It's really good to hear that.
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  So, yes, common themes in treating tendinopathies in the hip and pelvis.
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  Yeah, they may well be in insertional and stretching is not always the answer.
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  I wonder whether I'm going to dip into research that you've done.
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  Obviously, it's a long, illustrious career. I don't want to make you feel too
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  old, but I just want to we're going to go back to 2008.
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  Now, I don't like I said off air, I don't need you to recall the afternoon and
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  who you were with and that sort of stuff.
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  But I think it's just interesting. I just wondered because I looked on ResearchGate.
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  And again, I encourage listeners to go to ResearchGate and look up the names
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  of my guests because you'll get a lovely idea.
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  Obviously, reading just the abstract can be a little bit dangerous.
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  But in most cases, there's links or a lot of cases, there's links to the full text.
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  And in many cases, I hear that if you actually contact the author,
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  they'll be more than happy to give you where they can full text anyway.
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  But in 2008, your publication, the first one I could find on ResearchGate was
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  MRI Investigations of the Muscles Involved in Lateral Stability of the Hip.
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  So I was just interested in having you on the show how you
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  came about as that being you know one of the first published
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  papers and at that time did you realize then that this was going to be your
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  future that you're going to become kind of such a respected professional and
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  educator of this area of the body no but it was something that I guess I had
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  a burning desire to try to
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  figure out, you know, some more information about the hip.
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  And so that paper, well, I think that's actually a link to my PhD thesis.
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  So it was interesting. I did a coursework master's, a sports physio master's in 1997, a while ago now.
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  And that was a very intense year and I absolutely loved it, but it was a lot
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  of work and lots of exams.
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  And, you know, at the end of that That year I went, well, that's it with university.
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  I won't be going to university.
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  But, you know, as you start sort of,
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  applying that extra knowledge that you get from Masters, which is fantastic.
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  But there were still so many unanswered questions. And back then,
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  there was so little research on the hip.
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  There's been an absolute explosion in the last 10, 15 years, which is fantastic.
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  But back then, there was very little. And as is very common with people going into particular areas,
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  I'd had a bit of my own hip issue and so and
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  it had been to every course there weren't very
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  many courses either looked up everything the literature and
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  I'm going oh I'm going to have to go and try to answer some questions myself
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  so you know went back to uni to try to answer some questions and I think again
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  with a lot of PhDs that are driven in that way you've sort of got so many questions
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  and you expect to answer all these things when you go into a PhD.
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  But, you know, and actually I'd intended to do some EMG, but,
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  you know, there was so little information on the hip that we thought,
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  well, let's do some MRI studies first to try to figure out which muscles might
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  be most affected by, you know, joint pathologies.
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  And so then we might be able to, you know, direct the EMG, like figure out what
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  we actually want at EMG. Anyway, the MRI...
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  Studies ended up so big that my whole PhD ended up a MRI study.
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  And, you know, I initially started, you know, wanting to measure all the muscles around the hip.
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  And then it ended up that, you know, it was such a big project that I ended
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  up focusing on the abductor mechanism, which was the part of the muscular system
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  around the hip that tends to be very regularly affected.
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  It's probably most consistently affected across all different types of pathologies
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  with the hip and hip joint pathologies.
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  So it ended up sort of focusing more on the hip abductors and looking at people
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  with joint pathologies, so earlier joint pathology and more advanced joint pathology.
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  And then I had an opportunity to also be involved in a bedrest study,
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  which was really interesting. So their PhD ended up being a bit about pathology
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  and then about unloading.
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  And that was actually fascinating.
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  And I think it did start to really change the way I prescribe exercises and
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  the way that I looked at things as well.
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  Because my, so it was with the Berlin Bedrest Study, which is a study that was
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  run by the European Space Agency.
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  And that's because they were you know
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  looking at trying to keep astronauts up there in space for.
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  Longer with less you know effect on their musculoskeletal system
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  because it's you know unloading is you
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  know has such dramatic impacts on you know
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  not just bone of course we're aware that it has effects on bone
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  but on the muscular system and it's interesting that
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  all muscles aren't affected equally and so
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  my part of that study was to have a look at what happened to
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  the the abductors after eight weeks of bed rest and so
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  these were normal healthy they were all males but normal
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  healthy males and a lot of them were PhD students
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  and it was a bit harder than I
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  thought I think they thought it was going to be you know they
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  thought oh I'm just going to lie in bed and you know maybe write up
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  write my papers up and things like that but they
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  weren't allowed to even incline their trunk more than 30 degrees
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  they had to shower and do their
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  daily hygiene you know lying down
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  in bed and so they had force plates in
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  the end of the bed so they weren't even allowed to you know push into the
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  bed so they wanted them completely unloaded yeah it
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  was crazy so and there was lots of things done
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  to these poor fellows but my part of it was just to look at MRIs sort of over
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  you know every two weeks over that sort of period and it was really interesting
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  because the all muscles aren't affected equally by you know lack of gravitational loading and And like.
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  So within two weeks, like gluteus minimus, so our deepest hip abductor there
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  had lost on average about 23% of its muscle size, which is quite phenomenal.
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  Whereas muscles like upper glute max and TFL, which both, you know, superficial abductors,
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  the upper fibers of glute max being anything above the center of rotation of
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  the hip joint is more an abductor rather than extensor.
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  So those muscles didn't actually lose any significant size over eight weeks of bed rest.
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  And piriformis didn't lose size over that time frame either, which is interesting.
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  But lower glute max, which is an extensor, so it gradually lost size over time over that eight weeks.
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  So a bit similar to the quads, other studies done on quads in unloading situations,
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  they gradually sort of reduce, you know, size, but these deeper muscles involved
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  in, you know, joint support seem to be particularly affected by lack of loading.
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  So multifidus is also particularly affected.
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  Quadratus femoris seems particularly affected as well.
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  And so it really made me start thinking because we see similar sort of patterns
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  happening in joint pathology as well that, you know, we start losing those deeper muscles.
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  We see sort of that more of that fatty atrophy in those deeper muscles in people
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  with joint pathologies as well.
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  So that link there about loading, I think is so important because when you start getting joint pain,
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  you naturally start offloading that leg and you see people with hip OA standing,
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  they'll be standing on their unaffected side with the other,
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  you know, side bent when they, you know, get up and down out of their chair,
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  they put all their weight through their affected side.
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  So it's something that I think the lack of loading has a big impact,
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  you know, on muscles and changes in muscle contribution to the synergy.
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  So around the hip, all of our muscles work in synergies, of course,
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  and we see it all the time.
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  And your listeners would be aware of, you know, that that TFL dominance and
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  the TFL hypertrophy that we see.
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  So that's very common. When we see that, it's usually associated with some deficits
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  in the deep muscles, so particularly gluteus minimus, the deep parts of gluteus medius.
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  And so in terms of then how does that, you know, relate to exercise,
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  then I think getting your foot to the ground is really important to try to stimulate
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  that deeper part of your hip synergies, like particularly your synergies of
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  your buttock. So they're...
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  Important weight-bearing muscles. So I think having your foot on the ground is really important.
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  So like, I'm not a big fan of what I call leg flapping, which is leg off the
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  ground, you know, type exercises and clams are not my favourite either.
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  But this is sort of a process. I used to prescribe those exercises,
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  but this paper was part of, you know, my shift,
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  I suppose, in how I prescribe exercise and how I understand muscle function
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  and what drives muscle function and muscle health and weight bearing,
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  I think, for these particular muscles is so incredibly important.
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  So that's one of the main things that I learned, I suppose, out of that study.
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  That's brilliant. I've been surrounded for years of the importance of loading
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  and how to do it and why to do it but i'd never i've never heard that a lot
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  of it evidently came from yeah a study on forcing phd students to stay in bed
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  supine with force plates under their feet that's incredible,
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  i'm not i'm not sure what that makes you being involved in that i'm not quite
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  sure about the ethics of it but it's no i mean that opened doors i guess in
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  treatment and and it's so relevant isn't it to tendinopathy because tendons
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  it seems in particular need that loading to regain their stiffness and very
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  interesting very interesting.
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  And actually, something hats off to, who was it here? Carol.
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  Yeah, Carol jumped in very early on at 9-11 saying, should the tendon not be
• 23:13
  loaded as a continuation to release pain?
• 23:19
  Yeah, which is interesting as well, because thanks, Carol, because I've got a script here.
• 23:23
  I'm just going to ignore it because you guys in the live lounge are going to
• 23:27
  stimulate my questions for Dr. Alison Grimaldi tonight.
• 23:29
  So it's interesting.
• 23:32
  When it comes to loading, there's this continuum,
• 23:35
  which a lot of people read about with isometric first and then
• 23:38
  introduce the isotonics and some people i've heard
• 23:41
  and seen online which is a terrible place to learn sometimes but
• 23:44
  that the isometrics are overrated and it's
• 23:47
  not necessary and take them straight to isotonics but then other people will
• 23:50
  quote papers which show that isometrics have been linked in with actually
• 23:53
  reducing pain so what's your take on
• 23:56
  isometrics as part of let's stick
• 23:59
  with gluteal maybe to make it more concrete but yeah isometrics
• 24:02
  for a rehabilitation of gluteal tendinopathy sure
• 24:06
  i might just address i think
• 24:09
  that question might have come in when i was
• 24:12
  talking about compression and not stretching and i'm not sure if so i'll come
• 24:17
  back to the isometrics but i guess just addressing that question about should
• 24:22
  a tendon not be loaded and isn't stretching loading so i guess stretching Stretching
• 24:27
  is loading, but it's the type of load.
• 24:29
  So I guess it's that sort of balance between compressive and tensile loading.
• 24:34
  So when we're stretching, we're getting a really high amount of compressive loading.
• 24:40
  And that's one of the things that we...
• 24:43
  Think is like stimulates a tendon response to create changes in the tendon,
• 24:50
  but probably not only the tendon, the bursa and at the lateral hip,
• 24:53
  the iliotibial band as well.
• 24:55
  So all of those structures actually end up thickening themselves by,
• 25:00
  you know, laying down larger proteoglycans, you know, gel sort of molecules
• 25:04
  in those structures, which are hydrophilic, that suck water into the tendon and the bursa.
• 25:09
  And the iliotibial band has also been shown to be thickened over the ITB in
• 25:14
  those with gluteal tendinopathy.
• 25:16
  And so all of those structures become better at absorbing compressive load.
• 25:20
  However, particularly for the tendon, a tendon that is more adapted to compressive
• 25:25
  load becomes less adapted to its normal tensile load because the collagen fibres
• 25:31
  get disorganised and they're not all lined up in those nice lines to be able to absorb tensile load.
• 25:37
  So I guess I just wanted to address that first in
• 25:40
  terms of compressive and tensile loads are different things so
• 25:43
  yes we need to load a tendon but what we're doing
• 25:46
  in rehab of insertional tendinopathies is particularly
• 25:49
  in those early phases is trying to reduce exposure
• 25:53
  to compressive load while we gradually increase
• 25:56
  exposure to tensile load so then
• 25:59
  back to exercise mode then how do
• 26:02
  we do that hold on actually i should therefore say cow sorry
• 26:05
  if that's what you were implying and sorry i didn't realize you were going down
• 26:08
  that path of isn't stretching loading as well
• 26:11
  i just wanted to say because i've heard that again on
• 26:14
  social media it's like very polarized and as soon as some
• 26:17
  people start saying stretching is is excellent
• 26:20
  for everything other people say we shouldn't be stretching suddenly and then
• 26:23
  people come back saying ah but stretching is actually a form of load and therefore
• 26:27
  we should be stretching but then i think the research shows that yes stretching
• 26:30
  can cause a load but you'd need to do it something like 12 hours a day for six
• 26:35
  days a week for it to have the same load as a traditional resistance exercise.
• 26:40
  So again, it's interpretation of studies, isn't it? You wouldn't be able to
• 26:43
  give enough load, I think.
• 26:46
  The equivalent of going to a gym or something by stretching
• 26:49
  would you or am i mistaken no no i
• 26:52
  wouldn't think so particularly with tendons where
• 26:54
  you know and even the itb like you're going to
• 26:57
  get more load in the itb when you have muscles contracting
• 27:00
  it as well but yeah again if
• 27:04
  if you put someone in stretch position for 12 hours
• 27:07
  with gluteal tendinopathy i think you'd end up having to
• 27:10
  yeah put them on a walking aid the next day
• 27:13
  yeah you'd prove your point and get a bit of low but I
• 27:15
  don't think it would yeah be totally anyway so I
• 27:18
  just thought I'd mention that because I just hear it used as an excuse for
• 27:22
  people who are trying to defend stretching and we're not saying that stretching is really
• 27:24
  terrible but I think insertional tendinopathy and I quote it is it's an example
• 27:29
  of where stretching is not the the fix for all and unfortunately a lot of us
• 27:34
  and patients believe stretching is the solution for everything we need to educate
• 27:36
  a little bit don't we yeah no that's right and I mean again I'm not saying we
• 27:41
  should never stretch anyone one.
• 27:42
  But it's just, you have to understand the condition that the patient has when
• 27:46
  you're providing advice around exercise.
• 27:49
  And that's, you know, that's not a helpful thing to give to someone with gluteal
• 27:53
  tendinopathy. It doesn't mean that no one should stretch.
• 27:57
  But, you know, again, you know, prolonged, sustained stretching just before
• 28:01
  exercise is also often not a great idea.
• 28:04
  You know, a dynamic warm-up is usually better in those situations.
• 28:08
  But yeah, so it's It's just about the situation when it's appropriate or not
• 28:12
  to prescribe stretching.
• 28:13
  But if we go back then to the exercise modes and loading the tendon and how
• 28:18
  do we do that, I do start with isometrics for gluteal tendinopathy.
• 28:25
  And I often do it for proximal hamstring tendinopathy as well.
• 28:29
  And it's something that can help from a pain relief point of view.
• 28:33
  And if it helps, great. right?
• 28:35
  That's, you know, a great little tool that they have that they can actually
• 28:38
  give themselves some rapid relief actually with proximal hamstring tendinopathy.
• 28:43
  I had this patient once who was a cabbie, taxi driver.
• 28:47
  And so obviously he was sitting all the time and he had lots of sitting pain
• 28:51
  from the proximal hamstring tendinopathy.
• 28:53
  But so I taught him, you know, an isometric in standing, just,
• 28:57
  you know, hooking his foot under something and just pulling up.
• 29:00
  And so what he'd do is that he'd do a fair and then
• 29:03
  he'd jump out of his car and he'd stand up
• 29:06
  next to his sort of door and he'd put his foot you know
• 29:08
  underneath the door jamb and he'd just pull up you know do that
• 29:11
  a couple of times and he'd feel so much better so then he
• 29:14
  was comfortable to sort of do his next his next fair but of course that wasn't
• 29:19
  going to cure the situation but it was a really good thing for him a tool for
• 29:24
  him if you like for getting through his day with more comfort it by having something
• 29:29
  that he could do to give him some immediate relief.
• 29:32
  Now, it doesn't work like that for everyone, but for someone who it helps,
• 29:36
  that's fantastic. Full gluteal tendinopathy.
• 29:39
  The isometrics that we do, you know, I started doing isometrics for gluteal
• 29:44
  tenopathy a long time ago, a long time before Ebony's lovely research sort of came out.
• 29:49
  And initially, it wasn't to do with pain relief.
• 29:52
  That wasn't why I was prescribing isometrics. It was actually about retraining
• 29:56
  that muscle recruitment strategy because we do see such disorder in how that synergy functions.
• 30:04
  Contractions so normally when you recruit your abductors
• 30:07
  you and we use a lot of real-time ultrasound so
• 30:10
  we can watch it which is lovely so a normal recruitment in
• 30:13
  the abductors is glute min first so deepest abductor
• 30:17
  then the deep fibers of glute med then the superficial fibers
• 30:20
  of glute med and then finally tfl and upper glute max come on just as you're
• 30:25
  having to you know lift the load of your leg but in the preparation phase we
• 30:29
  get this early recruitment of the deep muscles And that's really important because
• 30:33
  early recruitment of those muscles helps stabilise that hip joint,
• 30:38
  helps stabilise the centre of rotation.
• 30:40
  Ready for those big muscles to then do their job and provide some of that power for lifting.
• 30:47
  So that's a normal recruitment strategy. But what we often see in people with
• 30:51
  gluteal tendinopathy, but joint pathologies as well, is that we often see an
• 30:57
  outside-in recruitment pattern instead of an inside-out recruitment pattern.
• 31:01
  And so we'll actually see TFL recruit first and sometimes like superficial glute
• 31:06
  med, you know, recruit with TFL and we'll see this sort of lagging behind in
• 31:11
  glute med. It's not like that they don't work at all.
• 31:14
  But there's just a lag in that sort of recruitment and reduced sort of recruitment
• 31:19
  in those muscles sometimes.
• 31:21
  And so what we do is then, you know, try to train them to re-instigate,
• 31:27
  you know, that early recruitment in that deep muscle system.
• 31:31
  And so I started doing isometrics, just training the preparation for lift phase,
• 31:36
  which is where that, you know, that motor control was sort of going wrong.
• 31:40
  But it was really interesting and it was fantastic when ebony's paper came out because.
• 31:45
  Because yeah i'd send someone home and i might have
• 31:48
  only you know got through that exercise and education and
• 31:51
  all of that on the first day and then they came back the next session and said
• 31:55
  oh that exercise you gave me it really helps with my pain and initially i'd
• 32:00
  go oh okay doesn't really make any sense but when ebony's research came out
• 32:06
  okay now it really makes sense.
• 32:09
  So some people get a lot of relief from doing isometrics, not everyone.
• 32:13
  And it doesn't necessarily have to be high load isometrics because what we were
• 32:17
  doing was low load isometrics because we're trying to keep the TFL out of it.
• 32:22
  So it was more motor control sort of training initially, but we were getting
• 32:26
  great sort of pain relief from low load isometrics.
• 32:28
  So even though Ebony's work initially was more high load, like 70 to 80% of
• 32:33
  an MVC, I'd say ours would be more 20 to 30% of an MVC.
• 32:39
  Of a maximum voluntary contraction and so yeah
• 32:41
  so it's I think it's a nice place to start but there's
• 32:44
  no way I'd put someone on isometrics and say right
• 32:47
  you go and do that for six weeks and and then we'll move on to the next phase
• 32:51
  it's certainly not that and all of my patients usually get isometrics and isotomics
• 32:57
  on the same day because they are moving and we have this you know it's not like
• 33:02
  they're in bed they're they're standing they're walking they're going upstairs
• 33:05
  stairs, they're getting in and out of chairs,
• 33:07
  this is our opportunity right now to actually start,
• 33:10
  movement training with them, which is their early isotonic type exercises. And so I love sort of.
• 33:18
  Direct transfer into people's everyday life. So, you know, I'd also be starting with, you know,
• 33:24
  squatting and bridging and lovely closed chain functional exercise,
• 33:29
  but, you know, teaching them how to do that more comfortably by,
• 33:33
  you know, positioning their body in a better way.
• 33:36
  So with gluteal tendinopathy, it's often about using excessive abduction.
• 33:39
  And so it's, you know, giving them clues of right, okay, don't shift to the
• 33:44
  side, you know, keep your knees facing straight ahead.
• 33:47
  And it's not, again, when we provide education, it's important that we provide
• 33:52
  it in a way that's not fear-inducing.
• 33:54
  And so it's not like, you should never walk like that or you're going to damage your tendon.
• 33:59
  It's not about that. It's cumulative loading. So I talk a lot about grumpy tendons
• 34:03
  and I just say to my patients, right, well, educate them around what the problem
• 34:08
  is and how certain joint positions are going to make your tendons more grumpy.
• 34:13
  Be. And so this is how that might apply in the things that you're doing in everyday life.
• 34:18
  And the big things are sitting positions, standing positions,
• 34:21
  sleeping positions, you know, walking upstairs, you know, and walking generally,
• 34:26
  getting in and out of chairs, things like that.
• 34:28
  And so when you, you know, crystallize that information into a meaningful way
• 34:34
  for the patient, and these are usually things that are painful for them,
• 34:37
  then it starts meaning something.
• 34:39
  And so exercises, sizes, if we can prescribe them in a way that directly starts
• 34:44
  targeting the problems that they're having, I think they get there a lot faster.
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  I've always admired, and you're doing it now, I love the way that you are so patient-centered.
• 36:03
  And I've heard you talk on other podcasts about how important the subjective assessment is.
• 36:08
  I want to talk about objective assessment as well, but I think we would do it
• 36:13
  injustice by not mentioning how important subjective assessment is as well,
• 36:17
  because like you say, it can be be different in the case of
• 36:20
  each patient and also the the rehab you give has to be built around their lives
• 36:25
  and what they can do and their understanding and they need to understand how
• 36:28
  important it is so can you give us some kind of ideas of where the subjective
• 36:32
  assessment should take us and when we're dealing with a patient in front of
• 36:36
  us with suspected due to tendinopathy.
• 36:39
  Yeah great point matt and yeah absolutely the the patient interview is something
• 36:44
  that it's just a wealth of information.
• 36:47
  And by the time you get to your objective assessment, you should pretty much
• 36:51
  have sort of narrowed down your potential diagnoses to usually two or three things.
• 36:57
  But so for gluteal tendinopathy, well, anything around the hip,
• 37:02
  like area of pain, I think is really important.
• 37:05
  And for tendon pathologies, you do often have a fairly, you know, localized area of pain.
• 37:11
  And so I do think that's very important for gluteal tendinopathy.
• 37:14
  Where is the pain and that area of pain should be over the greater trochanter.
• 37:20
  They might also get pain down the thigh, whether that's from the tendon themselves
• 37:24
  itself or whether it's actually related to the changes that I talked about in the iliotibial band.
• 37:31
  So we might have an ITB fasciopathy, if you like, down the side of the thigh
• 37:36
  as well. But area of pain I think is a good place to.
• 37:40
  Start in terms of you thinking about what might
• 37:42
  be some local problems sort of going on and
• 37:46
  so even in my patient interview I'll get the patient to stand
• 37:49
  up and point with one finger I say can you
• 37:51
  just stand up and show me exactly where that pain is and because if they can
• 37:56
  localize it fairly exactly it's probably likely to be something more local rather
• 38:01
  than oh it's sort of just running across my buttock and down into my thigh so
• 38:05
  that might tell me oh okay it might be something a bit bit more referred.
• 38:09
  So I'm going to be thinking a bit more about the lumbar spine.
• 38:11
  If it's less local and focal and they can't point to it, they sort of use more
• 38:16
  a broad hand stroke for where their pain is right across their buttock, down their thigh.
• 38:21
  So those things are important. And area of pain, again, when you're asking them
• 38:25
  about aggravating factors and night pain is very common with this population
• 38:30
  with gluteal tendinopathy and hip joint pathologies as well.
• 38:34
  And even with lumbar spine, you can get pain at night. But we want to ask those extra questions.
• 38:39
  So I think in a patient interview, well, in your objective as well,
• 38:43
  we become detectives. And I think that's part of the fun part of what we do
• 38:48
  as well, you know, being a detective.
• 38:50
  And so you want to ask more questions about their night pain.
• 38:54
  So I get pain lying on my side. So don't just go, tick, yep,
• 38:59
  they've got pain lying on their side. It must be gluteal tenonophily.
• 39:02
  Actually, a lot of things have pain lying on their side. So when they lie on
• 39:07
  their side, you know, what is it that hurts? Where does it hurt?
• 39:09
  And if they say, oh, over that bone on the side of my hip and it's like I roll
• 39:14
  onto this bone, I get sharp pain over my bone.
• 39:17
  If they're talking about the pain directly over the greater trochanter.
• 39:21
  Then, okay, yeah, that really sounds like gluteal tendinopathy.
• 39:25
  But if they're saying, oh, yeah, no, it's sort of just a deep ache somewhere,
• 39:30
  you know, deep around my hip there.
• 39:33
  And sometimes it's a bit at the front or a bit at the back. I mean,
• 39:36
  that might be more hip joint.
• 39:37
  So we might be thinking more OA, femoris tabulae impingement.
• 39:42
  Dysplasia depends on how old the patient is. If they're post 50,
• 39:46
  we might be thinking a bit more about OA. way. If they're sort of younger,
• 39:49
  we might be thinking FAI or dysplasia.
• 39:52
  Or it might be, yeah, when I lie on my side and, you know, I'm sort of a bit
• 39:56
  in a rotated position, then I get this pain that, you know, comes across my
• 40:01
  buttock, down my legs. Sometimes it hurts in my foot.
• 40:04
  You know, those are really important pieces of information.
• 40:07
  And so I think whenever we ask about aggravating factors, and sometimes early in our career,
• 40:13
  we're so fixed on the questions and And getting through the questions that we
• 40:19
  go, right, I've asked that, I've asked that, I've asked that,
• 40:22
  right, written down the aggravating factors,
• 40:24
  but we're not thinking about it as we go along sometimes.
• 40:27
  And that's where you get so much more information when you're thinking about it.
• 40:31
  And it's a puzzle and you're adding pieces of information to the puzzle.
• 40:36
  And the patient offers a piece of information and you go, oh, that's interesting.
• 40:39
  I want to know a bit more about that because that's going to hit me here or
• 40:43
  there. So I think area of pain, behavior of pain, you know, those aggravating
• 40:49
  factors are really important.
• 40:51
  Past history is so important or the history of, you know, this condition as
• 40:56
  well. So when did it come on?
• 40:58
  Oh, well, so this is a, you know, maybe 55-year-old woman.
• 41:03
  Well, it's sort of when I went through menopause, I started putting on weight
• 41:08
  and, you know, my cholesterol was a little high.
• 41:11
  And so my GP said look you really need to start
• 41:14
  losing some weight and you know looking after your heart health
• 41:17
  and so I started you know walking you know my kids
• 41:20
  were finally old enough that I didn't have to look after them
• 41:23
  all the time so I started focusing on myself and
• 41:26
  I started getting out there and walking and and he said
• 41:29
  okay and and how were you walking well you know it's
• 41:31
  really power walking so striding it out and I
• 41:34
  was trying to do lots of hills so that that's really good
• 41:37
  for my heart the GP said and so I started doing all this
• 41:40
  hill walking and so going from nothing to
• 41:43
  doing long stride walking which you know puts a lot of sort of impact you know
• 41:49
  up into the hip when you're taking those really big strides lots of hills which
• 41:53
  is quite provocative for the hip tendons as well and so there'd sort of been
• 41:58
  this sudden increase in activity levels.
• 42:02
  And then we've also got the demographic of the patient. So, you know,
• 42:05
  age, you know, menopausal status, you know, a little bit of being a little bit overweight.
• 42:10
  So we know that that's also linked with, you know, tendinopathies around the
• 42:14
  hip and lots of tendinopathies as well.
• 42:17
  And so, again, we've got the demographics, we've got this history,
• 42:20
  we've got area of pain, we've got behaviour of pain.
• 42:23
  Those things are really interesting. And then, you know, give us a lot of information about our diagnosis.
• 42:28
  Diagnosis but then as you said before Matt that information about
• 42:32
  what are the problems that you know how is
• 42:35
  this impacting your life so what are the functional issues
• 42:38
  that you have and then you know what do you want to do what do you need to do
• 42:43
  in your everyday life in your sport in your recreation in your occupation so
• 42:48
  those are really important things and it was because those are the things we
• 42:52
  want to focus on it was really interesting in the LEAP trial that we did on gluteal tendinopathy,
• 42:57
  that we did a secondary analysis looking at things that might moderate or mediate the effects.
• 43:04
  So might impact, so baseline factors that might impact your outcomes or the
• 43:09
  treatment effects of the three different treatment interventions we did,
• 43:13
  one of those being education and exercise, and then mediators,
• 43:17
  things that by changing this thing, it was the a change in that thing that might
• 43:23
  have created the treatment effects.
• 43:25
  And it was really interesting in that one of the things that ended up as a significant
• 43:30
  mediator, something that if we change that, that had a big impact on the overall
• 43:35
  outcome was patient function,
• 43:38
  patient specific function that was measured on the patient specific functional scale.
• 43:43
  So things that patients had identified, this is a problem for me.
• 43:47
  And if we change those things, then the patient's overall rating of condition,
• 43:55
  you know, seem to be, you know, significantly affected by the treatment.
• 44:00
  So it was interesting. So the message coming from that is that,
• 44:03
  you know, to optimize our management outcomes,
• 44:08
  if we can focus on the things that are important to the patient and they're
• 44:12
  are affecting their lives,
• 44:13
  that's likely to give them, you know, the outcome that they want in terms of
• 44:19
  their global rating of outcome, if you like, and their quality of life.
• 44:23
  So that also affected quality of life as well. So yeah, really important points
• 44:28
  about the things that we want to get out of that patient interview.
• 44:31
  It's amazing. Again, it's so valuable and you explain it so So,
• 44:36
  well, a lot of guests on the show have talked about the importance of subjecting.
• 44:42
  We say it time and time again, and a lot of the issues with our industry are.
• 44:47
  Is is jumping to the objective especially if you've
• 44:50
  just done a cpd course and it's like suddenly you've
• 44:53
  learned about this and guess what everyone who walks to the clinic the next day
• 44:55
  has got that thing you found it like why haven't i seen this before so
• 44:58
  we know we've got our own confirmation biases as soon as
• 45:01
  we put our hands on i love the way that you
• 45:04
  say get the patient to point to the
• 45:07
  area of pain because again if we jump in with
• 45:10
  our hands and go does this hurt you know guess what
• 45:13
  you know it might hurt but it's just because it's coincidence or if
• 45:16
  you went on the other side they'd probably say it hurt as well so it's really
• 45:19
  it's so refreshing hearing all of this stuff which we
• 45:22
  do to get a decent hypothesis
• 45:27
  and to understand what's going on and look already at
• 45:30
  ways of rehabbing this person in front of us before we've
• 45:33
  even touched them and and at the moment there's this
• 45:35
  again is it getting a bit better i don't know it depends where you look but
• 45:39
  this is like hands-on hands-off debate as if it's one or the other which is
• 45:42
  ridiculous because Because all of the stuff you've talked about means that when
• 45:46
  we do put our hands on and use the important palpation and all the different
• 45:51
  stuff we can do to assess, it's more meaningful.
• 45:54
  So it's not like one or the other. It's just it needs to be in that order, doesn't it?
• 45:57
  You've got to give them a good listening to, which I love as a kind of a quote.
• 46:01
  Some patients just need a good listening to.
• 46:03
  And they'll give you all the answers. They'll tell you how to fix them. You know, it's amazing.
• 46:09
  Yeah, absolutely. Absolutely. I think that's incredibly important that you get that information.
• 46:13
  And the thing is that there are so many tests.
• 46:16
  And I know that, again, there's lots of debate about how meaningful are all
• 46:19
  these tests. But again, they're just clues.
• 46:22
  We're sort of gathering clues in our objective assessment.
• 46:26
  But in my HIP Academy, for my video library, I've recorded over 100 different
• 46:32
  tests around the HIP. There are so many different tests.
• 46:36
  You cannot possibly do do all the tests to try to screen for everything.
• 46:41
  So you're always going to do a joint screen, a hip joint screen.
• 46:45
  You're always going to do a lumbar spine screen for anything around the hip
• 46:48
  and pelvis. So, you know, you've got those things that you've got to do.
• 46:52
  And so then other specific tests, you need to already, before you get to that
• 46:57
  objective assessment, have a bit of an idea of which things you're going to test.
• 47:02
  Otherwise, you're going to spend your whole time assessing and you're not going
• 47:05
  to get to any treatment and you might even be still assessing in the next treatment
• 47:09
  session if you want to do all the tests.
• 47:11
  So I think from a point of efficiency, it's also really important that you've
• 47:16
  got an idea of what you need to test when you get to that objective assessment.
• 47:21
  It's um it's interesting for professionals
• 47:24
  out there because now we know that subjective is
• 47:27
  so important and and thanks to educators to yourself hopefully therapists
• 47:32
  and listeners and people in the live lounge whether you've gone very quiet
• 47:35
  is it because you're scribbling away notes you can put the pen down we
• 47:38
  are recording this okay people if you want to ask questions you don't have to
• 47:41
  write a thing down but now that therapists are appreciating that we need to
• 47:46
  listen more and that we're kind of more facilitators rather than operators to
• 47:50
  quote kind of the diane jacobs and silver and all that but it means the subjective
• 47:55
  is going to take more time and it's important but.
• 47:58
  Unfortunately patients and clients aren't quite on the
• 48:01
  same page yet and we've got to be careful when they come in we
• 48:04
  might suddenly think i'm just going to talk to you for an hour and have this that's
• 48:07
  where the answers are i listen to dr allison groundy i'm going to touch you
• 48:10
  and yet again with classic mistake is that at that moment in time the patient
• 48:15
  just wanted to come in and feel good from a massage and they're not happy they
• 48:18
  don't come back and see you so again it's checking the expectations of the patient
• 48:24
  isn't it before you jump in with any protocol.
• 48:26
  Yeah yeah absolutely and hands-on is just so powerful and yes you definitely
• 48:32
  need to do a physical assessment but even in that first session if you can get
• 48:36
  your hands on a patient and i often do a little bit of massage in that first
• 48:41
  session for example with gluteal tendinopathy As I said, they're often,
• 48:45
  you know, tender up that lateral thigh and their TFL and the upper glute max,
• 48:51
  you know, is often quite, you know, tender and stiff, if you like.
• 48:55
  So I'll get them in a nice, comfortable position and I'll give them some massage
• 48:59
  while I'm educating them.
• 49:01
  And it's really great because they get their hands-on treatment that,
• 49:05
  you know, will give them some, you know, very short-term relief,
• 49:08
  but it'll give them some relief.
• 49:09
  But you're getting your hands on. And I think there's something about that in
• 49:13
  terms of that sort of therapeutic alliance.
• 49:15
  But you're telling them that I understand that you're in pain and that you need some relief right now.
• 49:21
  But while we're doing that for you, we're going to educate you about what the
• 49:25
  longer term, you know, treatment or longer term management is going to involve.
• 49:29
  And so, you know, I'll talk to them about, you know.
• 49:32
  The role that massage plays while I'm doing that massage, that massage can help
• 49:38
  ease some of your symptoms, but it's not going to be something that's going
• 49:42
  to solve the situation for the longer term.
• 49:45
  So while we're sort of giving you some relief here, I'm going to talk you through
• 49:49
  some things that you can do in everyday life to try to reduce that grumpiness in your tendon.
• 49:56
  And then exercise is going to be the other thing that's going to be so important
• 50:00
  in your long-term outcome and management of this condition.
• 50:04
  So I do believe hands-on treatments are useful,
• 50:07
  but not in, like, if we were just massaging and then they think that that is
• 50:13
  the treatment and then we keep just providing massage for months and months
• 50:18
  and months, you know, that's not going to ever get an adequate solution.
• 50:23
  It'll give them some short-term relief and that can be very useful
• 50:26
  as an adjunct but i think it's just important
• 50:29
  that we put that together with you know our education and
• 50:32
  our and exercise approaches as well it's fantastic
• 50:35
  man so that's really hopefully it's really empowering for listeners to understand
• 50:39
  that because again in this era we live in where it's kind of like hands on our
• 50:44
  hands off people don't understand it's not a case of that it's just you're going
• 50:48
  to do different things with your hands you know not everybody likes being touched
• 50:51
  That's what you could call it, like,
• 50:53
  again, Diane J, because it's all about this primal grooming.
• 50:56
  It's social grooming. It's like humans like touch.
• 50:59
  When we're educating kids, normally the best education is done with an arm around them.
• 51:03
  It's that contact which starts off, which opens up that alliance,
• 51:06
  if you like, that third particular alliance.
• 51:08
  So it's not a case of hands on, hands off, is it? It's just explaining to the
• 51:12
  client, this isn't fixing you.
• 51:13
  I'm not going to bend you back in position again. But this is what we're going
• 51:16
  to do as you're doing that. And it can be really useful.
• 51:19
  Yeah, that's right. Right. And even when we're doing things like movement education
• 51:22
  and like providing exercise therapy, and if we're doing functional things,
• 51:28
  you know, it's like movement training as well.
• 51:30
  We're going to put our hands on like, because tactile facilitation is really
• 51:34
  useful in terms of helping them find that, you know, that better position,
• 51:40
  that position that's going to be less provocative for them.
• 51:42
  So hands-on can be very useful, you know,
• 51:45
  not just in hands-on manual your therapy techniques but but also in the way
• 51:50
  we you know train our patients and provide them cues and feedback for what they're
• 51:55
  doing in movement training or exercise therapy.
• 51:59
  Amazing um i'm just looking at the clock and thinking great six minutes left
• 52:03
  i wish it was only we just started six minutes but there's you've already given
• 52:06
  such amazing information of allison it's incredible but i want to no i can't
• 52:11
  i can't go into anything else i was oh just quickly because i know it's topical
• 52:14
  as well and i've heard you talk about it before and i think you put it really nicely.
• 52:19
  Corticosteroid injections is something which a lot of listeners will probably
• 52:23
  either have clients coming saying, I think I need an injection, I need this.
• 52:27
  And unfortunately, sometimes they're told by other therapists.
• 52:30
  As they're moving around trying to find an answer they want.
• 52:33
  But what is the lowdown, according to you and your research on corticosteroid
• 52:38
  injections with either tendinopathies of the region in general or gluteal tendinopathies? Where is their place?
• 52:44
  Okay. So the evidence that we have for gluteal tendinopathy suggests that cortisone
• 52:51
  can definitely provide some short-term relief,
• 52:55
  but longer term that tends to be poorer outcomes, And the outcomes are often
• 53:00
  not better than wait and see or doing nothing in the longer term.
• 53:07
  So we did a randomized controlled trial comparing education,
• 53:11
  exercise, a corticosteroid approach, and a wait and see approach.
• 53:16
  And we looked at their global rating of change, so their global improvement,
• 53:22
  and we looked at pain intensity. So they were our primary outcomes at eight weeks and 52 weeks.
• 53:29
  And so at eight weeks, and I think someone in the chat there has asked about
• 53:34
  timeframe as well. So this might answer that question.
• 53:37
  So at eight weeks, education and exercise was superior.
• 53:42
  And so it had significantly better outcomes in terms of overall change that
• 53:48
  the patient had rated their overall condition, but also in terms of pain intensity.
• 53:53
  So education exercise had reduced pain intensity at eight weeks more than corticosteroid
• 53:59
  injection and the wait and see, of course.
• 54:03
  And then at 12 months, again, the education exercise group was again significantly
• 54:09
  better in terms of their global rating of change.
• 54:14
  So their overall outcome and their quality of life was significantly better.
• 54:18
  The pain intensity was
• 54:21
  similar so it was not significantly different
• 54:25
  between cortisone and education exercise at
• 54:28
  that 12-month period because pain had sort of generally you know reduced in
• 54:33
  all groups but the corticosteroid group and the education exercise group still
• 54:38
  had less pain than the wait and see group so there was still some effect on
• 54:43
  pain levels at that 12-month point So it's interesting looking at, right,
• 54:48
  well, why were they rating themselves as, you know, not as good compared to
• 54:53
  the education exercise group?
• 54:55
  And part of that is, you know, and that's why we did sort of the moderator and
• 55:00
  mediators things as well to sort of see what factors might have been affected.
• 55:04
  But so things like, you know, quality of life was certainly higher in the education and exercise group.
• 55:11
  So there's something that was changing in that group that was more than just pain intensity.
• 55:17
  One of the things we found that was interesting was pain constancy.
• 55:20
  And so we asked patients, so over the last week, as a percentage of time,
• 55:26
  what percent of time have you had pain?
• 55:29
  Where 0% is you haven't had any pain and 100% is you've had constant pain.
• 55:34
  And interestingly the education and
• 55:37
  exercise group had significantly lower pain
• 55:40
  constancy both in the short term and
• 55:43
  in the long term as well which is something to be really
• 55:47
  aware of for clinicians as well because patients will often come
• 55:50
  back and say the pain's the same but they might be talking about pain intensity
• 55:54
  and so you might get similar pain intensity but actually pain constancy is much
• 55:59
  less so if you've got a patient who has come in initially with I've got pain
• 56:04
  constantly or 80% of the time I have pain,
• 56:07
  but now you've got the same pain intensity,
• 56:10
  but the pain constancy is only 20% of the time.
• 56:13
  That's a really big improvement. And that's, you know, that really has a good
• 56:17
  impact on your quality of life because you're not having to think about this pain all the time.
• 56:22
  So that's, that's something that probably, you know, influenced that outcome as well.
• 56:27
  But I think the other thing about cortisone is that like within that very early
• 56:32
  period, like they do get some immediate pain relief.
• 56:37
  And we can get some change in education and exercise even within a few weeks.
• 56:42
  So we usually talk about tendinopathy management as it's a longer term thing
• 56:48
  because you need to do exercise for the longer term and to address any deconditioning
• 56:54
  and tendon health, that's a a longer term game.
• 56:58
  So we're sort of talking six to 12 months with that, but we can change pain
• 57:02
  relatively quickly, but not as quickly as cortisone.
• 57:05
  In that cortisone, you'll get an immediate response from having that cortisone injection.
• 57:10
  And the interesting thing that I see in clinic and actually looking at the results
• 57:17
  of the trial as well, we tracked activity levels as well for these three different groups.
• 57:23
  Now, it wasn't significantly different, but I'm mentioning it because it's something
• 57:28
  that I see in the clinic all the time in terms of behavioural response to different interventions.
• 57:33
  And so the education exercise group got obviously detailed, you know,
• 57:37
  education and advice, and they
• 57:39
  were told to reduce your activity for the moment, for the first few weeks.
• 57:43
  We're going to, you know, help you, you know, learn to walk in ways that are
• 57:48
  less, you know, aggravating and, you know, we're going to get your exercises
• 57:51
  going and then we'll gradually increase your activity levels again,
• 57:54
  usually after that four-week mark. And.
• 57:58
  The other two groups, the cortisone group and the wait and see group,
• 58:01
  they both did get a basic pamphlet.
• 58:04
  And that pamphlet did give them some information about what the condition was.
• 58:09
  And it basically said something like, you know, if you're getting pain with
• 58:14
  activity, reduce your activity initially and then gradually increase it,
• 58:19
  avoiding rapid spikes in activity levels.
• 58:21
  So just that basic piece of information.
• 58:24
  And it's really interesting to look at the traces of what
• 58:27
  happened so the education exercise group and the
• 58:30
  wait and see group their activity levels both
• 58:34
  came down for the first four weeks and
• 58:37
  then gradually increased over time the corticosteroid group who'd got the same
• 58:42
  information as the wait and see group their activity levels from baseline went
• 58:46
  up for four weeks and then it came down and stayed down lower over time yeah
• 58:52
  and as i said it wasn't statistically significant,
• 58:56
  but it's what I see in clinic.
• 58:58
  If you take pain away really immediately, I see it as robbing the patient of
• 59:05
  the opportunity to learn how to effectively load manage themselves.
• 59:09
  Because if the pain's not there the next time they go upstairs,
• 59:13
  they forget that actually my therapist told me to walk with my feet a little
• 59:19
  bit wider, to not shift my hips to the side, you know, the tips that we give
• 59:24
  people, you know, I started getting pain in sitting.
• 59:27
  Oh, I've been sitting with my knees crossed the whole time.
• 59:29
  You know, these things that pain is a really important teacher.
• 59:34
  If we take that away completely, really rapidly, then patients don't attend
• 59:42
  to that load management advice, not because they're naughty people,
• 59:45
  but just it's not there. The stimulus is not there to learn.
• 59:49
  And again, with exercise, are they as compliant with exercise?
• 59:53
  No. Again, not because they're naughty people, but because, you know, we all have busy lives.
• 59:59
  We've got other, you know, demands on us.
• 1:00:02
  We've got children and work and everything going on. If you don't have pain
• 1:00:06
  there saying, you need to do something about me, then they're going to go,
• 1:00:11
  well, actually, you know, my son needs me to do this.
• 1:00:14
  My work needs me to do that. I'll get to the exercise later,
• 1:00:17
  you know, and so we see less exercise compliance, less exercise volume,
• 1:00:23
  less attendance to load management.
• 1:00:26
  So a lot of the time, you know, our medical colleagues, you know,
• 1:00:31
  who are trying to do the right thing by their patient, but they're trying to
• 1:00:34
  give them that quick pain relief.
• 1:00:36
  But it's often given in the context of we'll reduce your pain quickly so that
• 1:00:41
  you can attend to your exercise.
• 1:00:44
  Actually, that doesn't happen in the real world. If you reduce the pain,
• 1:00:49
  they're not going to attend to their exercise.
• 1:00:52
  Not that I'm an awful person saying we need to keep them in pain.
• 1:00:55
  No, it's not that. We want to reduce their pain rapidly.
• 1:00:58
  But you want to have a little inkling there so that they get that little reminder
• 1:01:03
  and then immediately they start learning. They start learning.
• 1:01:06
  And these are the things that are going to change them for the longer term and
• 1:01:11
  help them them effectively load manage for the longer term.
• 1:01:15
  If we rob them of that opportunity, actually, when the pain comes back,
• 1:01:19
  interestingly, patients don't think from my conversations with them,
• 1:01:23
  they don't think, well, that didn't work.
• 1:01:25
  I'm not going to have another injection. They think, well, that worked.
• 1:01:28
  I need to go and have another injection.
• 1:01:31
  Even if the pain relief was only for two days, I'll go, well, that worked.
• 1:01:35
  I'm going to need to have another injection. And so it seems to set up this
• 1:01:39
  cycle of, you know, passive treatment, you know, seeking passive treatments and quick fixes.
• 1:01:45
  And so I think from a lot of behavioral effects that it has,
• 1:01:50
  and then of course, it's the biological effects it has on the tissue. So cortisone is toxic.
• 1:01:57
  It's a very powerful pain reliever, but it's toxic to tendon tissues.
• 1:02:02
  It's toxic to all our musculoskeletal tissues. So, and how much is safe?
• 1:02:08
  We actually don't have information for that, but we know that the more cortisone
• 1:02:13
  injections people have had around their gluteal tendons, the more unhealthy
• 1:02:17
  those tendons are, the more likely they are to progress to surgery.
• 1:02:22
  You know, the worse they're often going to do post-surgery.
• 1:02:26
  So, you know, more cortisone is not going to be a good thing for them.
• 1:02:32
  So, So it's important that, you know, and we don't want to make,
• 1:02:35
  if someone, a patient comes to you and they've already had a cortisone injection,
• 1:02:39
  of course, we're not going to say, oh dear, that's terrible.
• 1:02:41
  We can't help you now. But it's just, I suppose, being mindful that if they
• 1:02:48
  have already had cortisone injection,
• 1:02:50
  often our outcomes are actually slower and they might be reduced,
• 1:02:54
  particularly with multiple injections.
• 1:02:57
  You might have to lower your expectations about how fast they might progress
• 1:03:01
  and where you might get them to, because I think it does change the responsiveness
• 1:03:05
  of the tendons and the health of those tendons.
• 1:03:09
  But, you know, this is just, a lot of that is my.
• 1:03:12
  Clinical extrapolation of the research and what I've seen from 30 years of clinical practice.
• 1:03:18
  And so I would much rather treat a patient who's never had a cortisone injection.
• 1:03:23
  And so it's educating, you know, our doctors as well and say, don't try to help me.
• 1:03:29
  Like they're trying to be really helpful. I mean, they're trying to help the
• 1:03:32
  patient, of course, but often it ends up not being that helpful.
• 1:03:36
  And so I educate my referrers about, yeah, just,
• 1:03:39
  you know, can you just not help me don't don't
• 1:03:43
  give that cortisone injection and so but you
• 1:03:46
  know it's hard because the patient you know is pushing the
• 1:03:49
  doctor for you know you know a pain response but I'd rather them actually have
• 1:03:55
  some oral pain medication for a period of time um rather than that sort of local
• 1:04:00
  injection at the at the hip and then if you know so often patients will come
• 1:04:06
  to me for my referrals and And they might have a,
• 1:04:08
  like a referral for a cortisone injection,
• 1:04:12
  although I haven't had that recently, but, you know, probably earlier in my
• 1:04:15
  education process before the doctors could see, I suppose that actually,
• 1:04:20
  you know, we can have the effect without the cortisone, the patient would turn
• 1:04:23
  up with the referral and they'd say, the doctor told me to ask you about whether I should have this.
• 1:04:28
  And then I'd go, all right, it's good that you've got that up your sleeve.
• 1:04:32
  So we've got that up, you know, as a backstop, but let's try these things first.
• 1:04:36
  And then if you need it, we've got that, you know, we can fall back on.
• 1:04:41
  But, you know, let's try this first. And generally, I'd prefer people to,
• 1:04:45
  you know, if they're really severe, I'd prefer them to use a walking aid and
• 1:04:49
  use some oral analgesics initially and just see if we can get them calmed down.
• 1:04:54
  Of course, if they need it, they need it. If their pain is severe,
• 1:04:58
  they're not sleeping and things like that.
• 1:05:00
  But you'd be surprised how much impact we can
• 1:05:02
  have in a couple of weeks with some good good
• 1:05:05
  education and you know a walking aid
• 1:05:08
  if necessary if it's really severe limping so walking
• 1:05:12
  stick crutch or something yeah and that's not that
• 1:05:15
  like that we're saying you need to be on a stick forever now no this
• 1:05:18
  is a temporary thing and so often i use a crutch rather than a stick because
• 1:05:22
  a crutch seems like a an injury that you'll progress past rather than a stick
• 1:05:26
  seems like a disability it's interesting yeah good good points you know that's
• 1:05:32
  so a lot of patients will be happier to use a crutch than a stick.
• 1:05:35
  Very cool. And it is all about behavior. And I think that that conversation
• 1:05:40
  really can test the relationship you've got with the patient.
• 1:05:45
  It tests all your skills of active listening and letting them speak and then educate.
• 1:05:51
  Education is not something we're taught as clinicians, isn't it?
• 1:05:54
  We're typically taught, whatever we are, to do things with our hands.
• 1:05:57
  And we're not taught how to educate or to get on with people and help behavior change.
• 1:06:01
  It's missing from our toolbox. box so yeah it's fascinating
• 1:06:04
  to hear that but putting it into effect is yeah it's a little
• 1:06:07
  change of conditions look i'm keeping you past your time i
• 1:06:10
  know i mean i've got nothing to do now i've got somebody watching tv eat
• 1:06:13
  up my dinner go to bed but it's different for you you've probably got a whole
• 1:06:16
  day ahead for you so i'm conscious of that i do
• 1:06:19
  want to just quickly mention thank
• 1:06:22
  you for the questions in there sorry i didn't get to them but
• 1:06:24
  you can understand why i didn't want to interrupt that car gregory
• 1:06:27
  says just joined and already love what i hear re-watching tomorrow
• 1:06:30
  cloud car you will love this i know you and
• 1:06:33
  you will really enjoy the full hour and maria
• 1:06:36
  maxieri thanks for joining us and maria from the
• 1:06:39
  st school says absolutely touches context for health literacy yep lovely and
• 1:06:43
  maria is one of our national champions for modern approach to your hands on
• 1:06:50
  and massage and everything time frame we had gary benson here says was there
• 1:06:54
  and increased confidence and movement in the education and exercise group?
• 1:06:59
  Good question, Gary. Yeah, good question, Gary. And yes, there was.
• 1:07:03
  And that's really important.
• 1:07:05
  Well, what we measured was pain self-efficacy.
• 1:07:09
  Okay. So, and part of the questions in there are around, you know,
• 1:07:13
  doing your physical activity and despite the pain.
• 1:07:16
  And I do think that change in confidence is something that does underpin them,
• 1:07:22
  you know, feeling more like supervised training
• 1:07:25
  that we do feeling more confident in the way that they move
• 1:07:29
  I think that does really impact on
• 1:07:32
  their quality of life because they start doing more things and getting back
• 1:07:35
  to the things that they want to do and need to do and so yes confidence is something
• 1:07:40
  that I think is really important and education and reassurance and showing them
• 1:07:46
  how to move and sometimes I think education gets a bad rap because it's sort
• 1:07:50
  of like like, you know, you're making them fearful.
• 1:07:52
  Actually, no, we shouldn't be making them fearful.
• 1:07:55
  It's how you do it. And it's actually about empowering them.
• 1:08:00
  So if they can't walk upstairs because they feel like someone's ice-picking
• 1:08:04
  them in the greater Trichana, but you can show them how to do that without an
• 1:08:08
  ice-picking the greater Trichana, that's not fear-inducing, it's empowering and it's relieving.
• 1:08:14
  And they finally understand why they have this problem and what they can do about it.
• 1:08:19
  And it's, you know, the impact on their confidence, I think, is incredible.
• 1:08:24
  And that's what we showed in that first sort of eight weeks there,
• 1:08:26
  pain, self-efficacy, that confidence dramatically increased, which is great.
• 1:08:31
  Fantastic. Right.
• 1:08:34
  I love the way you provided a fantastic segue for Ebony, Dr.
• 1:08:37
  Ebony Rio, for next week. We'll be talking about pain and pain management.
• 1:08:40
  And you mentioned her paper as well with the isometrics. And yeah,
• 1:08:43
  so that's a lovely segue.
• 1:08:44
  Like I say, in two weeks' time, people, not next week.
• 1:08:47
  We're having a bit of a break. But the week after, Ebony Rio's not.
• 1:08:51
  She's flying somewhere and coming back somewhere. So that's why we're moving it forwards.
• 1:08:54
  But we will have the pleasure of an hour with Dr.
• 1:08:57
  Ebony Rio in two weeks' time, still at 9 o'clock BST. but i
• 1:09:00
  just want to make sure if people are interested in further
• 1:09:04
  education obviously there's so much great work you
• 1:09:07
  do for education as well as in clinics i'm just going
• 1:09:09
  to bring this up for people in the live lounge let's put
• 1:09:12
  it on here the website if you're interested people so drallisongramaldi.com and
• 1:09:17
  across social media thank you allison for just having dr allison gramaldi anywhere
• 1:09:21
  with a lot of people it changes it depends whether you're on twitter or Instagram
• 1:09:25
  or that it's just so simple Dr Alison Grimaldi is where you will find Dr Alison
• 1:09:29
  Grimaldi so well done on that I'm getting your name in there but yeah the website
• 1:09:32
  is a wealth of knowledge just talk us briefly if you're okay for a couple of
• 1:09:36
  minutes because I'm conscious it is.
• 1:09:38
  12 past where I am and where you are. You mentioned the Hip Academy.
• 1:09:42
  Let us know a little bit quickly, briefly about that.
• 1:09:45
  Sure. So, excuse me, Hip Academy is a group of health professionals from all
• 1:09:51
  over the world. So health and exercise professionals.
• 1:09:53
  And it's a lovely community that we get together, you know, every couple of
• 1:09:59
  months or so and do an extra lecture and a live lecture and questions and we
• 1:10:04
  do case presentations as well.
• 1:10:06
  And those are all recorded and part of our library of resources,
• 1:10:11
  but Hip Academy members also get access to all the hip courses.
• 1:10:15
  So there's four different hip courses, there's four eBooks as well.
• 1:10:18
  And then there's that large video library that I mentioned before that contains
• 1:10:22
  little short videos of all the different assessment techniques.
• 1:10:27
  And so that's not only diagnostic techniques, but muscle assessment techniques
• 1:10:31
  as as well, and exercises.
• 1:10:34
  And so that goes through how we'd, you know, prescribe the exercise to a patient.
• 1:10:38
  So it's got voice over there of the cues that we use for patients.
• 1:10:42
  Yeah, so there's lots of information there and information on reading x-rays
• 1:10:48
  and MRIs and things like that.
• 1:10:50
  So yeah, so it's a great community. And the bit I love best is the live meetings
• 1:10:55
  because we do have people sort of logging in from lots of different professions
• 1:10:59
  and different places all over the world.
• 1:11:01
  So it's great to get discussion from different perspectives as well about different conditions.
• 1:11:10
  So yeah, you're very welcome if you'd like to join us at Hip Academy.
• 1:11:13
  If you have a specific interest in gluteal tendinopathy and you don't want to
• 1:11:17
  do the whole Academy thing, there's a course on lateral hip and buttock pain.
• 1:11:22
  There's an e-book on gluteal tendinopathy and there's one on proximal hamstring
• 1:11:25
  tendinopathy as well, or you can get the whole e-book series as well.
• 1:11:29
  So depending on how deep you want to go into it, there are different resources for your needs.
• 1:11:36
  Fantastic. And hopefully, listeners, you can hear from the hour we've spent
• 1:11:40
  with Dr. Alison Grimaldi tonight.
• 1:11:42
  You can imagine how it's going to be presented in, if I can say,
• 1:11:46
  a wonderfully infectious, passionate way. It's just amazing.
• 1:11:48
  And that's important as well. There's so many courses out there.
• 1:11:51
  And one of the things is, is the person giving the course presenting it in a
• 1:11:54
  way that you can take in and enjoy it.
• 1:11:56
  So yeah, do check that out. And there's also on On the website,
• 1:11:59
  dralisongabaldi.com, there's also a blog.
• 1:12:03
  There is loads of information. Oh, I've just taken it off. There's loads of
• 1:12:06
  information for you to check out. So I do recommend you go there.
• 1:12:08
  It will be in the show notes, people, if you want to go and have a look.
• 1:12:12
  So yeah, do check it out. And there's some wonderful blogs there.
• 1:12:15
  And also, like Alison has said, links to the books and the video library.
• 1:12:19
  So yeah, a wealth of information, fantastic stuff.
• 1:12:21
  So we appreciate that, Alison. Thank you.
• 1:12:24
  And also, ironically, you're over in the UK in a week or so,
• 1:12:26
  aren't you? It's too late to book you people. Don't get excited.
• 1:12:28
  But you're coming over here.
• 1:12:31
  Yeah yep so i'll be over i think there
• 1:12:34
  might be there might be a couple of places left on a
• 1:12:37
  couple london courses i'm not sure but a lot of them are booked out but there
• 1:12:41
  might be a couple of places in london so vital pm is who's hosting it so that's
• 1:12:47
  available there and matt the other thing i just wanted to mention to your listeners
• 1:12:51
  is that course on my other website if they're interested in that.
• 1:12:56
  So there's another website that I have that is patient-facing, so hippainhelp.com.
• 1:13:03
  And if you're interested, or you might have patients that are interested as
• 1:13:07
  well, but there is a course that I've done there for patients on gluteal tendinopathy.
• 1:13:12
  And so that sort of goes through a number of educational videos.
• 1:13:16
  And so from your therapist perspective, that might be nice at least to sort
• 1:13:22
  of see what sort of education that I'm usually providing to my patients.
• 1:13:26
  And then there's also exercises there as well.
• 1:13:29
  And so there's videos of the exercises and cues about what things that we focus
• 1:13:34
  on in the exercises and information about how to progress or how to regress
• 1:13:39
  if you have a flare up or things like that.
• 1:13:41
  So that's another resource that might be helpful as well. And that's, what was it, hip health?
• 1:13:49
  Hippainhelp.com. Hippainhelp.com. We'll make sure that goes in the notes.
• 1:13:52
  Yeah, that's brilliant like we're saying off air seeing how you
• 1:13:56
  can educate a patient and using the terminology of patient we get
• 1:13:58
  on with that that's going to be a wealth of information as well so thank you for that
• 1:14:01
  yes all of that will be in the in the notes
• 1:14:04
  people so there we go it's 17 minutes
• 1:14:07
  past dr arson round i hope i haven't caused you to miss anything
• 1:14:10
  coming up no that's okay so and thank
• 1:14:16
  you so much everyone who's joined us live as well some amazing questions in
• 1:14:19
  there thank you for people listening to the podcast if you are listening then
• 1:14:23
  check out all of the links which will be in the
• 1:14:26
  show notes and do please leave a
• 1:14:28
  rating as well on particularly google podcasts apple podcasts
• 1:14:31
  because it just helps the information shared by
• 1:14:35
  our wonderful guests just appear more in google which is all about what's all
• 1:14:37
  about it's all about education like i say next week in
• 1:14:41
  two weeks time sorry dr ebony rio will be with us um
• 1:14:44
  to focus on managing tendon and pain which will be
• 1:14:46
  a lovely continuation of some of tonight's themes so if
• 1:14:49
  you listen to the podcast you want to join us for that then that will be june
• 1:14:52
  the 4th at nine o'clock bst british standard time so there we go right thank
• 1:14:57
  you once again dr alice good mouthy for your time it's been absolutely amazing
• 1:15:00
  really really appreciate it no worries thanks so much for having me and thanks
• 1:15:04
  all the listeners to um listening thanks people take care of each other we'll see you soon.
• 1:15:10
  Music.