187. What We Get Wrong About Lateral Hip Pain | Alison Grimaldi, PhD

0:00 post-partum months, often their Eastern levels are at a little bit of a low there as well. And then they've often got poor pelvic control coming out of, you know, those months of pregnancy and then they might want to start running to get rid of that baby weight and really not. So it's so important that we try to address that as quickly as we can because if we can get a patient a better night sleep, everything starts to turn around and feel much better. Welcome to Medicine Redefined, a podcast focusing on helping you reclaim ownership of your health. I'm Dr. Darsha and I'm Dr. Ultima Shraja, where your hosts, hair to challenge conventional practices and uncover the stories behind pioneers shaping the future of medicine. Our conversations not only focus on the individual level to dissect common practices for health optimization but also zoom out to enhance systemic change.

0:51 Join us as we look to break the status quo, move the needle forward, and put the help back in healthcare. Before we dive into today's conversation, I have an exciting update. My new practice refining health and performance is officially launching Sue. It's a practice built around health, longevity, and performance. The Medicine 3.0 approach we talk about every week here on this podcast. And here's the best part. It's a telemedicine clinic so you can work with me from the comfort of your home. Our founding member Roma is now live, so if you'd like to learn more or join the weight list, visit refininghealthrx.com. All right, let's get into the episode. Today we're joined by Dr. Allison Grimaldi. She's a fellow of the Australian College of Physiotherapists, Principal Physiotherapist at Physiotech and Adjunct Senior Research Fellow at the University of Queensland. With over 30 years in clinic and research, Allison is a go-to authority in HIP, growing, and Pellumbu pelvic disorders. She earned her PhD at the University of Queensland.

1:45 She's co-supervised multiple doctoral projects and presents internationally on HIP biomechanics at evidence-based rehab. She founded HIP Academy in 2020 to help clinicians translate research into practice. She has published widely, pioneered real-time ultrasound for HIP muscle assessment and still keeps an active caseload from everyday movers to elite athletes and running dance and field sports. In part one of this two-part series, we unpack the complexity of the HIP Lumbu pelvic region and why misdiagnosis here drives poor outcomes. We focus on extra-articular anatomy, especially the lateral HIP, which is still commonly mismanaged. We'll cover why Tricotiric presidice is over-cult and how to correctly identify gluteal tonnopathy, the anatomy that drives compression at the lateral HIP, the clinical test that actually move the needle and the simple daily tweaks that stop pain fast. We'll also compare injections with non-interventional care, discuss the landmark trial Allison helped lead, and where PRP fits alongside rehab. As I mentioned, the HIP is complex and there's no way to do it all in one sitting. So our goal today is to give you clear mental models and a plan for your own symptoms or your patients. Enjoy. All right, everyone. We have Dr. Allison Grimaldi here in front of us today. Dr. Grimaldi, thanks so much for joining us on the show. No problem. Thanks so much for the invitation. Great to be here with you. Yes. So there's a lot of joints in the human body, right? There's the knee, the ankle, the shoulders, the elbows even. Why the HIP? What got you so interested in researching? Well, I think it's a familiar story for many in that I'd had my own

3:18 HIP problem, you know, earlier, so in my early 20s, I suppose earlier in my career and it was something that you'd go along to courses to try to learn, you know, for example, and then, you know, went to the literature and there was so little back then on the HIP. And, you know, I really couldn't get the answers that I wanted for my own self. And so then I had to sort of reflect and go, right, well, I'm going to have to figure this out myself. And so, you know, that sort of headed me down into the direction of sort of doing deeper dives into what information that we did have, trying to make clinical links between that information and eventually sort of that headed me into research. And, you know, certainly my area of clinical interest has been in the HIP, but yeah, my own HIP sort of that out, which is good. But yeah, it's something that I think really was under investigated, you know, that 20, 30 years ago, but it's been such an exciting space to be in because there's been just so much research and information, you know, coming out, you know, in this last 10, 15 years, there's just been an explosion of research. And so it's been a really exciting space. And I guess now the challenge for a lot of clinicians out there who are wanting to understand the HIP is that there is just so much information now. And so now it's trying to, you know, figure out what's important and, you know, what is the clinical relevance of the information.

4:49 And so a lot of what I'm doing now is trying to sort of help other clinicians with, you know, deciphering the research and condensing the research messages, I suppose, and putting it in a more clinically relevant framework. Love that. So, I mean, we're obviously very excited to get into all those topics that we're going to talk about that you've really been preaching about that we've learned now in the last 10 to 15 years. And I was prepping for this. I'm just learning about how complicated the HIP is. And this goes beyond just, you know, our training for ultimation, I mean, ultimation a little bit more as force medicine. Why is it though that we are now playing catch up with the hint? What was it, you know, in the past that we weren't looking at that we now are? Yeah, it's interesting. I think there was a big lag in the research because well, one, there was a lot of research in back pain. And of course, that is a hugely impactful condition. So we understand why there was a lot of research focused in that domain. And then there was a lot of research also, knee and shoulder perhaps. The HIP lagged a little bit, I think, because it is a complex area. It was quite difficult to research in terms of like muscle, you know, understanding muscle around the HIP. Then it's really only, there was one EMG study in the 1970s, only one. And then it's only been, you know, in this last decade that we've actually had access to form and wire information to understand a little bit more of the function of the

6:19 deep HIP muscles. And we still don't even have enough of that. But we do have a lot more information now than we did. Yeah, I often like to help people get one of the reasons I think that the HIP is more complex than perhaps any other joint. And I'll keep the spine out of this, but I'll just talk about peripheral joints, because you have an overlap with multiple specialties, right? So we were talking about this offline. And you've got the orthopedics or musculoskeletal folks. You have, you know, pelvic pain is so an entity and you have urology, you have GYN, you have a lot of referred patterns coming from the GI system as well that could manifest as like proximal, you know, superior hip pain, even growing pain that we might talk about a little bit about. And then, of course, you know, you have the fascia, the skin, all the structures, any type of scar related stuff that could potentially cause it. And so oftentimes, they are these, in medicine at least, we like to create these boundaries, right? So like when it comes to the hip or the pediatric surgeon, look at the ball, the socket, the tendons, you're going to stay around that. And then the neurosurgeon, or maybe peripheral nerve surgeon, like you're going to mess with the nerves and then the GYN, or urologist, like this is your territory, whereas like the body doesn't really respect that. And I like to tell people that bodies don't reach textbooks. And oftentimes there's overlapping syndromes and adds a ton of complexity. So, so let's maybe start by keeping it simple.

7:36 I think it would be worthwhile for the audience. If you're not watching, just to kind of conceptualize what the hip joint anatomy looks like. So maybe just give them a primer of the main structures. Maybe we can do the inside of out approach that you like, starting from the, you know, the osteocinematics of that moving out to the main attachment. And then we can talk about perhaps the lateral hip pain and the infamous trochanteric brosilitis. Okay, so we just want to talk about the anatomy of the hip. So if we think about bones first, the hip joint is a ball and socket joint. And so we've got usually a nice congruent socket. So a socket that sort of matches the shape of the head of the femur. We should have a fairly spherical head of femur for our typical optimal anatomy, perhaps.

8:26 And so that ball and socket joint makes the hip joint inherently quite a stable joint. And then we've got multiple sort of layers of muscles around the hip that sort of attach, you know, from the pelvis down onto the femur there and moves the hip in each direction, of course. And so around the hip joint, of course, we have the ball and socket joint and we have the capsule and ligaments that are around that hip as well. So those passive structures, so the shape of the ball and the socket and the capsule. And then we also have the labrum. So the labrum is a fibro-catalaginous piece of tissue that joins on all the way around the edge of that socket. So that helps make the socket deeper and helps improve stability and help protect the hip joint.

9:18 So all of those passive structures are important, as I said, for both stability and health of that joint. And then we have all the muscular systems outside that help us, you know, move the joint and control some of those large joint forces that we expose the hip joint to during every day movement and function. And then we've got nerves, of course, that serve the muscles, serve the joint and, you know, transit sort of through those muscles as well. Don't know how deep you want to go there. So I think that's good. I think hopefully people, if you're as long as you're not driving, if you just pull up a picture, you'll be able to get a good sense of that. And I think as we go through the specific pathologies or maybe some of the syndromes, we can, when we can highlight some of those. So lateral hip pain, let's start with there. And again, as complex as physiology is, we want to simplify it, right? So we like to put things in different buckets to make it easier for us. So we can make the diagnoses. And Allison, I gotta be frank with you, I don't really know exactly what the healthcare business model in Australia is. But for us, we want to do that for diagnostic purposes. So we can get bill appropriately, get reimbursed. So for lateral hip pain, I see this all the time. And I have the added advantage, much like you where I'm doing diagnostic ultrasound illness, anybody who comes in where there's a question on what might be going on. Yet there are people who, on a routine basis, almost a daily basis come in and they say they have bursitis on the outside of their hip. And that's what they're talking about when they have this pain,

10:50 there's a bone, it's called a greater choke entries, talked about, and there are a bunch of different burses that go through there. But this diagnosis of trochanteric bursitis and you inject that's something that just does not seem to go away despite formal changes being made to greater trochanteric pain syndrome for over a decade now. What can you tell us about that? And I'm curious, you've been doing this a lot longer. How often do you actually see, you know, subglute max bursitis or trochanteric bursitis as it's described normally? So I guess, you know, clinically, it's something that we see intermittently, but almost always associated with changes in the gluteal tendons. And the research studies that we have available suggest that it occurs in 20 to 30% of people who have trochanteric pain, so pain over their greater trochanters, which if you do have visual sort of is over here. And so that is usually in association then with changes within the tendon. And the evidence we have to date suggests that isolated change in the bursa is quite rare. So two to eight percent with the information we have available at this point in time. And we can also get changes. So not only in the tendons joining on to the greater trochanter, but even in the IT band, the earlier to your band that runs over that greater trochanter there. And so often with people with trochanteric pain, we may have multiple sources of pain there, but it seems that the dominant

12:23 issue is the tendon issue. And then plus or minus, you might have some changes in the adjacent bursi or the IT band. How often in your experience and your reading of the literature, will you see some of the subglute medias bursa or the subglute medias bursa, those be irritated. And I'm curious if you see that when you're using your diagnostic ultrasound effect. Yeah. So it seems to be less common than the trochanteric bursa or the subglute medias bursa. But certainly that can occur when we sort of see that change. It's often not as obvious because the trochanteric bursa is bigger when it's got some extra fluid in it. It's much easier to see on ultrasound in imaging studies sometimes with MRIs, sometimes I think it's hard to clearly delineate, you know, where that hyperintensity is, but if it's sort of below the tendons, we're thinking subglute meds, subglute med. I can't tell you the exact figures on that. I don't think we've got studies that are large enough in, you know, breaking it up into the different, but it certainly does occur, but it's not really something that's going to change our approach because it's all related to the same mechanism and that sort of that compressive sort of loading or that combination of compression and tension of those soft tissues over the side of that bone there. Yeah. So let's talk a little bit more about that, right? People

13:55 might ask, well, why does this happen? I've actually been getting a lot of people who come in and they're just interesting in the why and less interested in getting better, believe it or not, which is cool. I respect that. You know, I often ask, well, can we do both? But some people are okay with the pain and they just want to quote unquote solve the problem, root cause, so to speak. So you mentioned you got the glute minimus, right? Which is a bit more anterior structure, a little bit more in the front, but again, it's one of the glute muscle smaller ones. If the glute medias, the glute max is the big muscle, that's going to be your workhorse power muscle. It's more responsible for like sprinting and that kind of stuff. That's typically people think when they think gluteus, why are the glute medias in minimus, the stabilizer muscles, like you said, why are they susceptible to compression? What structure over them to tee it up for you is what's going to cause that irritation and why is that the one or those two, the one that are most often implicated in this trochanteric pain we're talking about? Sure. So it's really around the anatomy of this local region. If we're just talking about mechanical causes, of course there are other contributors such as hormonal, metabolic, you know, and of course pain and persistent pain also has like a social driver's, but if we're just talking about the local mechanical forces here, then we have the gluteus minimus is that deepest gluteal muscle that sort of sits on the side of the pelvis, we often think of the glutes as being on our backside, which they are. The glute max is that big muscle

15:25 at the back, but the gluteus medias in minimus are more fans of muscle at the side of the hip, and the gluteus minimus joins into the front of the crater trochanter, so the front out to edge, so the anterior facet hip, and then we have the gluteus medias that is over the top of that. It's a bigger muscle, so a very strong muscle in a normal healthy muscle, so it's a muscle in the body that has one of the largest physiological cross-sectional areas because it's lovely sort of fan, sort of multi-penate sort of structure, so it joins over to the lateral facet of the greater trochanter, which is like the side, the very outside of that bone, and so then over the top of that, we've got the iliotibial band or the ITB, IT band, and so it joins from the side of the pelvis, runs over the side of that greater trochanter, that bone at the side of the hip, then it runs all the way down the side of our thigh and joins it just below the knee there, and so those tendons and the bursi that sit between the band and the tendons and the tendons and the bone, as they can get compressed around the side of that bone, and so we call that insertional tendon optic, because it's sort of around the insertion of the bone as it's sort of coming around the side of that bone, and so I think that anatomy just predisposes to higher levels of compressive load, and compression is normal, but it's just if the area is exposed to high levels of compressive

16:58 load, either a sudden peak of load or repetitive high loads over long periods of time, that we might get changes in those tissues, and eventually we might get pain, but the iliotibial band, when we are in particular positions, that band will wrap around the greater trochanter and cause that compressive load, and so that will be in any position, so if you think of an IT band stretch, so anything where your knee is across your body, or your hip is out to the side, so hip adduction, adduction, that will wind up the iliotibial band, and we've got some nice research from Burnbound and colleagues quite a while ago now, but they managed to put a little force transducer underneath that ITB in a live human, and show that significant changes in compressive load at the greater trochanter there, as your knee moves across your body, or as you move into that position of adduction, but even without the iliotibial band, even just because those tendons join over the side of the bone there, when you do move into adduction, the under surface of those tendons will be compressed by the overlying fibers, and we tend to see the change or the pathology in these tendons start to develop in the under surface, because they're the parts of the tendons that are exposed to a most compressive load. For folks at home, could you give some examples

18:28 of things that might contribute more stress onto that IT band, like deep chairs or leg crossing, things that are going to wind up that IT band, and then also how does our gate pattern and walking mechanics, how do they layer more load on top? Sure, that's right, so we can have positional forces that are purely related to where the hip is and how much that band is wound up, and so sitting, for example, when we're sitting if we cross our knees, so one leg over the other leg, then that puts the hip in an adducted position, so that does wind up the iliotibial band and increase that compression. The other thing about sitting is that the quiz that ITB, it's sort of part of a broader fascia at the side of the leg, the fascia line up, and that fibrous, fibrous sleeve, if you like, it is also continuous up into the gluteal fascia, so the fibrous sleeve over the glute that runs up into your back, and so when you've got your hip flex, that does tend to also wind up that fascia at the side of the hips, so a lot of the people with gluteal tenopsy or lateral hip pain will report pain sitting in ditches or when driving, so in positions where their hips are more flex than 90 degrees, because that tends to wind that pressure cooker, if you like, from the iliotibial band tends to wind that up, and particularly if your knees are crossed or your knees are held together, so that's more of a passive loading,

20:00 but your absolutely active loading, active forces contribute to that as well, and that's a lot again around how your pelvis and your hip move and where you put your trunks, so where you put your centre of mass of your body relative to your hip, so we've got some nice kinematic evidence around that, so some studies that look that, you know, how do people with lateral hip pain work at walk, and they tend to walk in ways that actually increases the load at the side of the hip, and so that can be related to too much pelvic tilt, so dropping the pelvis down as you're walking or shifting your pelvis to the side, or leaning your body to the side, particularly leaning your body a little bit away from your foot when you're weight bearing on that side, and so basically movement patterns that create extra challenge for the muscles, and they're sort of working hard, so the tendon is under tensile load, so tension, so the muscles are contracting, and we're moving into a position where the iliotibial band is causing that compression, and so the movement patterns together with how the together with the compressive forces, those two things together can contribute to the development of pain over time.

21:26 What are some of the common reasons for those abrid gay patterns? Is it an issue of like a motor control? Is it strength? Yeah, that's the million dollar question, that's it. We don't really have evidence for that in terms of the chicken or the egg. We know that from cross-sectional studies, from people who have this condition, that they are weaker in their abductors, so they're weaker in the gluteus medias and minimus, so if you're weaker, that is often associated with some excessive adduction in your movement patterns, but there's not always an absolute strong correlation between strength and movement patterns, so there's then movement patterns themselves and maybe an additional factor alongside or separate to strength, so you can still have adequate strength on a strength test and yet you're still moving in ways that are not optimal for the health of these tissues, but definitely strength and movement patterns are an important thing, but then there might be external things as well, for example, if you're walking or running and you're doing that on a camber of a road, so that's going to, so on the downslope down to the gutter, then that's going to sort of put your hip in a, so the downside hip closest to the gutter is going to be more in abducted position, so there can be external factors as well that contribute to that.

22:55 Other things can be around length tension relationships in that muscular tenderness complex, and so for example, if you tend to be longer in those muscles, in those structures at the side of the hip, then your optimal window of function is going to be at a longer length, which is going to be in a more abducted position, so that length tension relationship may also contribute to this sort of loading, and it's one of the links that may link postural habits to movement patterns, because if you spend a lot of your time in static postures sitting with your knees crossed or standing hanging on one hip, so you're always in a position where these tissues are at length, we get structural adaptation, and so these tissues get longer over time, and so the longer they are, you have to, you know, there'll be more efficient at along the length, and so that may actually be another contributor that may feed into the way people move, but we certainly would need more, you know, research to sort of look at those links.

24:03 I love that. I'm excited to kind of talk about load management, because there are some cool things I learned from you that I hadn't even considered that have been instrumental in my own recovery, but also in how I guide my patients, but before we do that, let's just talk about for the clinician, or even maybe the patient, right, if they think that this might be something that they're struggling with, this specific entity that we're talking about, what might be some specific telltale signs, aspects of the history, and the exam that might suggest, oh, this is more of a gluteal tendinopathy, trochanteric pain, as opposed to something else going on that we alluded to before. Yeah, great, and I think that patient interview, that history, the description of the symptoms is so, so, so very important in terms of that, that early clinical reasoning around, could this be gluteal tendinopathy or something else going on?

24:57 So in terms of the history, I guess, you know, first looking at the patient demographic, so who is the patient in front of you? The largest group that we have with this condition is postmenopausal and so if you've got all perimenopausal, so if you're looking at 50, 50 plus female with pain right over their greater trigonoduct, then the risks that they have this condition already significantly increases, so area of pain and your demographic, but it's important not to miss it in other populations because we can get it in males as well, but in that older sort of 50 plus age group, we're sort of looking at more one in four females compared to one in 10 males, so less common in males, but then in our younger age groups, we can see it in younger runners as well, we quite commonly see this in, again, more females, but postpartum mums, often their eastern levels are at a little bit of a low there as well, and then they've often got poor pelvic control coming out of, you know, that those months of pregnancy and then they might want to start running to get rid of that baby weight and really not controlling around the pelvis, so we might see it in that scenario, and then the other scenario to be mindful of is in those with acetabular dysplasia, so again, more common in females, and so around 40%, 40 plus percent of those younger people with acetabular dysplasia, there's a study from Denmark saying that they have

26:28 a doctor-related pain as well, and about 30 percent of the group that they looked at also had changes in the gluteal tendons on imaging, and so dysplasia also tends to overload those muscles because they're working so hard to cope with a shallow socket, so demographic is first thing to consider, history, now often in our postmenopausal females, it will either be that there's been a sudden change in activity level, and it might be, you know, putting on a little bit of weight with the menopausal change and going, right, I'm going to get out there and start pounding the pavement and doing lots of hill walking or or starting, you know, taking up running or going to boot camp and suddenly starting to do, you know, burpees and jumping split lunges and things like that, and so there's been this rapid increase in load, and so tendons don't love rapid changes in load, and so that might be a stimulus, or it can be something a little bit that might think a little bit more innocuous, which might be just going on holidays, but asking those extra questions, right, where did you go, what did you do? I went to Lisbon and Portugal, and it up and down, hills like this, so there was sort of doing lots of hill walking or cruise boats, I've seen a few people cruise boats because, yeah, and I'm staying on the bottom level, so for health, they decided I was going to take the stairs all the time, and so, you know, sudden increase in stair climbing, so often there's been something like that in the history, in others, it won't be

27:59 as clear as that, it might be just that they've had a fairly sedentary sort of lifestyle, the muscles and the tendons have become poorly conditioned, and then to the point where even the forces of everyday life represent a relative overload for those tendons, so looking for those sorts of histories, then area of pain, as I mentioned, is really important, so it needs to be pain over the greater trochanter, and that is important in trying to differentiate between lumber-related pain, hip joint-related pain, now both of those other things can also cause pain at the lateral hip, but it's not as likely to be tenderness over that bone at the side of the hip, and one of the most common things that we get reported to us in people with this condition is that it hurts to lie on their side at night when they're lying on their side, and so when they're lying on that bone, it's tender on the bone, and that's an important differentiation, so for patients my hip hurts at night, don't just note that down, we want to have more information, so is it when you lie on your side, is the bone tender, so if they say that, then that's more likely to be gluteal tendinopathy, but if they're saying more like, oh no, it's sort of like a deep vague ache somewhere deep around my hip, that might be more hip joint, if they're not saying tenderness over the bone, or if it's more, no, it's more when it's top side, and certainly gluteal tendinopathy

29:30 can be painful when it's the top side, when you're lying on your side, just because that knee, if it's hanging down into adduction, but that might also put load on the lumbar spine and pelvis, and so again, is it focal tricandric pain, or is it sort of pain that sort of runs from the back across the buttock down the leg, so those things are important questions to ask, and then how far the pain goes down the leg, with gluteal tendinopathy, it can transfer down the lateral thigh as well, whether that's a referral from the actual tendinopathy, or whether it's a source from the iliotibial band, there probably is some source from the iliotibial band in those people, so they can have pain down the lateral thigh, and occasionally even into the lateral leg, but it shouldn't go into the foot, and obviously if we're getting pins and needles or numbness into the foot, those sort of symptoms, then we're definitely thinking more nerve related issues, so either from the lumbar spine or from the hip with gluteal syndrome, but more commonly from the lumbar spine, so those things are important, but listening to those clinical history, and then when does it hurt, lying on my side at night, standing on one leg to dress, walking, particularly upstairs, uphills, or for you know, you're more active population, it might be, you know, running again, particularly uphills on unstable surfaces, on the canberra road, on a beach, things like that, so they're the typical presentations that we get. Yeah, the piece about the refer pain,

31:01 that one's really interesting to me, because you know, I can imagine it, it becomes a real catch 22, is people love diagnosed IT band syndrome, right, and if you google it, a lot of pain reading down the thigh, that's probably going to be one of the first things that comes up, and they're like, well, you know, I got to stress the IT band, and as you highlighted earlier, stressing the IT band is exactly what's going to further exacerbate those tendons and compression, and then all you're doing is potentially making the problem worse, and so I think this is why like that nuance that you described, and I'm actually guilty of this myself, is, you know, when you're limited with time, and you have a few minutes, you say, okay, does it hurt when you're laying on that side, they say, yes, to take that extra, that at next level, to dig deeper, well, okay, well, what kind of pain is it specifically, is it more of a deeper acre, is it more very superficial focal? I will say this, that patients aren't very good, sometimes at discerning the difference between the two, they're like, well, it just hurts, but what I really appreciated learning from you was that controversial piece that you talked about, so let's just say you have an individual able to come in with that right pain on the right side of the choke enter, but then hey, it hurts even when I'm left side, and you know that they have maybe a wider pelvis, and then you see they have significant adduction, and so, you know, one of the recommendations, I think you've made it, so you often will have them a large pillow, not just a pillow between the legs, which is what, or between the knees, excuse me, which is what I would tell them, because you're still creating that rotation component, but all the way down to the feet, that's actually been a teenager, so I want to thank you for that one.

32:31 No problem. Yeah, so that is important, so with that sleek position, and sleep is just so critical for this population, and with the patient focus groups, like besides our patients in clinic talking to us, but in terms of our research, we've done patient focus groups in patients that we've had involved in our studies, and the thing that just keeps coming out is the sleek deprivation, and how much it affects their sleep, so it's so important that we try to address that as quickly as we can, because if we can get a patient a better night sleep, everything starts to turn around and feel much better, and so yes, if it's the top side when it's painful, big fat pillow between the knees and the ankles, because if the ankles are still together, that external rotation tends to sort of wind up those tissues at the lateral hip as well, but often people say to me, I've tried a pillow between my thighs, or between my knees, but often it's just been a thin pillow, so as you say a thicker pillow, often I might get people to put two pillows in one pillow case, so they don't slide around, but to make it thick enough, the other position that can be quite useful, because some people find, oh, you know, that slips out and then you know, end up in the poor position anyway, but the other position that's we find very successful is like a half turn between side lying and prone, so if they're half way, it means that they can lie on their affected side again, because they're rolling far enough

34:05 forward, that they're rolling off the greater trochanter, and then their weight bearing on their antirelactual side. That position though is most successful, if they do still have a pillow in front of them, so a normal sort of long pillow, but I get them to roll it lengthwise, and then they can wedge it underneath the top hip and underneath their abdomen there, and so that's wedging them in that position, so they stay there, and then the top hip is also open, because the top hip is relatively more abducted, and so that's a really successful position for a lot of people, but it just takes them a little bit to figure out how to get successfully in that position, but if they're lying on the affected side, it's really shouldn't feed back, because that tenderness will go away if they roll far enough forward, that they've got the weight off that greater trochanter, so that's another great little position for them as well.

34:59 George, can you imagine doing all that education, troubleshooting in the 20 minutes that we get in clinic, and this is why I think I'll buy my students and the residents who work with me, and I said, if you're not going to have the privilege of being able to do all the things that you're talking about yourself, you better find a network of people that you can refer to who are going to be able to take the time to do that, but I think also the other piece is to reference Dr. Chris Standard previous guesses, you sometimes give this type of information and bite-sized pieces, because I imagine that's what maybe physicians who might be listening to this are thinking, there's no possible way I can make the diagnosis, troubleshoot, offer other stuff, and do this, but you don't have to do all this in the first visit, so we can do this over subsequent visit as well.

35:43 And so I would say with that, then, that go for the big rocks first, if you like, send to what your patient has said to you, so if the leap is a big issue, make sure you address that on day one, or if they've got stairs in their house and they're getting 7 or 8 out of 10 pain, walking upstairs, then try to address that on day one, because if you can change those big ticket items for the patient, then things will start changing much more quickly, so do it, don't just do it that everyone has the same thing that you address on day one, listen to what the patient says, and address their big ticket items first, and so stair climbing simple things, just like, just walk with your feet slightly wider when you're going up the stairs, because often these people with their doctor weakness, they stand on leg, they're pelvis shifts and translates, they put their foot up onto the next step, and it's actually in front of their pubic synthesis instead of in front of their hip, and so they're quite abducted as they go to transfer the weight up, and that can be quite painful, and so if we can get them then to just plant your feet slightly wider, simple things like that can make a difference in using a rail on the hand opposite their painful side as well. I want to just plug your, you have an amazing masterclass paper, I think it's open access, you made it open access for everybody, published earlier this year, March of 2025, so I highly recommend people to go check that out, certainly a lot of

37:13 important information if you want to understand this region a little bit better, and you've got some really great stuff on there. I had a follow-up question for you, I think that, and we had talked about this during your workshop as well, I think you had mentioned, or it's highlighted in the paper, that the direct palpation, and what's the other one, the direct palpation, and something in the 96% PPV I'm thinking, what's the second part of it, just lateral pain and direct palpation, right? So there was a meta-analysis by Consellor and colleagues in 2023, I think it was, so they looked at the combination of tests that were most likely to give you the highest diagnostic accuracy, and they found that pairing palpation with resisted abduction was most useful in both ruling in and ruling out the condition, but you do need something else in your test battery, because if resisted abduction is negative, which sometimes it will be, then you're only left with palpation, and you can't make a diagnosis on palpation alone, because it doesn't have the best positive predictive value, it best actually for ruling out the condition, so if they're not tender on palpation, you really need to consider other diagnoses, but if it's positive, it might be gluteal to not be, they might just be a bit tender over there, over there behind there, and so you need to have other tests, so besides that resisted abduction, the other tests that were shown to have good positive predictive value were the single leg stance, the 30-second

38:46 single leg stance test, so standing on one leg for 30 seconds, side onto a wall with your fingertip for balance, just on the wall, on the close side there, and we're looking for reproduction of trigandric pain over that 30 seconds, so that had really high positive predictive value. The other one was fader test, which is flexion 9 degrees, full adduction, full external rotation, and then adding some isometric internal rotation, so some resisted isometric internal rotation in that position, and that also has a strong positive predictive value, and so if you, so those two tests are good for confirming a positive diagnosis of gluteal tendinopathy.

39:32 Yeah, that's the one actually like a lot, I think some people will also refer to it as the hipguritation test, is that kind of the same thing? Yeah, so there's in that meta-analysis they did actually collapse those two tests together, but they're slightly different, so the de-rotation test is 9 degrees hip flexion, full external rotation, and then the patient actively pushes themselves back to a neutral rotation position. When we did the LEAP study, we modified that test because we were just finding that in clinic, the adduction component was so powerful, and that made sense from the research showing that adduction creates compression, so we wanted to maximize the compression, so that's why we use flexion, adduction external rotation, and then the resisted part of that test is isometric because we want to keep them compressed and add that active tensor load, so it's just a slight variation, and we find we tend to get more positives on that than the standard de-rotation test.

40:33 So in the de-rotation, there's no resistance. There is resistance, but it's got isometrics, it's more isotonic, so they push themselves out of the compression position, we keep them in the compressed position when we contract the muscles. Yeah, cool, awesome, thank you for that. You mentioned the LEAP trial, kind of a landmark study, I think, and you've referenced it time and time again. What was the one main takeaway that you have from that LEAP study? I guess the most exciting thing that came out of it for us is that going into that trial, we hypothesized that we had two primary endpoints, a short-term end point, which was eight weeks, and a longer-term end point, which was 52 weeks, so 12 months.

41:17 And we had hypothesized that, so we're comparing the education exercise program versus a corticosteroid injection versus a weight and C approach. So we had hypothesized that that eight-week time frame, that the courtesone group that had the courtesone injection might have superior results, but certainly by the 12-month point we expected the education exercise group to have superior results from previous literature showing that courtesone usually has more of a short-term effect. But the exciting thing from the trial was that actually at that eight-week time point, the education exercise program showed superior results, far superior over the corticosteroid group and the weight and C group. And so that was something that was terribly exciting because the only research that had looked at exercise prior to our study, they hadn't shown a positive until 15 months with exercise. And so you can understand then why our medical colleagues would want to give corticosteroid injections to their patients because they're not going to wait for 15 months and let their poor patient be in pain for that role. But this was a great message from the study that we can get quick results. Of course not one or two days that you can get with a corticosteroid injection, but we have to sort of weigh the risk versus benefit up. And certainly,

42:50 even within a few weeks we're seeing changes and that education piece is a really important part in that changes in symptoms. And eight weeks we had just under an 80% success rate, and that was maintained out to that 12 months. And so that's the biggest message that education exercise can give you short-term gains. So you don't have to, you know, work for 12 months until you see a result. Just to clarify, the corticosteroid group was just steroid or steroid plus education exercise. So the steroid group and the, so they were, yeah, cortisone by itself, the simple cortisone injection and the weight and C group was, yeah, weight and C. But both of those groups did actually get a basic education pencil. So not all the detailed load management information, but what we thought was fairly vanilla advice, which was more like if it hurts to walk, just reduce your activity levels and then just gradually build them up again avoiding peaks of activity. And so that was actually really interesting because both of those groups got that information and the education exercise group, of course, also got that information plus a whole lot of more detailed information on the load management side of things.

44:11 But it was interesting to look at what happened in the traces of activity levels over time. And so if we look at the activity levels from baseline to four weeks, the education and exercise group and the weight and C group who'd been given that basic information, they both reduced their activity levels for that first few weeks. And then they gradually increased and stayed sort of higher over time. The interesting thing in the pattern of what happened with the corticosteroid group, even though they were given that information, they didn't adhere to that. So their activity levels actually increased the four weeks. Then they sort of dropped back down to eight weeks and then they stayed lower over time. Now there wasn't statistical significance between the group, but the pattern is just so much what we see in clinical practice. So it's something to just be really mindful of with corticosteroid injection. Often it's sort of promoted as we're giving you this window of opportunity to, you know, to rehab. But often it's almost a negative from a behavioral standpoint because they're less likely to adhere to advice. They're less likely to change the way they move because they're not getting that regular reminder. And so it's almost like robbing them of the opportunity to learn how to manage their own condition. So question for you actually, Althalash, when you're talking to patients and you're trying to decide between using something like

45:42 torridol or even a corticosteroid injection, how do you think about that balance between trying to resolve whatever issue the patient may have in the near term versus actually trying to fix that problem in the long term? Well, I think and I've shared this with Alison offline is I probably use a lot more torridol. You and I have talked about this than we do, right? Because it hasn't really shown to be tino toxic and my toxic and counter toxic, although there are some individual studies that showing that maybe it might have some harm. So I tell people at this stage that's probably a better option. That being said though, the conversation that I'm having is are we playing the short game or the long game? And that's what I tell people, right? So to like this happened today, right? So it wasn't for a hip, but so an individual who was going hunting tomorrow, they're going to hire, they got to catch some deer. And you know, like look, we got to do the rehab. We got to do all that stuff, but that trip is right there. And so we opted for torridol.

46:40 Again, recognizing that if they don't make those long term changes that Alison talked about, we're going to be having a very similar conversation in two or three months. Like we're going to be right back to square one. So I'm very honest. I think my approach is very much like here is the menu of options. I can guide you, you know, as long as it's medically reasonable, of course, and a viable option. I think this is going to be a more reasonable approach long term. But like the people that you talked about, so the person who can't sleep and who hasn't been able to sleep for a while, then it's working two jobs. And you know, if we can maybe give them a little bit of relief using ideally torridol, for short term relief, corner concern, if we absolutely need to, although I don't do that a lot for tendon, but every now and then we'll do that with the understanding that they do need to make those changes for a district, or we're going to have the same conversation in those instances. I'll do it. The one thing I'll say else, and I know we've kind of talked about this is I'd be curious where the PRP group would stand with that. I know people have mixed opinions with that. We've talked a lot about different PRPs, but really be interested if we had a separate arm looking at like lucasite rich PRP into the tendon, although I can't think of any good orthobiologic interventionist who would do PRP and not include a comprehensive rehabilitation program, keyword being a good interventionist, but even as a standalone, like we know that corticosteroid at maybe two months outperforms PRP, but again at three to six months, even more than that PRP is better. So I don't know if you've got a chance to look at some that literature, or I know you briefly touched on in the last workshop. Yeah, well, there's

48:12 fairly limited literature. So mainly one RCT, two papers from one RCT, and the longer term data is a bit problematic because of patients moving between groups and things like that. But yeah, so that, as you mentioned, shows clearly that the PRP group did better than the corticosteroid groups. It, as far as we're aware, it's a natural substance at least. It doesn't seem to have those same sort of toxic effects as the core design. It won't give you those rapid pain relief that you'll get from a corticosteroid injection, but perhaps has lower levels of risk associated with it. But that program also, of course, had, so that RCT also provided an exercise program wasn't supervised, but they gave some sort of education and exercise program associated with that. And as you say, if you're using PRP, we definitely want that in conjunction with an exercise and education program. And that's where you're likely to get most benefit out of the PRP anyway. You know what's interesting, at least in the business model of this country, is PRP is typically not covered by insurance. So it's an easier buy-in. So to your point, if you put a bandit on their disincentivized to go ahead and do that, but now if a person's putting up money, they're more likely going to do that rehab program and make some of those changes else. And so I tell them, listen, we don't want to sell sabotage, right? So if you're going to make this financial investment,

49:46 time-based investment, you know, PRP, particularly in tendons, is actually going to probably make it worse for a couple of days because you have that inflammatory period where it's actually quite sore, especially if you're doing what we call it synotomy where you're taking a needle and going in doing multiple frustrations to create a little bit of an injury and irritation. But when people are paying, they're like, okay, I'll actually make this investment. I'll make the changes. So I've actually been more successful with that approach as opposed to the, all right, here's the injection, go nuts. Yeah, yeah. And that's great that, I mean, as long as it is accompanied by that sort of education, because I've certainly seen, you know, patients who've been given PRP and then basically told you rest. So PRP and rest. And I'm like, why would you do that? That doesn't make any sense at all. So it's great. I think it's really that combination. And of course, I'm from the perspective that I would suggest that education exercise give that a go first. And then I'd say PRP, you know, those sort of secondary sort of interventions, if you're not really having an outcome. And even with the sleep, we can get, like, if we do have an opportunity to get them on the bed, so get them in the bed, position them, often just that positioning advice can get them a bed asleep relatively rapidly. And if they come in limping, I would, you know, even give them a short-term opportunity to use a walking aid, just a single stick or a single crutch, I'm just

51:18 to let it settle quickly. So we can turn the pain around relatively quickly. So if we can avoid the the core design, particularly, that'd be great. But it's as other options that are safer than that would probably be preferable. Love it. Yeah, Alison, I obviously have an issue where I thought that for some whatever reason, we were going to be able to get through a lot of this stuff and we're 50 minutes in and we've just done a scratch the surface. So how much time do you actually have today? I don't want to keep you here. No, I've just got a research meeting in about half an hour or so. So go a bit more or I've had different session if you want. Yeah, I'm thinking maybe we could park it and maybe we could do like hip joint pathos. Awesome. Alison, thank you so much. Okay, sounds good. Thanks for listening to the other episode of Medicine Redefined. If you enjoyed this episode, please be sure to check out some of the additional resources in the show notes. Please also check out our social media platforms where you can find more content like this. You can follow us on Instagram, Twitter, and TikTok at Med Redefined. We also want to thank our team for the production of this podcast, specifically Ethan Geo on video, Harita Yekorean social media, Zanablegmani on research and Sarah Hahn for newsletter. Also, if you enjoyed this show, please be sure to subscribe, review, and share with anyone who you think will gain value from this as well. Now, time for the ever so important disclaimer. This podcast is intended for general public use and is for educational purposes only. It does not constitute the practice of medicine, no should be construed as medical

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