Post Concussion Syndrome with Iyad Salloum

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Iyad Salloum of Insync Physio in North Burnaby, BC, Canada. We're talking about post-concussion syndrome. When can people actually get back to exercising Iyad? 

Iyad: Oh, hey Mark. Yeah, well that's a great question. Typically it depends when we see these people. So if I happen to be, let's say on the sidelines of the ice rink, and then I see the concussion happen live, you know, usually they're able to do quite a bit of intervention then and there it's with the education and letting people know what to do. What we've started doing more recently is once we have a confirmed diagnosis of a concussion, usually most people will see their physicians first and to get this diagnosis or their appropriate healthcare provider.

We kind of start 'em off with one or two days of rest just to kind of help things settle down a bit. Tends to be a lot of fatigue involved at first, and then, you know, soon after that we try to get people, once we kind of figure out kinda what can different impairments are at play. We design a program that helps them do that. So, but we typically get people moving within 48, 72 hours, depending obviously on the severity and what else is affected and if there's any other complications. 

So for example, for dealing with an isolated traumatic brain injury without, let's say any significant neck injury, like no fractures or anything like that, we're obviously gonna move people a lot earlier than later.

We see a lot of people who come in six months post-concussion and then who have not done anything because they're still, unfortunately feeling symptoms. And then those are the ones where we need to be a little more kind of deliberate with our programming and also figuring out a safe entryway for them to start their programming.

Mark: Having been involved in combat sports and had my bell rung more than once. Mm-hmm. It's very common. I mean, we had no idea back then. It's 40 years. Mm-hmm. 45 years ago. But what about multiple concussions? How does that affect things? 

Iyad: That's a bit of an interesting one. And it tends to be where, we know you're more prone to future concussions, for example. When you have that, and obviously like how far apart the concussions are, matter. 

Unfortunately, sometimes you see it in different sports where an athlete gets cleared or an athlete hides the fact that they potentially suffered a concussion and then they go back out in quick succession and they get a second impact pretty quick.

That could be very dangerous. Could definitely prolong the recovery. It could be even life-threatening if they do it quick enough. So that's where, you know, we really advise that people get cleared medically before they go out. And there's proper steps to take for return to play.

If you've had them more successively, like let's say consequently, but far enough away from each other. I mean, it's gonna affect the recovery, of course, but the principles won't change as much. We just try to make sure that when we get people back that they're, we don't just do one bout of clearance for example, testing. 

If let's say you've had four concussions and you know, maybe the first two were well managed. Oh yeah, you cleared one practice without symptoms, so you're good to go and just go get kicked in the head a hundred times after that. You might maybe lengthen that return to play a little longer just to make sure they're actually okay and coping with a variety of the stresses that are involved with the sport. But for the most part yeah, obviously you don't want to have a lot of concussions. That goes without saying. 

Mark: So how does the post-concussion syndrome, how do you manage that if you're having the symptoms after the fact, say a week or two later, when is it safe to start exercising again?

Iyad: So we will get people exercising again, within two to three days after the concussion, once we kind of see things settled down. We'll get people to do some form of aerobic exercise. Typically, this is done based on an assessment, so we'll assess people in our clinic, we will get 'em doing either a treadmill walking test to see their tolerance or a bike test. We could do any of those. 

There's always more than one thing in a concussion. That's kind of why it's so intriguing and interesting. And why maybe potentially so complicated. So there's that kind of exercise response that we get. 

There's also sometimes the neck involvement for which we can get headaches and dizziness contributed from that. And obviously if you walk in your head, for example, your neck is moving a little too much. You can get these symptoms and people think, oh, it's all the concussion or it could just be whiplash that's suffered as a result of the initial injury.

We will also assess the basic visual stuff and some vestibular stuff, which is in your inner ear, which helps you balance in different things. And then we can kind of identify our main target. So for example, if we have a student we're dealing with, we would probably prioritize returning to school first before we try to get them back to, let's say, high speed sprints.

So they'll be some kind of cognitive component there too. So like how much reading to do at a time and how much screen time and all those things. But yeah, exercise, we try to get people in pretty early. But then once we have that assessment of the treadmill or the bike test, like we talked about, we will be able to give them very specific parameters, for example, either based on exertion level or on time, or if they're, some people have those smart watches that can track their heart rate. So we can give 'em a heart rate prescription based on that too. 

There's a lot of different things that we could do with that and just keep people moving and start to build up their tolerance to movement and exercise gradually. And it actually could be really important at reversing some of those exercise intolerance signs. You know, so it's kind of funny cuz if you can't exercise, the fix is to not rest necessarily for too long, but maybe a gradual exercise program to schedule that within their busy schedule.

Cuz what you'll have most of the time is people have, let's say, a job or school plus some family obligations, plus some medical appointments, plus some other things that they have to kind of contend with all at the same time. And it becomes a failure of pacing. So you start seeing days where people have 10 hours of strenuous physical or cognitive activity. And then some days where it's a little less cuz they're crashing from that and maybe their sleep schedule's a little irregular and all that stuff. So that's where we figure out like, you know, where to place the exercise in the week versus just tell somebody, Hey, I need you to get me 30 minutes a week of something where they kind of have a bit less guidance there. 

So again, as I'm saying, there's a lot going on there, but it's like exercise is gonna be essential and we can do it really early. We just have to figure out where to fit it in their schedule. And then how much. That's the amount. It's not a yes or no. It's a how much potentially. That's a probably a better question to ask. 

Mark: What are your guidelines? How do you set that, the how much factor? 

Iyad: It's really easy. It's a tolerance test. We put people on a certain thing. We try to go until they either get symptoms or we keep going until they don't get symptoms.

And if they don't get symptoms, that's great. That means there's no physiological response that's, let's say that's bad to exercise. So that's great. So that clears them for a lot of different movements and exercises right away. If let's say, the heart rate starts to tick up in the 130, 140, it's just an arbitrary example and they start to get symptoms, then we would try to get them exercising maybe at a level below that. Or maybe changing if they're walking on an incline, maybe changing the level of the incline or maybe changing the speed or maybe changing a few other things. 

So that's kind of what dictates it. Again, if you have a lot of neck pain, sometimes people find walking to be sore and painful initially. So until we control neck symptoms, you can get 'em on a stationary bike and doing some of this stuff. So yeah, it's never guessed. It's always based on we assess here and this is your tolerance level and then you get the prescription to follow. 

Mark: How common is it for people to have ongoing symptoms after they've had a concussion?

Iyad: We don't have great numbers in BC but it's pretty common is what I could say. There are lots of people who, let's say, intervene with it really early on and they just kind of go 1, 2, 3, and they kind of follow the steps and within a few weeks they're back to normal. And there are some, unfortunately who maybe they start to develop more of a persistent case. But we don't have great statistics in Canada. We have some global statistics which are, you have big ranges anywhere from one in four, to one in ten. So it just varies. 

But it is common enough to be a problem. And we're seeing a lot of it in the clinic and I think it's just important for people to know. If you're failing to exercise and keep up your tolerance, it's not because the exercise is bad necessarily, it just might be that you're doing too much at once and maybe failing to pace yourself adequately.

And maybe the conversation should be, let's plan your week out in a little more a depth instead of trying to guess and see if you're gonna do well or not, and then react by sleeping through the next two days. Cause that's what we see. People go a little too hard and then they crash, and then it's like they're napping three hours in the middle of the day.

Well now your night schedule's messed up so you can't sleep so well. And then the next day is messed up and then it's like takes them till the weekend to like kind of get on level ground again. So again, it's probably just useful to start eliminating some of the noise in the program and just kind of focus in on a more of a gradual program.

Mark: If you've had a concussion. If you've got concussion syndrome or concussion symptoms after the fact, even if it's later on, you need to get in to get professional help at Insync Physio in North Burnaby. You can book online at Or you can call them (604) 298-4878 to book your appointment. This is your brain we're talking about. You wanna look after your brain, and it really helps to have professionals helping you. Thanks, Iyad. 

Iyad: Thank you.

Planks to Strengthen Shoulder Injuries in Rock Climbing

Start in 4 point position on your hands and knees. Engage the lower core of your low back and pull in your low abs below your belly button. Pull the arm and the ball aspect of the shoulder joint into its socket on affected side.

Then straighten out one leg and then the other leg while maintaining your spine in neutral and your shoulder socket engaged. Avoid pulling down with your lat muscle. Hold for 10 seconds doing 10 reps 3 sets in total.

This exercise works the shoulder muscles to help with more optimal stabilization and movement reactivation patterns after an injury. If you have any pain or problems performing this exercise please stop and consult with your local Physiotherapist before continuing. 

Rehab after Surgery with Iyad Salloum

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Iyad Salloum of Insync Physiotherapy in North Burnaby. We're gonna talk about rehab specifically after surgery. How you doing Iyad? 

Iyad: I'm great, Mark. Thanks for doing this. How are you? 

Mark: I'm good. Is this something that you guys see a lot? People come in for help from a physiotherapist after they've had surgery?

Iyad: Yeah. A lot of orthopedic surgeries and even some neurological surgeries will involve a fair amount of rehab afterwards. Sometimes in the hospital, even like if somebody has like abdominal surgery or whatever, you'll see a physio involved. Unfortunately, what tends to happen is when people go home, they're discharged from the hospital, they're kind of left to their own devices sometimes, and then they have to figure out what to do.

Now, in some cases, you're lucky and you have some kind of instruction that's given post-surgically, like, you know, like a protocol of some sorts to follow. So that kind of helps a bit. Especially if the person has some exercise background. But often we see a lot of people kind of leave it be for a while and then they come in maybe a bit too late sometimes, and then they're like, oh, I wonder why it hasn't changed in the last month or so. It's because maybe they're not progressing their tolerance activity as well as they could have. 

And then in other times where people are told right away by the surgical team, we need you to kind of rehab this so, you know, consult a physiotherapist and work with them. So that's where we'll see them from the beginning and we take them along their journey and we work from anywhere from the adolescent kid who has a knee surgery after a ligament tear of some sort. All the way up to, let's say multiple traumas where somebody has like several fractures and they get, you know, potentially some hardware put into their legs and then all the way up to hip and knee replacements, which will happen typically in their like older group.

Not necessarily, but most commonly will be in the older group where people have had a long bout of arthritis, either the knee, a hip, and then they get the surgery and we'll help 'em come back to whatever level they need to come back to. 

Mark: So what's important about this in terms of changing the healing for someone? 

Iyad: It's actually really interesting. I was talking to one of our surgeon colleagues, and he labeled it as an interesting thing. He says, like, you know, to heal from a surgery perfectly, it's a three-way dance. So there's the surgery itself, and there's what the therapist recommends and there's also what the patient does.

So it kind of ends up being influenced by the three things. So obviously, like the surgery itself going well or not going well, it's gonna matter. But then also the rehab program has to be tailored for that person. Like for example, if you have a soccer player who wants to get back to high level soccer, and they had an ACL reconstruction, that program needs to prepare them for a return to play to soccer. Not necessarily just running in a straight line or just being able to do a squat, cuz that's great, but probably not enough for that person. 

And then the other thing that comes down to it is, you know, unfortunately as in a perfect world, you'd have supervised exercise day and night. But then some people are gonna need to do some of the home programs on their own, which usually we coach them through it and like, again, most surgeons are quite supportive of that, and they'll try to emphasize the importance of them doing the stuff at home. So we'll see that kind of emphasis on like some home program, but where it affects healing is in function.

So the way I kind of describe it to people, I'm like, okay, yeah, you had an ACL reconstruction, the surgery fixed the structure. So now that you have something that's restricting that shin from moving in let's say, abnormal way, well now it's up to you to make that knee work for you. And the way it works is like, you know, you gotta expose it to early phases, it's a lot of range of motion. Just to get over the stiffness and the swelling and all those things. And then you progress strengthening you know, there's flexibility in strengthening and there's a whole bunch of stuff including coordination. Control exercises that we would kind of work the way with.

And then, you know, I find it the most helpful also for people who tend to be a little more on the cautious side. So you see a lot of hesitation. People do a little less than they should sometimes. Obviously there are people who do too much. But honestly, for the most part, I see people who tend to under, let's call it underload themselves and under stress it because they're worried that it could, for example, harm the surgery or harm the knee or harm the hip or harm the ankle, whatever surgery they've had.

And I think this is where, you know, we work really closely with the surgeons to kind of give them the appropriate dosage of movement so that they're not under moving, but also not going overboard at the same time. 

Mark: How often is getting that chain of movement that needs to happen, it's not just a knee that's involved in rehabbing a knee. How much is it, and if someone's had a not necessarily a traumatic injury, but maybe arthritis or something, how often is that a really key component for the healing? 

Iyad: Yeah, of course, of course. That's a really important thing. Like, it's really funny actually, sometimes we have people coming in with boots and they said their instructions are not to weight bear for six weeks.

What we are able to do is get people exercising in non-weightbearing conditions. So we could do a ton of different loading programs and even like cardiovascular programs that don't involve weight bearing on the foot, for example, or on the knee or on the shin or on the affected area.

And that's kind of like, I guess, where we get to be as creative as we wanna be and we 'd stress the person's body in a good way so that they don't lose their capacity in other areas. So imagine you had a foot fracture and then you're not allowed to weight bear. Well, we could still get people strengthening their quads and their hamstrings and their musculature. And that won't affect necessarily the healing of the foot, but then it makes it so that when they're allowed to weight bear, their function is a lot higher to start with. And then we don't have to kind of go back and rebuild on some of those areas that have just lost their tolerance and capacity to do what we need them to do.

And again, this is gonna depend on person to person, obviously. Like if you're doing stuff in your ultimate goal is to be able to walk around with your friends. And that's obviously gonna be a lot different than somebody who wants to get back to rugby or soccer or hockey or anything else like that.

So that's where we tailor it to the individual. But then, you know, early days, a lot of it tends to be education heavy, where we just tell people like, look, this is what you're allowed to do. We give people some parameters to function between,. And then also educate them on when it indicates that if they went too hard or didn't go hard enough, like, cuz you know, people are scared of pain sometimes and rightly so if you don't know what you're dealing with.

But if you at least understand what that pain actually means, or it doesn't. You're much better off psychologically, cuz you're gonna be a lot more comfortable and confident, you know going through the motions and then doing your rehab. 

Mark: Bottom line, is it fair to say that this is about getting you back to the activities that you want to be doing quicker and more the way you used to be able to do it before the surgery.

Iyad: Yeah. And then like a lot of it is removing uncertainty. I really wanna emphasize like that uncertainty is usually the killer. People just look around and wonder like I'm gonna try to run for the bus today. Like, that's kind of like how I've had people kind of tell me. Yeah, that's when I did realize I couldn't run anymore.

You know, after like three months full stop after an ACL reconstruction. So, you know, it's about being, and also accountability is a big part of what we do. Sometimes when you're consistently being followed by someone, you kind of are more on top of things. But yeah, it is about building you up to what you need to do, and it's about restoring your function as well as we can.

But also it's really important for troubleshooting. I find sometimes we're able to identify things that maybe weren't obvious in the early doors, but you know, you'll start to see something and you'll start to see if there's potential complications that happen afterwards. Just having that contact point, like last month we had somebody who had a routine knee surgery.

The surgery was successful, it was great. Unfortunately, one of the wounds got infected. The patient had no idea that it was infected. You know, after two minutes of looking at it, we referred them back to their family doctor. They were able to contain that infection. It was starting to kind of spread around their knee.

So it was, it was good that we kind of dealt with that pretty early. But like that's kind of another area where, you know, again, in a perfect world, you see your surgeon every day, but then unfortunately that's just not gonna happen in any way, shape or form. Just because of the workloads and also like the role description that we each have and how we kind of fit into this healthcare model. So like that's kind of where, again, most of the time, you can think of it as like coaching to get you back to where you need to go.

Mark: If you've had surgery and you wanna recover back to well full function of whatever that is. Whether that's gardening, running, professional level sports. And you're in Vancouver or North Burnaby, the people to see are Insync Physio. You can book online at They have two locations, North Burnaby and in Vancouver. The Burnaby location, you can also call (604) 298-4878 to book. You have to call and book ahead or book online. They're always busy. Thanks, Iyad. 

Iyad: Thank you.

Knee Injuries Rock Climbing with Wil Seto

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Wil Seto, he's the principal at Insync Physio, physiotherapists in Vancouver, BC, Canada. We're gonna talk about knee injuries from rock climbing. How you doing Wil? 

Wil: Hey, I'm doing great. Thanks, Mark. Yeah, rock climbing injuries related to the knee. It's a good topic.

Mark: So what's typically causing this? 

Wil: Well, there's one really main one, like in terms of rock climbing. It doesn't matter if you're looking at what kind of rock climbing that you're doing, cause there's different styles or types, I guess, categories. Like there's what's called bouldering, or you're not using a harness or a rope. And you're essentially climbing a boulders. And in the advent of gym's popping up with bouldering gyms you know, you you have a lot more of these sort of knee injuries related to the rock climbing.

And then also in sport climbing where you're climbing up with your rope and you're doing certain maneuvers that are more technical that can cause strains into the ligaments, especially in the knee or into sort of like that cushiony area that sits between the two bones and knee and the knee joint called the meniscus.

So yeah, I wanna talk a little bit about that today because that's something that I think is really important to really understand and also look at how that can be preventable. 

Mark: So what symptoms is someone gonna exhibit other than their knee hurts?

Wil: Sometimes they may actually swell up and so you might see some inflammation into there. And so there might be what we call the sharp, you know, principle where you have an injury. Sharp is an acronym. S stands for swelling. H stands for, there's heat, it feels hot. A is the altered function. R is for redness. So it's like discolouration in red from the swelling. And then the P is basically the pain. 

And so that's usually sort of a good little acronym to go by. And then, typically it will also hurt and feel like you don't really want to use that leg and that knee for specific maneuvers when you're climbing. And there's two real common ways of injuring it actually in technical aspects of climbing, where you're looking at what's called the heel hook, where you're basically using your heel and your foot like a lever. Kind of keep yourself up and it takes the weight off of your hands and arms a little bit more. And it also just helps with your body position. Sometimes body position and balance with a heel hook can really help you through the next move. So there's that part of it. 

And then the other part that can really contribute to an injury, is really just looking at when you're climbing that is, is when you're rotating excessively and you're dropping your knee to the point where it goes beyond the range and it can injure the meniscus. 

Mark: So when you're diagnosing it, does it make much difference, what the course of treatment is based on what you diagnose? 

Wil: Yeah, absolutely. So if it's an instance of you know, like a ligament strain or tear, then it's a typical four to six week timeframe, kind of thing, in terms of being a more of a mild to moderate injury. Where you're looking at it being from a full healing, full recovery, and fully rehabbed.

And so being fully rehabbed that final stage means that now you have the right things that you're doing to make it strong and feel like you can climb 100% and feel like you know what you're doing and then you're not gonna re-injure it.

And that's gonna be a process too, as you go through that recovery, the healing recovery and rehab phase. And for a mild injury it would take like four to six weeks and then get more moderate into more severe. So that would be definitely going beyond that timeframe a little bit more. And that's important to recognize.

Mark: What if it's a meniscus tear or some other thing like that, as opposed to a ligament?

Wil: Those can be a little trickier. And the reason why is because you're meniscus, it doesn't have the same blood supply or the nerve supply. So sometimes you might even hurt as much, but it's just locked. Sometimes the symptoms are a bit different, so they can really alter your function. So going back to that whole sharp acronym. So your altered movement and function is going to be more noticeable. 

So one of the other aspects I didn't actually talk about with bouldering is the falling part where you're falling right on the knee, you're not falling properly. So you wanna like do kind of like a fall and roll and really not fall on like extended knee and that's where you injure ligaments potentially, and then have more impact on the meniscus.

So that meniscus injury can be more complex. And then if it doesn't retain more normal functioning of the knee joint that's been injured, then we wanna look at more of a diagnostic next step. Because that way that'll help guide us towards management and then ultimately the rehab.

Mark: And how often does a knee injury require maybe surgical intervention? 

Wil: That all depends. I guess from my experience, it can be like, I would say outta the knee injuries like maybe 25% of the time. Depending like from even more serious major ligament ruptures into some more of the major ligaments that don't happen as often in rock climbing.

But I have seen it like the ACL which is one of the major ligaments of the knee to like meniscal injuries and very rarely do you get surgery done on like your collateral ligaments in the knee. So those are the side ligaments. And so the reason why it really depends is you wanna avoid going under and having it surgically operated if you can.

And so really the goal is to retain that function. Say you even have a meniscal tear, you want to just retain that function and get it rehabbed properly. Because the more that you can preserve that meniscus without having to snip it away and get into the knee and really surgically operate it, then the better it's gonna be in the long run. So that's key. Because if you're rehabbing and you're trying to really push through this and it's just not getting any better and you can't even walk, then getting in there and doing something about it, if we've had the proper diagnosis and have followed the proper channel of the medical path and looking at, you know, what's going on. That's when we wanna maybe look at more that surgical intervention that can help. 

Mark: How often is overtraining a component of knee pain in rock climbing? 

Wil: I think that with overtraining, it has a factor. More in the aspect where like if you're not using your core and you're doing like what's called a lazy type of heel hook and you're doing a lazy knee drop where you're over rotating and you're not engaging the core and you're not fully connected with that lower part of your body, with being on the wall or on the rock, then that can lead you to really cause your range to be over extended.

Or to get into that position of the knee where then it's more compromised. And then ultimately you add that with then you go to torque for some more difficult maneuver or move or using more power force. Or you have a fall on a rope or on the boulder and then you land, then that's a combination of it's been overused and you're not strong enough, and then you have the trauma on top of that.

So, it's kind of a tricky question because it's like sometimes people like say, yeah, it didn't start hurting until I had the fall. But then they've been doing things like they've been noticing that's been feeling tight doing that specific heal hook maneuver. Or that knee dropping maneuver. And so these are things that you need to look for, even just for those little things. And they should not last for more than like, you know, five or six days. Those little kind of things that you notice in your body and your knee, especially. 

Mark: How much is working someone through that so that they don't overtrain, they use their body properly, is incorporated into the rehab process?

Wil: Oh, it's super important because if it's not incorporated and it's not part of your rehab routine, then it can very well happen again. And then you can also get something worse happening or you can have something else happening.

A really good example, we had a client that came in that had this happen and rehabbed the knee properly. But then stopped doing the routine and the exercise of keeping it strong and then started to have back problems because they weren't engaging in the core. So it's kinda like you go in to see your dentist and you have cavities, and then now he's like, do you brush your teeth every day? No, I try to do it once a day. And then your dentist says, well, maybe it'd be good if you do it twice a day. I think that'd be really good. And then it's gonna help your cavity prevention even better. So you do that for the first little while, but then you stop that. It's the same thing. 

Mark: If you're having some knee pain from your rock climbing, if you've had a fall, if you've got some kind of trauma that you wanna get looked after, the guys to see in Vancouver are Insync Physio. You can reach them on their website. You can book for either location in North Burnaby or in Vancouver at Or you can call the Vancouver office, (604) 566-9716. You have to call and book ahead. They're always busy. And they'll get you moving right and better. Better than ever. Thanks Wil. 

Wil: Yeah, you're welcome. Thank you, Mark.

Hip Pain – Pinchy Hips with Iyad Salloum

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Iyad Salloum of Insync Physio in North Burnaby, and we're gonna talk about hip joints. How you doing Iyad? 

Iyad: Good, Mark, how are you? 

Mark: Good. Pinch, pinchy hips. What are pinchy hips? 

Iyad: Yeah, some people get pinching sensations in the front of the hips. They feel like whenever they do certain movements or stretches that like the front of their hip kind of catches. Most commonly, they'll classify and describe it as like, oh, it feels like a pinch, and it's hard to localize. So they'll kind of say, it's somewhere deep in there.

They'll put their hand, they're like, somewhere in the middle of there. It's kind, it's hurts. So it's kinda hard for people to put a finger. And yeah, that's a pretty common presentation for people who have some soreness that's coming from the hip joint itself. And there's a variety of things that could be affected there.

So you could have somebody who develops this over time, through let's say, training, just doing a bit too much. Maybe doing things a bit in a way that is provocative for them, or it can happen slowly over time and they don't notice it and then suddenly they notice they're a little stiffer. Some people call it, oh, they describe it as like maybe my hip flexor is tight.

That's kind of one of the sensations that they feel cuz the muscle in the front of the hip gets really tense. But those are all kind of responses to a sore hip joint. So, those are kind of what what we would look at then is depending on the age and if there's any traumatic episode or not. Or how it developed, and we would assess the joint itself. Sometimes with imaging from their physician, sometime without imaging with their physician. And we would kind of determine a treatment plan based on what they're presenting with us and what they need to be able to do.

Mark: Does that the, what you're diagnosing, does that change what's possibly causing that feeling? 

Iyad: I mean, usually the way we would approach it from a physio point of view would change a small bit depending on what you're dealing with. So for example, that symptom in the front could present with sometimes buckling sensations where people feel like literally their hip is slowly giving out, not maybe coping well with certain movements. And sometimes they just say, I just feel really stiff after I run, or after I hike, I just can't feel like I could walk anymore in like really severe cases. And sometimes they'll feel it like that they're really good with a lot of things except when they do a day in the gym where they do a lot of squats. 

And then in that case, we would just look at different ways that they need to be able to move and adjust their program accordingly. So like the load management here isn't necessarily just, oh stop doing this activity. It also tends to be looking at different, let's say areas that are not addressed, areas that they're under loaded in that maybe can benefit from a bit more strength, maybe a bit better control. And then also we sometimes will change the way to do things.

Because what we are learning more and more about people is that no two hips are the same. So you and I, you know, we have different haircuts, so we probably also squat very differently. So that's kind of one of the things that you would work with somebody who's you know, can coach you through that movement and just help you find your optimal way to do it.

Mark: And is it actually changing, like, is there a specific muscle dysfunction, tendon ligament dysfunction that's going on. 

Iyad: So you can get some, usually if it goes on for a while, you can get involvement of some of the connective tissue, like the ligaments and maybe even the labrum, which is one of our things that helps provide some structural stability to the hip.

Creates labrums interesting, kind of creates a suction cup effect between the ball and socket joint, and it kind of helps create some congruency between the surfaces, so that two surfaces fit a lot better with each other. Some people when they in prolonged aggravation patterns, they will affect the labrum.

And that's kind of the progression of, of these things. And the most common thing that some people will get a diagnosis of is called femoroacetabular impingement syndrome, where you have just a let's say a ball in the socket that don't quite fit each other. So you either have an overcovered socket or a too big of a ball for the socket and the tissues in between have to respond to different stresses then. And that's where like, you know, when we come in is we would try to adjust and let's say identify certain provoking things and then maybe see if we could change it. 

So in running it would be looking at mileage, looking at let's say angles of incline looking at a different training pattern. Like if somebody's just not cross-training enough, that could also predispose them to certain things. And also, like sometimes we would do some gateway training. So we would just change a thing or two about their running style to make it a lot less impactful on that injury. So that's an example of that.

Sometimes with lifting, we would again change multiple things, like maybe the depth of the squat, the width of the squad, even sometimes just change the exercise altogether, but keep them strengthening or maybe address some of the deficits. Because you can have also muscular components to this where let's say the control is really poor. So you're just moving in a really, like, you're kind of robbing yourself of good movement mechanics, so then you feel stiffer than you actually are because you're just moving in let's say a pattern that's not necessarily the best for you in that case.

So yeah, there are muscular components and there are all also structural components, and that's like where we would try to figure out what's going on and address it that way. That's why the name has a syndrome in front of it, so it's not like one single thing that gives you the presentation. There could be a multitude of factors that kind of come into play, and you just have to look at what the person's doing and what they need to be able to do and kind of work with them that way. 

Mark: And so again, depending on the diagnosis, what's sort of the typical course of treatment then? What timeframe are people looking at to get better?

Iyad: So it depends on when they come in. So if you are just starting to feel it and you know, it's not, let's say as irritable. So it takes a long time to come on and it goes away pretty quick. I mean, that makes sense that it's not gonna take as long of a recovery time. And then if unfortunately, sometimes we see people who are like, oh yeah, like now walking two blocks becomes really tough and the hips become really sore. Well, in that case, we just have to kind of be a little more basic and a little more rudimentary with our approach. So there's definitely exercise components. There's a lot of education. And so we try to find things that actually are provocative and try to like limit those for short periods of time.

And then we also try to find movements that they can do very safely, very well, even under decent loads sometimes where we could get people lifting weights even when they're sore and doing it safely. We just have to tweak a couple of things about their program. And from there on, it becomes a goal-based treatment progression.

So if you are going back to be a hockey goalie, you need to be able to do very different things than if you're in Ultimate Frisbee, you know, field player for example, or you have to just be able to, to sprint and change direction a lot more. Meanwhile, the hockey goal is gonna need to be able to drop their knees in and collapse in a bit more quickly, especially with more fast movements and kick side to side a lot easier with their legs spread out wide.

So that's kind of where your recovery is really different and it depends on what we're trying to get you back to. But also depends on how sore you are coming in and how progressive this thing is. And obviously things like your training history and how, let's say all those things are gonna factor in to timeline. So it's really hard to give you a one number on how long it takes on average. 

Mark: Is it fair to say that the sooner you get in, the quicker your recovery's gonna be. No matter what that length of time on the recovery is. And also the more diligent you are about your following what's been prescribed, you're gonna recover quicker.

Iyad: Yeah, generally I tell people this, I'm like, you know, even if it's not a physio problem. So for example, if it's not something that like just rehabilitation's gonna help, we'll help you go seek the right advice. So, for example, if this needs something that needs our orthopedic surgeon colleagues to jump in and help out, we're able to look at things and just refer to the appropriate areas. We work closely with our family doctor colleagues. Just make sure that every client has the access that they need to deal with that issue. And most of the times people come in and see us because they worry about something need surgery, and it might not need any of that and just need some bit of a tweak in their training program.

So it's really beneficial just to figure out what you're dealing with first. And that's kind of where I tell people just go get it checked out. And if chances are it's nothing serious. But you wanna know that right away because unfortunately all hip and groin pain kind of feels pretty similar, which is like, you get random tightness in the hip flexors or the adductors or you get buttock pain sometimes. And then sometimes it's also pinchy sensation in the hip. So those are pretty vague symptoms and those are pretty commonplace and like multiple different things. So unfortunately, just pain location alone here doesn't tell us a lot.

Mark: If you're having pinchy hips or any kind of hip pain get into Insync Physio. You can book online for either office, They have an office in Vancouver, as well as in North Burnaby. You can call a North Burnaby office to book (604) 298-4878. You have to call and book ahead. They're always busy. Insync Physio in North Burnaby. Thanks, Iyad. 

Iyad: Thank you.

Knee Injuries Running with Wil Seto

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Wil Seto of Insync Physiotherapy in Vancouver. We're gonna talk about knee injuries from running. How you doing Wil? 

Wil: I'm doing well, thanks. How about you? 

Mark: Good. So is it typical that your knee would swell up or is it just a pain thing from a knee injury from running?

Wil: Yeah. So if you get swelling in your knee and you run, like whether you're a recreational runner or someone who's a little more avid or competitive, that's not normal. So there is probably something going on and it could be like a few different things.

But primarily when we look at like the main things that could be happening in the knee, if like, say you've never had an injury before and you didn't like twist it or you didn't have any specific trauma, then it's most likely an overuse repetitive thing going on. And there's a few different kinds of things that could be happening.

Like number one, it could be an overuse IT band issue. So it's sort of like a connective tissue thing because there's a lot of imbalances in the muscles. And so typically going back to this whole like overuse and imbalance, that's usually what it is. So whether it's like an overuse imbalance where the IT band is pulling on the kneecap in a certain way, or it's like maybe a tight hip flexor that's pulling in on the kneecap, like with the quad muscle. Which is one of the quad muscles. There's four muscles that make up the quad. One of them is actually a hip flexer. And so that and then coupled with, okay, so how is the running gait? Like, how is your actual stride frequency?

Like what is your stride per minute kind of thing and what is your actual technique look like and how is your overall form. So we go from like your cadence to your vertical form and how much you're leaning into it and what that looks like when you're taking a step on each foot. So we can determine that. 

Because that's important to look at and then we assess you a little more closely with that muscle imbalance. Are you really weak, like say in your glute med? And is that glute med in your butt, that butt muscle not stabilizing your knee? Then you're not getting that stabilization where you're taking so many steps per minute, then you're just gonna have that sort of faulty mechanical problem happening over and over and over again. And you go for your training run and this can be something that starts to ensue. 

And it usually happens when you start to do a few things. Like you start to increase your training, so you start to increase the intensity, whether it's through more speed work or hill work or even more mileage. Say like you're training for something that's a little more intense, like a marathon or half marathon even. Or you're looking at off road training, where you're not looking at training for a trail race or something like that where you're getting on cambered surfaces and now that's a little bit more gnarly and harder and you gotta have more of that stability core strength.

Now obviously having a preexisting injury or where you've injured yourself before, that can play a factor. Because if you have something that you never fully rehabbed from, like say you sprained your ankle, then that can work its way up into stuff that's happening in your hip, hip flexer, and in your knee. And so I'm seeing somebody right now that has that exact problem. Where they've never had any problems, they're an avid runner and they ran a half marathon back in the 1st of February, the first half. And they sprained their ankles. It was an old sprain, but they never fully rehabbed it properly.

And they had been compensating and this person did a great job of compensating. Excellent job. They were able to get by and, and run the half marathon, but then started getting knee pain after. Obviously, you know, she pushed her pace and got bit of a personal best, but like, you know, she couldn't figure out why she was having knee pain.

Mark: So when you're diagnosing something like that, what do you see? Is it a gait issue? You sort of mentioned three things, so over training, a gait issue or an old injury, like what's the split between those? 

Wil: Yeah, that's a good question. So the gait allows us to see sort of the functional, bigger picture of what's happening and what they're doing. Now, if they have like a specific impairment already, then their gait's gonna be affected. Like if they're limping in, we're not gonna set your gait right away. We're gonna wait until that impairment part of things are healed up, whatever it is. So then when we look at the muscle imbalance part of it, then that's where we really wanna assess like, okay, so what is actually imbalanced.

So what's weak? What's tight? What's being overused? What's being over activated and what's being under activated? And then also the structure. So is there maybe something else going on in here? Is there like an old injury that they maybe don't remember? Like is there like a deficient ligament here that maybe got injured because it's deficient now? Or possibly a meniscus or a cartilage issue, maybe. Those are a little bit harder to ascertain in an actual assessment. But you can start to point towards those areas in that direction if you suspect a certain thing. 

Mark: So how much of the rehab processes, like maybe manual therapy or IMS, and how much of it is some weight training, load-bearing training that's strengthening, weakened parts in the chain of muscles. So your knee actually operates properly while you're running? 

Wil: Yeah, it depends. And so when we look at the manual therapy and the IMS and all the stuff that we do for you and on you, those are just things to facilitate and to reset what's going on and to facilitate a more optimal movement pattern. And same with the exercise prescriptions that we give that are tailored to address what's weak and address what's tight or not activated or under activated or what's over activated. Because we wanna essentially reinforce a more optimal movement pattern in that joint or joints, cuz it's usually more than just one part. So if you're getting knee pain, you know well what's going on in the hip?

Mark: And typical course of treatment? 

Wil: It depends. Like we had some people that got fixed in one shot. Like it's amazing. There was this one gal, that all I did was just change her gait pattern. And after one session we changed, I mean she had a tight IT band, so she had an IT band overuse injury. So we settled that down and then changed her gait pattern, night and day. Like, she couldn't even run past 5k after a 5k run, she was always having extreme and pain and it would swell up. After that first session, she was running like 10, 15 K, no problem. 

And then there's other individuals where it's more of a gradual process. So it's a little bit more involved. So it really depends on the individual. And then if you add other injuries that you've had on top of that and you're like compensating and you haven't really fully rehabbed. Like, here's the thing, you can feel good and you feel pretty decent, until you don't. But you don't know that you have deficiencies and you just think that you're doing okay, then that could be a problem. 

Mark: Is it fair to say that the sooner someone gets in, if they're starting to notice something, the easier and quicker it's gonna be to heal it up in most cases. And then as well, once they've got a prescription, don't stop, when you find what works. Don't immediately stop , keep going. 

Wil: Yeah, that's pretty accurate. But what I would say is a rule of thumb, like let's say you go on a run or a training run, and especially if it's a little bit harder and you're a little bit more sore and you're like, oh, a little bit swelling in the knee, and then you ice it. You do the things that you know that you shouldn't do to calm it down. If it doesn't calm down after a few days, that's when you should be getting looked at. 

But yeah, it's fair to say, you know, give it a couple days and then if it happens again, like say it calms down after two, three days and then you go, oh, it happens again. And then that's when you definitely wanna get looked at. Because you wanna assess what's going on. And especially if you know, oh yeah, like I did have that, I tried skiing like a year ago and I had a little minor tweak. Oh yeah, that's right. I remember that. Or, you know, like it could just be something as simple as like you fell on your knee and you had like a contusion, like swelling type of thing, where it went away and you don't think. 

Swelling in itself in your knee from whatever cause it could be like a ligament tear, but even, let's say you got whacked in the knee by like, you know, I don't know, whatever. Let's say your, hockey stick playing. Yeah, hockey stick and nothing has technically been torn, but the swelling, the mere fact of the swelling can actually shut down muscle activation patterns.

Mark: And that's where you can help with reestablishing the proper chain of events that need to happen that we take for granted, cuz it's all unconscious. But that can really be, we can overcompensate in a lot of mysterious and not good ways. 

Wil: Especially when you get into that part where you hit the threshold where now you have dysfunction and pain because that's now an indicator. Think of that point where you cross that threshold and you feel pain and definitely dysfunction, as now the indicator that something is wrong. No different than when you're driving and you look at your dashboard and you see the flashlight indicator, the check engine. You're gonna ignore it?

You put the tape on it. Yeah. Yeah. You can put the tape on it and ignore, or you can bring it into your mechanic and do something about it. 

Mark: If you want expert help for your aches and pains, especially knee injuries, knee swelling from running. The guys to see are Insync Physio in Vancouver. You can book online at You can call the Vancouver office to book (604) 566-9716. Get in there, get running better. Set a new PB. Thanks, Wil. 

Wil: You bet. Thank you, Mark.

Knee Pain – Osgood Schlatters Disease with Iyad Salloum

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Iyad Salloum of Insync Physio in North Burnaby, BC, Canada. We're gonna talk about an issue that's happens mostly with young gentlemen as they're growing. How you doing Iyad? 

Iyad: Good Mark. How are you? 

Mark: Good. Awesome. Fancy name for this one. 

Iyad: Osgood Schlatters Disease. And then we have a few other types of things that kind of fall in the same category of injuries. So the most common one, most people will know this as Osgood Disease or Osgood Schlatters Disease, and usually affects boys as they're going into the adolescent years, and tends to be from an issue of overactivity, like doing a bit too much, a bit more than they're able to handle.

And it comes in as like pain in the front of the knee and it'll affect you right under where the kneecap is. And we tend to see this a lot with people over a long period of time where they're just persisting through a bit of pain, and they're just kind of patching up and managing, and just kind of going along and playing a lot of soccer and maybe a high impact jumping sports.

So I've recently been seeing a couple of gymnasts who've had this cuz of all the tumbling that they're doing, and the way it kind of presents is just like localized knee pain. Really painful with impact weight bearing and sometimes also resisted exercise because you know, your quads pull right on that spot that hurts in the knee.

So yeah, usually when the bone's sore, you can't really do much with it. And you know, it's one of those things that most people will look online and read that it's self-limiting. And it typically is when, you know, most kids grow out of it. The annoying thing and the unfortunate thing is it can be really, really painful and it can like actually stop kids from being as active as they'd wanna be and maybe participating in the sports that they want to do.

And it's usually really funny cuz sometimes when we advise parents on like, well your kid's probably doing a bit too much and maybe we need to change some of the training routine a bit. And not necessarily just with rest, but also to modify a few activities, maybe do more of something and less of something else.

It's met with a bit of this kind of, oh, well, it's self limiting, so we'll just leave it be, but then, you know, it's not really a fun condition cuz it can really affect people's activity level. Especially a lot of young, active kids. They really love sports. Gives them a bit of identity, gives them something to explode their energy into. So that's one of the most common ones. 

We also have something similar to it that can affect the heel, which is called Sever's Disease. And it's the same idea as where you have pain just in the heel where the achilles tendon inserts and it happens from the same thing usually. Lot of activity, repetitive impact.

This one I see a lot in soccer and I guess also, because if you think about the cleats, they don't really give you lots of cushion support. And here in Vancouver we have a lot of turf fields, which are really nice, ripe for impact. And they don't give you as much cushion as grass does. And that could be one of the factors. 

Obviously it's a little more than that, but it tends to be also one of those volume related things. So if you are doing just a bit too much, not getting enough adequate recovery, maybe there's also some other risk factors that could predispose the kid to getting it sooner than later.

But there's so many factors in there. But it tends to be one of those things where we would see, and you know, then people usually come in when they're kids, like a lot of pain. 

Mark: So what, is there a root cause to this other than just over-training? 

Iyad: That's the most common one. Unless the kid has some form of like, let's say bone abnormality, it tends to be that. The other thing to keep in mind is like as kids are growing their bones, like we, stuff like good open growth plates. So the bones are a little softer than you would expect in let's say immature kid or somebody who's like, let's say in, in their teen years, and the tendon is not, let's say, a weak structure.

So the tendon even tensioning through the bone, puts a bit of a force. And if that happens, like let's say enough, you might ask, well, why does the tendon not get affected? Well, in those age groups, the tendon sometimes could be a little stronger and they're a little better at handling the loads than the bone. And then that's usually could present that way. 

Now with boys, if they develop this as they're into their teenage years, a little further in, they'll develop more likely things like lip patellar tendon problems, which is the pain just immediately under the kneecap, and they'll get a bit less of their bones getting involved.

Like the most common people I see in the clinic with Osgood Disease, and this is not based on any studies, is they tend to be between 9 and 13. Those are the most common ages I'll see them in. And it tends to be kids who are just, are incredibly active, which is a great thing but maybe doing a bit more than their bodies able to handle all at once.

Mark: And so is the diagnosis, is it fairly straightforward?

Iyad: Tends to be. I usually confirm with some form of imaging. Like if we need that, but it tends to be pretty easy to diagnose in the absence of a few things. Obviously if somebody comes in unable to weight bear, we wanna look at that. We wanna look at that pretty seriously, cuz kid not being able to weight bear, I would highly encourage everybody to go check with their physician right away. And this is like, cuz it doesn't tend to happen so much. And then it's one of those things where we just wanna remain vigilant for some of the things that could be a bit more serious than like, let's say just the early stages of Osgoods or Sever's. 

So that weight bearing thing can be really important. Sometimes kids with hip pain can also report knee pain. So they can actually come in with knee pain when it's actually just the hip. Well, that's also something we wanna consider. We wanna kind of keep an eye out for.

But yeah, for the most part most of us working in orthopedics get to identify that pretty well. And then sometimes a need confirmation with an x-ray and sometimes it's really just confirming kind of what you already know.

Mark: So the treatment generally is then a little bit more flexibility in the training program. A little bit lighter training program. What does that look like? 

Iyad: Potentially that, or sometimes we just get 'em training different things. So for example, if you're doing training for like cardiovascular fitness. You're just doing a lot of aerobic exercise. Well, there's some things that you could do that are probably a little less strenuous.

So that's one of the things we would do right away. We've gotta keep the kids active and keep 'em busy. And then if we're out of the very, very acute phases, we start some strengthening program, which can help with their ability to tolerate more impact. We could also change some, again, it depends on extensive it is and how bad it is and how necessary it is. 

Sometimes we could also look at running retraining and could look at strengthening up and down the chain. Because if you get somebody who's really sore, let's say with Osgood Schlatters Disease, and then you try to give them quad exercise, that might be really, really sore early on.

But later on it might be actually appropriate where you're trying to get them to do a bit more of that good load to the system to get them a bit more used to, let's say the good stressors that you would wanna put through their body and gets them a bit more adapted to the stresses.

Mark: If your child is having some issues with knee pain, heel pain, get into Insync Physio in North Burnaby. You can book online at You can book for the Vancouver office there as well. You can call as well, Burnaby office is (604) 298-4878. You have to book ahead. They're always busy. Insync Physio in North Burnaby. Thanks Iyad. 

Iyad: Thank you.

Shoulder Injuries in Rock ClimbingTreatment & Initial Rehab

At an arm’s length away from the wall, place your hand on the wall at the level of your eyes with your weight on it. Engage the lower core of your low back and pull in your low abs below your belly button.

Then pull the arm and the ball aspect of the shoulder joint into its socket while having your weight on the wall with your one hand. Avoid pulling down with your Lat muscle. Keep this engaged for 10 seconds x 10 reps 3 sets each side.

This exercise starts to work the shoulder muscles to help with more optimal stabilization and movement reactivation patterns after an injury. If you have any pain or problems performing this exercise please stop and consult with your local Physiotherapist before continuing. 

Groin Pain with Iyad Salloum

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Iyad Salloum of Insync Physio in Burnaby, British Columbia, and we're gonna talk about groin pain. How you doing Iyad? 

Iyad: Good, Mark. How are you doing? 

Mark: I'm all right. It's a new year. The snow is falling. It's cold. Welcome to BC. So, groin pain? What's the deal with groin pain? 

Iyad: So this is such a big injury, or let's say, call it complaint, because it could be caused by so many different things. And the remarkable part about it is that whatever your age group, you can have a different cause or contributor of groin pain. So, for example, we see this in some pediatric groups when they're playing too many sports or sometimes after a trauma.

Like, we're talking like really young kids in the age of like 8 to 12 sometimes. And then we could see it also in our very, very elderly population due to changes in the joint. And then everything in between. You could see it, for example, in athletics and sports. Pretty common to have groin pain in hockey and soccer.

And I think it's really important to identify what type of injury potentially you're dealing with or what type of mechanism is causing that groin pain and then kind of devise the proper treatment because of that. Because if I had somebody who's, for example, between 8 and 12 and unable to weight bear because of their hip pain and groin pain, I'd wanna get that looked at to make sure we're not dealing with any injury to the growth plate or injury to the femoral neck, which can be pretty serious. So we would definitely like, wanna rule that out first. 

And then if it's somebody who's, let's say a little older, playing a lot of sports, we can just look at lots of things from volume of activity to quality of movement to potential, like how much can their tissues actually handle and how much are they actually using them? And then kind of work our way up. And in cases where we're dealing with, let's say, an advanced arthritis case of the hip, we can still do quite a bit with exercise. However, sometimes we also have to kind of work closely with our medical colleagues or even consider surgical options. If it's, let's say a bit too developed and a bit too advanced. 

Mark: So I guess the first question is, can I just solve all this issue with stretching? 

Iyad: That's a really good question. And the answer is no. Rarely do we see actually stretching be the only thing you would use. Most of the time, it gets really funny. Depends on the type of groin pain. Like, so sometimes it could be helpful and it could be a useful tool to get out of symptoms, but also to kind of re-expose the, let's say the affected area to a bit of stress.

Cause the stretching is not considered necessarily like a really high load through those musculature, through the joint. But in some cases, for example, if I have somebody that could get provoked with stretching, you know, that's where we usually see clients who've had this for a few months and then they're like, okay, that's it. I can't cope with this anymore. And they try some DIY versions of stretches that they find online. And those stretches could be helpful if you were dealing with just the musculature, for example. That's just a bit maybe not exposed to different lengths, and then you're like, oh, it feels really good when I stretch.

However, in those cases when they do this, like, yeah, I actually notice that sometimes stretching can make it a bit more sore. And that's where I can just say a blanket yes, the stretching is probably a no-go in this case. 

Mark: What about hernias? 

Iyad: Yeah, so that's actually one of the things we would wanna look at because there's a lot happening in the front of your hip and thigh and kind of lower abdomen. So you know, you can have a hernia potentially. That could be a reason. There are some tests that we would use to just kind of, even if we're suspecting that, we would then refer on to our medical colleagues for some confirmation.

 And then like the treatment for a hernia is gonna be a lot different than if we have, for example one of our hip flexors in the front of the thigh tendinopathy there, where we'd wanna load it a bit more gradually, you know what I mean? Meanwhile, the hernia, we would wanna maybe modify some of the exercises so that we don't exacerbate their conditions.

This is why I thought would be useful for us to talk about it because I feel like there's just a lot of unknowns when it comes to groin pain and we're learning more and more about it every day. I've seen a few resources online saying, oh, if you have groin pain, do this. And I feel like that's where we're probably missing the mark a bit because groin pain is a symptom. It's not an injury specifically. And we have multiple things. We call them like these diagnostic entities. So we have like a hip flexor related issue, a hip joint related issue. You have, for example, an inguinal region, which would be usually associated with the hernia related issue. And then you have the adductors, which are your inner thigh muscles. It could be related to that too. 

So there's like, these are the big four major entities. And then we look at also potentially, does this person have a low back condition that's referring to the front of the hip. Any of those things. So that's where it's good to have a set of eyes on it and just kind of get the right idea of what you're dealing with so you can actually intervene with it appropriately. Because sometimes it could be felt of the hip, but not caused by the hip, if it's the low back, for example.

Mark: So how often is it an issue of over-training or not proper warming up or whatever that issue is that, like you've alluded to versus mm-hmm. an imbalance, which we see often in other parts of pain issues that people have. 

Iyad: So generally speaking, I'd say the over-training could be, let's call it actually training errors, like more than over training specifically, cuz sometimes under training and then the return to normal could be just as bad as a contributor.

So in certain age groups, I'd say if you're not looking at non-traumatic causes like somebody didn't get, you know, a big fall that landed on the hip or like a big impact in like a collision sport or anything like that. You could see a big proportion of those being caused by that.

And then in some cases it could be like a prolonged slow buildup. Like in the case of, let's say hip arthritis, that's just kind of developed a bit over years and years and years. So in that case, it's hard for us to just pinpoint and say it's over training alone. Cuz there's a lot of factors that go into it, like your metabolic health, your body weight, inflammation in the body could also contribute to this.

If you had small, repetitive, old injuries and they didn't get a chance to heal properly, that could also potentially predispose you, along with this overtraining. That could be, for example, what made you feel it. But it's highly unlikely to say that, oh, you ran once and that's why your hip has become arthritic. Because that doesn't hold up. You know, running isn't necessarily bad for you. It's actually quite good. But as if anything, you do too much of something all at once, it might make you a bit more likely to be sore and maybe need to come into one of our offices to see what we could do about it.

Mark: So when you're prescribing, once you've diagnosed exactly what the root cause is of the pain, mm-hmm, or it could be multiple issues, I'm sure. Yes. Then what's the typical course of treatment look like? 

Iyad: So a great question. Again, it depends on what are you trying to get back to. If you are just like, Hey, I just need to be able to walk around the block and be able to run my chores, do my errands, that kinda thing. And that's gonna be a very different thing than if you're, let's say, div one soccer player that needs to be able to sprint at high speeds repeatedly, cut and change direction. You know, so the demands will be very different. 

The other thing that really determines this is also like, you know, what level are you coming in with? For example, if you have these goals that you wanna be able to get to and you're let's say under loaded and rested too long, then the buildup time's gonna have to be a bit longer, obviously, than somebody who has tried to stay active with the injury. That's typically what we would try to do. Our first approach would be activity modification to try to keep up as much of your load tolerance and your capacity as possible. And then we can kind of add more sequentially or gradually on that. 

And then sometimes we would also need to maybe talk about changing certain habits. So we could do some gateway training, for example. Play with that, which we talked about previously, like the gateway training could just be like changing the mechanic of it, which it might not fix all of it, but it can definitely make you get more mileage out of what you currently have. And then kind of continue training instead of having to completely stop.

And that's usually the biggest issue is we stop too long, we lose capacity. And then we try to go back into it and then, you know, we're like, oh my God, it's flared up now with a lot less. Even though when we stop, it feels good when it settles down and you're feeling normal. But then the second you go back at it again, you're like, oh wow, it's sore again.

So we think we reaggravated it, but in reality, your tolerance was here, you rested. So it dropped a bit. And then you try to go up again. Well, now your tolerance has been lower because you've just been doing nothing. And then that's kind of a vicious cycle where we rest and spike up too much.

Mark: Timeframe to heal?

Iyad: Very good question too. It really depends what we're dealing with and it really depends what we're working towards. So I'd say anywhere from four weeks to eight, six months to a year, it really depends. I think we're looking at different things. 

So for example, if we're dealing with something with, it depends on something called irritability. Like, you know, that's a really good thing to kind of look at. It's like, well, how long into your activity does it get bothered in? So if you're the kind of person who I feel at a 10 K of running, you know, that outcome's gonna be so different. And if somebody else is I feel it in my first three steps. So that sensitivity level really matters. 

And then also healing and in that sense is the very different in these injuries cuz it's all about how much tolerance can we build up to get you to your goal. So giving a blanket term doesn't make sense. Most tendons, for example, that we're dealing around the groin, will take about 12 weeks of a good loading program to kind of be able to handle that strain and stress. So that's probably like as specific as I could be with you in the absence of all the important pieces that we could use to frame this.

Mark: Of course. Well, if you've got a lot of pain in your hip, the guys to see in Burnaby, North Burnaby are Insync physio. You can book online at You can call the office to book (604) 298-4878. You better call and book if you've got pain. They'll get you feeling better as quickly as possible because they will diagnose the root cause of what's going on. Thanks, Iyad. 

Iyad: Thank you.

Inner Thigh Groin Pain in Soccer with Iyad Salloum

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Iyad Salloum of Insync Physio in North Burnaby, British Columbia, Canada, and one of the top physiotherapy clinics in North Burnaby. We were talking about inner thigh groin pain. How you doing Iyad? 

Iyad: Good, Mark. How are you today? 

Mark: Good. So I know we're gonna label this as inner thigh groin pain from soccer, but this really bridges a lot of different sports that have a lot of cutting and moving in different directions. Does it not? 

Iyad: Yeah, basically, the inner thigh muscles, they're called the adductors. So you know, we can have adductor related groin pain from multiple different, let's say exposures. Typically we see it in like, let's say the more sprinty type sports where you have a lot of change of direction because you are putting lots of tension and strain through those musculatures, especially when you're trying to cut and change direction really quick.

You need to kind of put a high amount of force in a short period of time and then pivot and continue going at that same speed. So that's kind of where we see this a lot in hockey potentially, or soccer. And then in other times we'll see it, let's say more traumatic reasons.

So we had a skier who, as you were talking earlier, caught an edge and thigh got pulled up to the side, so suffered an injury to the inner thigh, and that caused quite a bit of groin pain from him. So you could have that as well. It could happen over, let's say a repetitive pattern where you're just doing too much all at once and, you know, maybe not adequately recovering from it, or maybe you're overloading your current capacity. So if your tolerance level is this arbitrary number here and we're doing this a bit too much without adequate recovery, that could do it too. 

Or you have the big force all at once case, which, you know, those tend to be pretty hard to miss for most people, and they don't kind of sneak up on you. They come in all at once. And then we kind of would look at addressing that in as many ways as we can. 

Mark: So let's just define this adductor. What movement does the adductor actually do? 

Iyad: So that's a really good question because I think the muscle suffers from a bad name because it's called the adductor. And adduction is usually when your thigh is, let's say, in your thigh coming towards midline, it's called adduction. So that's basically it, so basically moving inwards it's either left or right. So that inwards movement is one of the things that the adductors will do, but the adductors also can help us rotate our hips so they can actually help us twist.

They can also help us if most of you know, like the time when you haven't done squats in a while and you do a bunch of squats and next morning your inner thigh is really sore. So the adductors can also extend the hip. So they can push us up basically. They can work with the glutes, and then there's some abductors that also will help the hamstring do their job.

So we're looking at quite a big repertoire. And then in our front, we have some abductors that also can flex the hip. So some of them are hip flexors too. So this is where I think the challenge comes in. You have people who can try to do, let's say abduction based exercise only, and you know, just trying to do a lot of squeezing type exercises and where you're missing out, basically. Yeah the thigh master. And it's not a bad exercise to do sometimes. It could be quite useful, actually. Quite neglected muscle group. But, you're not probably addressing the total function of the muscle.

Like, you know, you think about the muscle that it has multiple fibres that go in different planes, in different directions, and then it's really key for us to try and address the function instead of just specifically training the tissue only. So there's some theories out there that because the muscle does so much of the different tasks that maybe you can have a deficit, for example, in your hip flexors, and your adductor starts to potentially try to help out because when we move, we don't think of specific muscles. We think of global movements. 

So whatever's available, we'll try to help out sometimes. And then we can kind of build these, let's say patterns that strain one area a bit more than the other. And then that's kind of where, for example, if we're treating an adductor, we wouldn't just treat the adductor or we'll just see where's there a deficit in those surrounding musculature and try to kind of address that too. Because the last thing we'd want is somebody to rehab their adductor, feel really good, and then go back into play and then pull up with another injury somewhere else, for example. 

Mark: So, as always complicated to diagnose. What are you looking for? You mentioned this a little bit, but I'd like to emphasize it. What are you actually looking for? 

Iyad: So, in cases where there's trauma, we wanna look to see if there's potentially any like major injury to the structure. So the muscle or the tendon attachment to see if there's like any, you know, big injury there. So we would look at from bruising to strength to range. We can do palpation, it's a good test too. It's not the most comfortable area to have someone poking around for sure. But it can have some clinical use to do that because in the latest criteria to diagnose it, we'd look at those three things. 

So you'd have to have pain in that region, and then you'd have to have like tenderness to touch and then some kind of, let's say, weakness in one of the tests that we would use to assess the strength of it. And then you'd probably lose a bit of range just because that's typically what tends to happen.

I can't move my hip too much when I'm really, really sore there. So it could be protective, let's say restriction of movement or it could be that sometimes the swelling could be there and it kind of limits my movement and sometimes it could be just weakness that I just feel like I can't move because I just don't have that ability to leverage properly, you know, to push off of things properly.

So I feel like I'm stiff, when reality I just don't have the ability to move, full stop. So that's how we would try to, you know, see that. We would try to see if it's the only thing we're dealing with too. And there's really been a lot of recent studies on this where we look at not just rehabbing the local area, but we also look at rehabbing the trunk.

So for example, how you control your low back, your pelvis in conjunction with the adductors because control issues there can also spill downstream. There's a big study cohort out of Ireland that looked at this and they did some really cool stuff with like, even 3D measurements and stuff, and they found that, yeah, an intervention even to the, to the like, you know, to what we classify as the core musculature, especially in running and sprinting can also help the adductor related groin pain.

Mark: Hip bones connected to the thighbone , in other words.

Iyad: Yeah, like that song says, exactly. 

Mark: So how much has it changed the course of treatment, depending on what you actually see and which adductor positioning or fibres are causing the issue? 

Iyad: Yeah. So I wanna just clarify. The abductors themselves, it's a group of muscle, it's not a singular muscle. So I have a couple in the front, couple in the back. They're quite big as a group. 

Yeah obviously like the more widespread, like if you have a very focal injury, it's gonna be a little easier potentially to come back from than if you have multiple little things all over the place.

The good news is, a lot of the times, our clients are surprised by how much we get them to do right off the bat. They think we have to rest and avoid, and avoid, and actually we can push in like a loading program without affecting them negatively.

If anything, like we speed up the recovery a bit more cuz they're able to kind of get started on something a bit more meaningful for them. And you know, the toughest thing on athletes is when you tell 'em, Hey, you're gonna sit down and do nothing, for example, right? And this is anywhere from like a university level varsity athlete you know, to a pro all the way to the weekend warrior. Sports can be a nice outlet for a lot of people and just having them completely withdraw from that could be, you know, negative in other areas beyond the hip pain and the groin pain. 

So yeah, we would get people started quite early and it's really just about tolerance. Is it appropriate to get this person started more aggressively? We wanna make sure that they're safe to do that, obviously. Like, so this is where, I guess it depends on is it just a single spot? Is it multiple things that we're dealing with? You know, multiple different things. Because sometimes, like, you know, there's nothing that says you can't have your low back and your adductor hurting at the same time. And maybe that's more limiting to them than the adductor injury. So it just depends on what you're dealing with.

And then obviously, the timeline depends on your target. What are you trying to get back to? What's the level of like, what's the capacity, what's the max? Let's say torture you should be able to handle with your hip muscles and with your leg and with movement. Because a lot of the times you'll see people who test normally on the bed because the load's not the same as sprinting for 90 minutes in the soccer game. So that's where you'd wanna kind of match the intervention to the level that they're trying to get back to. 

Mark: If you've got some kind of inner thigh groin pain happening. You wanna see the experts at Insync Physio in North Burnaby. They will diagnose exactly what's going on so that your recovery will happen more efficiently and effectively. And you can book online at There's two locations, one in Vancouver, one in North Burnaby. Of course you can call the North Burnaby office, (604) 298-4878 to book. You have to call and book ahead. They're always busy. And thank you so much for watching and listening. Thanks Iyad. 

Iyad: Thank you.

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