Mark:  Hi, it's Mark Bossert. I'm here with Iyad Salloum of Insync Physio in North Burnaby, BC, Canada. Today we're talking about hip pain, specifically maybe from running, but hip pain of any kind. What's going on with hip pain, Iyad? 

Iyad: So usually when we see runners come into the office it'll tend to fall into one of four categories. So the problem with the hip is it's such a vague area. So some people will point to the outside, to the front of the hip, the groin to the inside and then sometimes into the buttock region. So I think just calling it hip pain is probably not doing it enough of a justice. So, I guess 1 of the things that we would try to instantly dive into is try to figure out what happened and how it started and all that stuff.

But the main thing that we want to do is try to figure out what kind of thing are we dealing with. So, are we dealing with an irritation of a joint? Because that could happen. Some people are more predisposed to it, and it could happen, for example, with just high running volume. Or maybe people who are new to running, that trying to still learn the skill, because it's a skill after all. It's kind of like juggling. You can't just do 5 bicep curls and become a good juggler. 

So same thing. If you're doing a few squats and you want to pick up running, it's not going to be a simple transition. Or could it be sometimes the tendons? So, for example, we see this a lot with, menopausal women, outer hip pain, and that could be the gluteal tendons. The glute medial tendons specifically can get affected.

And some people call that trochanteric bursitis, but that's one issue. The other issue could be the joint itself. That could be either some form of cartilage injury. Could be arthritis, or it could just be a labrum injury. So those are all things that could fall into that joint pain thing.

And then we have some of the muscular components which I feel like most people think they have, which is tight hip flexors. That's what the diagnosis that they get given, but it's not as simple as just tight hip flexors. It could just be that the hip flexor insertion, which is where the tendon is, is actually affected, or it could be a small injury to that. Those are all possible things. 

And then we would have to kind of figure out, is it any of those or is it just the bone? Because guess what, just because you have a bone injury doesn't hurt differently in the area. It all hurts kind of roughly in the front. 

So, we had a lady come in the clinic with basically what most people told her was just tight muscles in the front, so she wanted some exercise to stretch it out. Well, the clinical exam only showed those symptoms of tightness when they were weight bearing. And when we did other tests to figure out that muscle length, that strength, actually, when it wasn't in the weight bearing position, they were totally fine. Zero symptoms, perfect signs, actually perfect range of movement, good strength.

And so we kind of went down the rabbit hole a bit. We found out that there was a bit of a reaction in the bone. So she was developing a stress fracture actually. And it wasn't a fully complete fracture, but there was something that we were able to pick up on x ray. It was advanced enough.. We worked with an orthopedic surgeon with her on modifying activity.

So we reduced running because we had to because she was at risk of exacerbating that fracture and then we started working on some other things to allow her to heal better.

Mark: So stress fractures do take longer. They don't heal as fast as a complete break. Why is that? 

Iyad: So, it's still relatively under researched, I would say as an injury, but what we do know about it is if I was to suddenly have a traumatic experience and break a bone, we get a massive inflammatory response that happens. Which is important if you want to contain the area of injury and start to send, let's say, send the troops to the right spot so you could start you know, the healing process. Now, in cases where you have a gradual stress fracture, we see it just be a little slower. And it's because probably 1 of the reasons could be that the inflammation response is much more muted. And it's a bit slower of a build. So it also tends to be a bit of a slower recovery.

The other thing is this could be a factor, which is that people just sometimes don't know that it's a stress fracture. And I don't blame, for example, that one client of ours, they just felt some tension in the front of their hip, and that was their only symptom. And I don't blame that person, for example, for thinking it is a tight muscle, because that was their symptom, was some muscle tightness. But maybe that protective muscle tone was just their response of trying to offload or protect or change the way they move to just make it feel better.

So, all of those factors could be into play. And then another thing to think about is basically, is that person dealing with some degree of bone weakness, like osteopenia or osteoporosis? So that's where the bone mineral density is a bit lower. And having that, one of the things we would work on is with our medical colleagues is on like potential adequate supplementation.

We would put them on some different exercise programs that tend to kind of be a bit more, let's call it pro bone building or maintaining the bone mineral density. So those are all things that have to be considered when we're dealing with somebody who has a stress fracture. 

If it's purely from adding a lot of volume, and that's one easy kind of almost, let's say, a very direct cause and effect, but there are other reasons why people can develop stress fractures easier than we need to be aware of. Because we don't want to see that, for example, in other areas. Maybe in the other leg or in some other areas in the pelvis or the foot or whatever, things that could prevent them from moving.

And, you know, as we know, the less we move, the more our bodies get affected in many other ways. So that's the last thing we want to see, like an injury from somebody trying to do something that's good for their health, take away from their actual health. Because now they have to do like a more aggressive, let's say, resting program.

Mark: So basically that client that you mentioned, she started to take charge, be responsible for her own health by getting expert help. First from her trainer, from her doctor and they recommended that she come in to see the physios at Insync Physio, so that she could find out okay is it this muscle issue? And you guys diagnosed because you're the experts on, okay, here's what's actually going on by referring her back to get an x ray?

Iyad: Yeah, I think, like, that was really important. I think we work closely with all our colleagues and from the community setting, where you have the fitness experts all the way to the medical system where we work closely with surgeons and with sports medicine doctors and the family doctors. And I think, yeah, this is not a simple, yes one person can figure this out because they provided us with adequate input for us to suspect something else was going on. And we have the ability to, the time really and like the facility to assess the function of that person adequately.

And then we were made a referral back and then luckily we got that person started on the right track instead of constantly doing this big boom and bust cycle where it recovers for a bit to go for a run, flares up and then they're resting. So that kind of big stop start, we got them off that, we're trying to ramp them up a little more gradually to their tolerance.

Mark: You're having running hip pain or hip pain of any kind from whatever sport or movement you're involved in. Get in to see the physiotherapist at Insync Physio. You can reach them online to book your appointment at insyncphysio.com. There's also hundreds of videos on there, on all types and stories of repairs and issues, body and vendor work on your body, on how to feel better and keep moving at insyncphysio.com. Or you can call the North Burnaby office at (604) 298-4878 or Vancouver (604) 566 -9716. Thanks, Iyad. 

Iyad: Thank you.

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, insyncphysio.com. 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.

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 insyncphysio.com. 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.

So what we really wanna focus on is making sure that we have what's called functional mobility of your hips. And the reason why that's really important is because even though you may work on doing things like stretching and recovery work to get your mobility for your hips after you climb, or for your next climbing session, what you really wanna make sure is that you have that strength when you go into that range. 

So here's an exercise that I really like to do that I often prescribe for people that have really tight hips and that really want to make sure that they maintain that mobility in their hips for their rock climbing training progress.

So basically they're just really simple things that you wanna do, but you wanna make sure you keep your hips level, you engage your core here. That way you're not doing a lot of like, tilting and shifting. And so with high steps, you know, you really wanna be able to have sort of rotational, being able to work on getting your body as still as possible and having it not move past mid line too much. Being able to come up with the foot. 

You'll do 10 of these, and you can go a little higher too. Now, as you go higher with the step, then it's gonna be a little bit more difficult obviously. So as you can see, my hips are pretty tight and what you really wanna work on is keeping everything pretty still.

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Iyad Salloum of Insync Physio in North Burnaby, British Columbia. We're talking about hip pain today. This is probably even more common than I would think with older folks. Is that right? 

Iyad: Yeah, so the specific thing we wanna talk about is you know, specifically outer hip pain. When people tell you, you know, the outside of my hip feels a bit sore and it kinda tends to be quite limiting and very painful in certain cases. You'll see it favouring, let's say an older population and it tends to affect even women more than men, quite a bit more, unfortunately. 

You know, there are several causes for this that that could maybe predispose women more than men. We've actually been seeing a couple more of these, we had a really sunny October, so people were out and about moving around a lot more. And we saw this in a few hikers, you know, so we had a couple of seniors coming in actually just happened to come in the same week, same exact presentation, just went on a big hiking trip, and then suddenly started developing soreness in their outer hip.

And, you know, it feels a bit tight, feels a bit stiff, so they start stretching and then it starts to get progressively worse. To the point where they just tell you that they can't lie on it, they can't really sleep well. It kind of gets really, really bothered. 

He could walk a flat line, but that's about it. Like any kind of incline or stairs gets to really, really become bothersome. And I think the reason it's a tough one to kind of almost get at is because it could present also like an arthritic hip. So when you have arthritis in your hip, it can also give you pain in the outer hip and, you know, on excessive exertion.

But the thing we're talking about specifically affects the actual tendon of your glute muscle, your glute med muscle where it in inserts to the outer hip. Though that tendon can get affected like any other tendon, like our Achilles or our patella tendon. And it tends to get really aggravated with changes in your, let's say, loading patterns.

So if you, you know, haven't really been active that much, and you start doing a whole bunch of incline walking and stairs, well that'll do it. And then, when it flares up, it tends to get really aggravated with stretching , even though you might not be harming it just really, really gets irritated and triggered with repeated stretching. And then unfortunately it feels, you know, tight and uncomfortable, so people have the instinct to try to stretch more sometimes. 

Mark: Other than just an increase in load, are there any other causes that manifest this? 

Iyad: We do see it with impact. So if you fall flat on your outer hip, and if you're you know, if we're lucky enough not to have any like bony injuries or anything like that you can get that.

Because your glute tendon, especially glute med tendon is quite exposed on that outer hip. So we have like a big bony prominence, just the beginning of our thigh, just below the pelvis, and that's where those insert. And that really plays a huge role, that muscle, it prevents us waddling when we walk when it works, you know, normally. And so that could be a reason. And then when most people kind of end up Googling it, they find something called trochanteric bursitis, which is the most commonly viewed thing where it's classified as the inflammation of something called the bursa, which helps kind of almost like lubricate the surface between the tendon and the bone.

However, what we're finding is that bursa seems to be a victim of just the tendon at large. So if the tendon sore, the bursa could get sore. It's hard to get the bursa kind of happening on its own. You'd have to have some very specific mechanism or somebody rubbing that specific part only to get it. And it's really rare that you just get it out of the blue. 

So when we see, a lot of the times our first thing to do is actually try to identify are we actually dealing with that versus let's say an arthritic hip. And the management's really, almost a bit surprising to a lot of people cuz we will exercise it a lot. But we would just start off with also avoiding certain things like a stretch for the first week or so, just to give it a break. 

Mark: And what is the typical course of treatment? 

Iyad: So, again, you wanna identify triggers. So it's a lot of, let's say, not necessarily avoidance, I would just say, let's call it controlling the triggers. So if you can do a little less of that, that would be really good. We wanna keep people active, obviously, as much as possible. So like if somebody's used to walking a lot and we wanna keep them walking, ideally we would find a distance they're comfortable with. We would probably change them from walking big hills to more like a flat surface, a flat road, even on the treadmill, if they could tolerate that.

So that's number one. It's really important not to let people kind of decondition, you know, cause they tend to have taken quite a significant rest when they come and see us already. And it doesn't seem to kind of go away. They're like, oh, it only feels good now when I'm not doing anything.

So the second they get back to activity, it flares up. And then we will try to give specific exercises that, let's say are tolerated by that affected tendon, but also let's call it like comfortably uncomfortable, so that it kind of tends to work well without flaring them up for too long. 

And and then obviously it depends on your goals and where you want to go. So if you are trying to just get comfortable walking 30 minutes a day, obviously your treatment isn't gonna be the same as somebody who's trying to get back into running or doing some pretty intense hill work and hiking and stuff like that. So that's where you'll see a big difference between different people. And it depends a lot on their goals and where they're at already. So some people tend to be very, very affected and some people are less so. So it's not like a, a one size fits all because of the spectrum of presentation and also goals that people wanna get to. 

Mark: So is this a thing that if you just quit and didn't do anything for a year, it would go away?

Iyad: It only seems to get better at rest. That's the thing. So rest makes it better at rest. That's what we're finding with actually almost all the tendons in our body. And I mean, it makes sense, you know, we constantly think of muscles as atrophying, but tendons actually really get affected structurally when we don't put like the right amount of, let's say, stress through them. 

So yeah, like it'll probably feel better when you're not doing much. But then the second maybe you return to any form of exertion on that area, it can flare up and people think, oh my God, I thought I got rid of this. And we see it a lot. We see it with shoulders, we see it with everything. We see it with Achilles tendons, we see it with even some cases of knee pain where you know, we think rest is the way to go. But really the key thing for us tends to be about finding an activity that anybody with this can tolerate and kind of progressing them from there. And they do really well, exercise programs tend to be quite effective here. And we're having a lot more studies show that compared to other, let's say even pharmacological interventions, which is quite good. 

Mark: If you're having some hip pain get in to see the folks. Sooner is better. Always. Your recovery will probably happen quicker. The sooner you get in there, rather than you waiting around. It ain't gonna get better by itself. Go see the folks at Insync Physio in North Burnaby. You can book online at insyncphysio.com or you can call the office to book. Burnaby's office number (604) 298-4878. They also have a location in Vancouver and you can book online there as well. Thanks Iyad. 

Iyad: Thank you.

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Wil Seto of Insync Physio in Vancouver. He's the clinical director. He's the big cheese, the chief cook and bottle washer. He's the chief joint manipulator. Maybe that's even better, at Insync Physio. And we're gonna talk about something that's a little tricky. Hip pain running injuries. How you doing Wil? 

Wil: Hey I'm doing really good, thanks, Mark. Yeah. Actually, funny enough, I used to be a chief bottle washer at a restaurant when I was growing up, and in some ways I still am at home with the young babies. Yeah. Yeah. So this is actually a really good topic to talk about because you know it, this is definitely peak running season with the weather that we're having.

You know, it's cooler, which is perfect. And it's prime running season too, cuz it's not rainy. And so people are getting out and what I'm seeing is a lot of people coming in with hip pain from running. And one in particular is a woman, a client who came in to see her physio team.

And you know, we do share the caseload here. And this one patient had a pain going on her hip and she started up running in the fall and then did a couple races and I think she ended up doing Turkey trot or whatnot just as a sort of like a training race. And she was having trouble just like even like sitting for more than 15, 20 minutes and the pain was going down basically right into the outside of her bum cheek area and then referring a third of the way down her thigh, on the backside.

So, a lot of the times when you kind of start having that stuff coming on and if it's like after a run or during a run, you know, can be a little bit troublesome or a little bit worrisome. And then after the run, it doesn't go away, then you should try and do something about it. I mean with this particular client, she was trying to do exercises to relieve it that she found online and she was just trying to do some self massaging on it and nothing really worked. 

So we ended up assessing her and it turned out that she had, what's called a thicker iliac joint or SI joint dysfunction happening. On further questioning, it turned out that she has had a couple kids and because of that, she's got some hypermobility in that whole SI joint and pelvis. And then when we looked at things a little bit more, there's a lot of imbalance going on. And this is someone that's also quite an avid runner.

And at one point she has done quite a handful of half marathons, a few marathons. So she's not like new in the game. And she was having this kind of ongoing hip issue, and it was getting worse and worse. And then I think she ended up going on a trip and she was away with her family for a couple weeks and then it got really bad and then she came back, sat on the plane and, you know, and she was like, Oh, I could barely move the next day. 

So that's usually, you know, the presentation that we see people finally like, this is sort of the cherry on top, I can't take anymore, and you know, the straw that breaks the camel's back.

When we looked a little bit more closely at what was going on, there was a lot of imbalances. And in addition to looking at what's going on with SI joint, there was some ligament instability. She could walk and all that stuff okay, relatively easily, but the main issue was running hurt it. She started in the first like five minutes was kind of okay, then it started getting worse. And then sitting for more than 15 minutes was bad. So she was quite rotated out of alignment. 

And so we were looking at why she was like that. It turns out that it was because she had this instability in through there, all these ligaments that were really loose, probably from her pregnancies before in the past. Her kids are like 10 and 7 or something like that. And then she has these imbalances where a lot of things are just so tight. And then that tightness was just not allowing other things to actually activate and turn on. 

So these imbalances were affecting her actual running pattern or what we call her running gait. And so when we looked at it, we were like, Oh, you're totally not activating this. And then when we actually went in there specifically, look at how strong she was, it was astonishing for her where her one side where she was getting the pain, it was like she was failing. It was like 40%. Like she could barely hold that up.

And then on the other side, she didn't have any problem. They were like, Oh, wow, that's crazy. So we looked at why that was going on and we had to like do some adjustments to kinda get things aligned and it was affecting our whole back, all the way up into her lower back. And so we assessed that obviously, and it wasn't coming from her lower back or upper back in terms of the main cause.

So we think that that unstable SI joint had been trickling up and everything's just been seizing and everything was sort of like, I guess lack for better word, stuck, in the thoracic segment of the mid back area. So we essentially did a bunch of adjustments first and kind of realigned things that in itself kind of helped her, but that wouldn't sustain it, and I'll tell you why in a second.

So we did all these adjustments and then her strength where she was failing went from like 40%, to like 70%. And she was like astonished at how much of a difference that made. But then that bringing it up from 70 and keeping it even at 70 to bringing it up to 90 and potentially up to 95, maybe a hundred, possible, is only possible if we actually prescribe the right exercises.

So we assessed her and looked at, this is totally like this. It's not actually opening up. The mobility is actually not great when it goes into an extension and as a result you're not able to activate certain things. So what we ended up doing was reinforcing certain things. We had to do a lot of soft tissue releasing as well, and then suggesting certain other modalities to release that soft tissue.

So whether it being massage therapy or other forms of deeper releases like IMF or just working on some more active relief stuff with other therapists, that was important. Make sure we gained that mobility and then reinforcing it by working on opening up those areas that are tight and strengthening. So we call that up training. The areas that are not actually turning on that are down trained. And then those areas that are up trained that are just on too much, we gotta settle those down. 

So we sent her on her way with a bunch of prescribed exercises specifically for her, and she was doing great. I said, You know, like you can check in with me if you want. And she was pretty functional, but I said, You can check in with me in about a week, or you know, a couple weeks or something like that. And she was doing really great. But then she stopped her exercises and she ended up having to go away somewhere and she didn't do her exercise for a week and then came back and she was frustrated.

Because she didn't have enough time, she was only able to do them for like four or five days, and then because she didn't have time to do exercises, it came back, same thing. And then that physio basically treated her and got everything going again, and she's good again now. She's really on top of her stuff. That's the homework, so to speak. 

And she's looking at running another half marathon as sort of a training run before she does the the BMO next summer. And that's her goal. She hasn't really been running in a while and she wants to get back into that running routine. So that's been two weeks since we last saw and we haven't heard from her. And we said check in with us in about two, three weeks. So I think the physio is seeing her next week. 

Mark: So it's an important part, and we've mentioned this before, an important part of your healing process is to, I don't know, I keep thinking repattern or retrain the proper firing of muscles. Once they've loosened up, once you've rebalanced and readjusted everything so that things are firing in the right order, the right way they should be doing. And that takes practice, basically. You gotta have some reps in so that you rewire your neurology to work right. Is that a fair assessment? 

Wil: Yeah, absolutely. And I think the other key factor here is knowing what ones to do. Of course. Because I mean, she was trying to do all this stuff before she saw us on her own and she didn't know what to do and she was just like, Oh yeah, I'm tight here. And then trying to do stuff that was almost there, but just little tweaks that maybe she wasn't getting right.

And then also when you're so stuck, and use this quotations, stuck and out of alignment, that it doesn't matter how much you're even doing the exercise correctly, you gotta give yourself a fighting chance. What I mean by that is that you're gonna be on good neutral ground where everything's all on alignment now. Then we can actually have a fair fight.

Mark: Yeah. Let the healing grow from a place where the soil has been tilled a little bit and is ready to take that seed of the exercises. If you're having some running issues, if you've got some hip pain or even back pain, from ramping things up cuz suddenly it's running season. The guys to see are Insync Physio. You can reach them on their website, insyncphysio.com. They have a North Burnaby office as well. And to call the Vancouver office, (604) 566-9716 to book your appointment. You have to call and book. They're always busy. Thanks Wil. 

Wil: Thanks, Mark.

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Wil Seto of Insync Physio in Vancouver. He's the head clinician, the expert, the guy many time voted best physiotherapist in Vancouver. Of course his clinic has also been voted the best physiotherapy clinic a number of times. And we're gonna talk about hip pain today. How you doing Wil? 

Wil: Hey, I'm doing well, thanks Mark. Yeah, hip pain. More specifically cartilage related type of hip pain. 

Mark: So what kind of symptoms, I mean, it's pain in your hip, but how would you know that it's the cartilage versus arthritis or a growth in your hip or, or? 

Wil: Yeah, no, those are good questions. So the technical term, when we talk about the cartilage in the hip we refer to it as the labrum. So quite often, if you get an injury or a tear in the cartilage of your hip, we call it a labral tear. And you're right about like how do you know that it's not like a tumor because it could be right. And that's one of the causes and actually. 

I'm glad that you actually brought that up because we had a patient that came in to see one of our physios, this is a while back now, a few years ago. And he was having hip pain that just wouldn't go away. And these are the kind of things you wanna look for, like there was no trauma and he didn't do any sports or any exercise in particular that brought this on. And I remember one of our physios who was treating him, you know, was telling me about him. And he brought me in to kind of take a look at it and and I was like, yeah, like, this is interesting. It's strange. Because there was no real mechanism of injury, number one. And when I say that, there was no trauma and there was no like acute trauma and there was no like repetitive type of trauma and there was no incident. And so we said, you know, go see your doctor and get some scans and get it checked out.

So he did that and it turned out that he ended up having a tumor, the size of a baseball in his hip. And so I'm glad that you brought that up. So it could be that, but I mean that was very rare, like that happens probably less than 1% of all hip pain and these type of cartilage type of errors that we see.

But that's what we thought it was initially because it was acting a lot like a cartilage tear, like a labral tear. And you know, we get the classic symptoms of it catching and clicking but you can imagine finding a tumor the size of the baseball, of course, things are gonna pinch in there. You know, of course things are gonna not move right in there. 

So some of the other symptoms, if there is more of a tear in the labrum, that cartilage portion, then there'd be specific movements that cause it like if you ended up getting in a car accident. And that can cause sort of the shearing force and you're already in this you know, flex position or something like that, and it can damage sort of the back top side versus the posterior superior portion of that labrum. Or if you're in a hyperflex position, if you're just doing a lot of stair climbing and for some reason the stats show that the Asian population tend to have a lot more of that.

I don't know if it's because you know, they tend to squat more or something like that. So doesn't have to be an acute trauma. It can mean it's sort of this repetitive thing. And so they found that they have more of that tearing on that posterior superior side. But then they also found that the highest incidences seem to be related to kind of more in the anterior superior, which is on the front top part of that hip labrum. And so anything that involves twisting compression, in terms of the mechanism of an injury. 

So on a repetitive and on longer sort of chronic scale and maybe even things like, okay, let's say I do a lot of training and I suddenly add stairs to it. And then I just start to feel a little bit of a low grade ache and that builds. So it can start up as a small injury, a small tear and start to build into a bigger tear and then escalating into a bigger one and then causes a lot more symptoms and eventually dysfunction where you can't even walk. And so you experience pain whenever you try to run and even walk and even just standing. And even bringing up your knee in hip flexion, try to put on your pants, put on your socks. 

We have a couple physios that are seeing a couple of patients that have that exact problem right now. An older gentleman that came in, very active, likes to swim. Took some time off. Didn't feel comfortable going in the pool during this whole pandemic. It's been a long stretch. Went back in January for the first time in like, you know, year and a half or whatever. And started swimming four days a week. And it was actually kind of a funny injury. He tried to, you know, prop himself out of the pool, like mantling pulling out of the pool and put his right hip into this hyper hip flexion and tried to get himself outta the pool with his leg up. Felt a little tweak. He thought he just pulled the muscle kind of went away. 

So this is sort of how it starts. It went away and then he tried to do the same thing again the following week. And then it got worse and felt even sharper. And then it started clicking more. We haven't sent them in for scans yet, but our physio team sees a lot of this.

And what ends up happening is that you know, for quite a majority of them, there's stuff going on in the labrum, at the cartilage area. That's usually the presentation. There's some kind of trauma, whether it's like an acute type of trauma or some kind of micro trauma or repetitive type of trauma. 

And another cause is if you have like, so related to trauma, let's say you injure the hip and you don't injure the cartilage and you have a hyper mobility. So there's all the laxity in there. Or maybe a little bit of laxity. And because of that, then it's more unstable. And then the hip joint, so you have sort of like, it's a ball and socket, and so what ends up happening is that ball portion, because more unstable, then as you twist and turn in a ball and socket type of joint, then it can cause some injury in that hip, if it's more unstable. 

If there's a lot of multiple imbalances, like we were talking before then yeah you add that to the mix. Then that can cause more compression. And then you go to try and get into the range that you're used to for flexion or extension. Then you will tear that labrum. 

So there's also certain conditions that you're born with. Let's say you have what's called, like when you're a child, you have certain diseases in the hip where it's just more lack or congenital hip dysplasia where you know, when you're born, your hip kind of gets dislocated and gets put back in. That can be something of an issue that can cause a type of labral tears.

But there's also like the degeneration component, like as you get older, it's just tends to wear a little bit more and you're more prone to having it wear out. If you have other preexisting injuries to maybe your back or, you know, things that are related to the function of your hip.

Obviously we know how the back is really connected with that hip. So if you've had, you know, certain back issues or certain back conditions and that can affect the hip and usually the symptoms are right in your hip joints from the front. We call that the anterior right to the lateral, and it feels like it's deep inside and it feels like there could be like a locking and catching type of pain. And it can be from like a constant diffuse ache to a sharper type of pain sensation in there. And usually that will progress a little bit more as that degeneration occurs more and more. 

Mark: So what kind of things do you do to diagnose this? 

Wil: Well, it's kind of tough to actually say that it's a labral tear, but we can always say that it's like probability that it is. And there's certain things that we do in our examination procedures to look at it's the probability is likely that it's this, based on these different tests that we're doing. And quite often people will think, oh, like when they have this especially in the initial stages, that they might have pulled the hip muscle.

And so we obviously wanna rule out any of the muscles if they've been sprained. And then we also check out whether or not if there's a hyper mobility or instability natural joint. Because like I said earlier, like that laxity and that hyper mobility can play a factor in this.

And then sometimes there's like, there's a condition called Ehlers Danlos syndrome where you're just sort of locked through all the ligaments in your body and not just ligaments, but through other parts of your body that can also lead to issues with the labrum. And some people have gone on living into like, you know, their fourth or fifth decade of their life, not knowing that even had Ehlers Danlos syndrome. So it can be mild to more severe.

And so these are things that you do specific testing, you go back to the doctor, but you know, it's sort of these genetic markers that you look for that can add to that. So these are all things to consider. 

Mark: And how bad does it get to be before you are, or when's it the best course of action, is to refer someone to the doctor for scans and whatever treatment the medical doctor might provide. 

Wil: Yeah. So basically, we are seeing patients sort of like first line. So what that means is that we see them before they've even gone to the doctor, quite often. We have about like 25% of the patients that will see a doctor first because you know, they're not really sure. And they go to their family physicians who they trust. But usually we see them first and we'll diagnose it or we'll look at what's going on based on the tests.

And then we wanna treat that. And we wanna treat it, especially if we think it's an orthopedic thing. If there's other sort of signs that if it's really obvious, like, oh, that sounds like it might be something more going on on that initial assessment. Then we will refer you back to see your doctor and to get more testing done. Because I think that it's important to work with your family physician to really solve and get at the root cause of your aches and pains of what's going on in your hip. Because there could be more going on. 

Even though we may be suspecting that it could be like a possible labral thing, but if there's other things going on, like there's unrelenting pain. And pain that's like a 10 outta 10 without any relief with any kind of positioning or movements, you know like there should be some kind of relief, if it's biomechanical issue. Unless it was just a fresh injury. 

So those are really sort of warning signs right away like if it was like a gradual thing, like there was no true mechanism of injury. But they're having this 10 outta 10 or 12 outta 10 pain. That's a huge warning sign that something else might be going on. And especially like, there's no lead up to this. 

Mark: And let's say it's not that bad, and so you're moving forward with treatment. What is a typical course of treatment? 

Wil: Yeah, really addressing if there's a hyper mobility or instability, stabilizing the joint. And that also means that looking at okay, well what's imbalanced. Because usually if there's instability, there's also an imbalance in the muscles, but let's say if there's no instability, we wanna look at what's not working properly.

So we want to start to address the movement to function. So quite often the hip flexors are super tight and not functioning properly and they're not allowing the extension mechanism to work properly. But it becomes a bit of a dilemma because let's say like I was saying earlier that it's the anterior top portion, which is the anterior superior portion of that cartilage that usually gets damaged.

And usually what happens is, it's a hyperextension compression type of injury. But then quite often you need to activate those muscles in that range. Like your glutes, because they're not activating properly. So then what happens is we gotta start to address the movement function of it. So we have to look at how do we get your hip moving better without aggravating it?

Because even the act of getting it moving, if we produce pain, that's gonna shut everything down because pain will also cause things to not work properly. Swelling will also cause things not to work properly. So we wanna address those things. We wanna settle it down, if it's acute. Take the swelling down. Do whatever it takes for that part of it.

And then now we wanna start addressing okay, the mobility issues. And then we can start addressing the strength issues and then kind of doing that together maybe. And then the functional mobility. So now we've gotta work on the core aspect in getting what is overactivated and what is underactivated.

And then part of that is addressing, okay, well can we walk on this now? Can we go upstairs? Can we even just put on your pants? Can we even put on your socks first thing in the morning? So those kinds of things.

Mark: Does it change when someone's had a hip replacement?

Wil: So that's a good question because slightly different. It does change because there's a lot of positions that you want to avoid. And when you have a hip replacement you essentially have like automatic instability. And so usually with the hip replacement, the cartilage is all worn out. So there is no cartilage. And so you're not really looking at rehabilitating the hip with respect to a torn cartilage that you're trying to maintain and keep intact. Cause now there's basically no cartilage there. And now you're just replacing it with a total new hip or partial hip or whatever you decide to choose. And now you're looking at strengthening and trying to maximize function and avoiding certain positions and letting the postoperative part of it heal first.

Mark: So if you're having hip pain, the guys to see are Insync Physio. You can reach them on their website at insyncphysio.com. You can book for either office. You can call the Cambie office at (604) 566-9716. Or the North Burnaby office, you can reach them at (604) 298-4878. Get in there, find out what's going on with your hip, and if there's more going on, then they can look after it, they'll refer you to your doctor. Or they'll get you started on the path of recovery and get your hip working properly again. Thanks Wil.

Wil: Yeah, you bet, Mark.

For tight groin muscles caused by hip injuries, you might want to give this exercise a try.

Start in 4 point position on a mat with your legs as wide apart as possible as if you are trying to do the splits. Then push your butt backwards towards your heels and hold this position for 30 seconds. Perform 3 sets each time, 2 times per day.

This is a simple exercise that can help with improving the mobility of your groin adductor muscles. If you have any abnormal pain or problems doing this exercise, please consult your local physiotherapist before continuing.

This exercise targets the activation of your gluteus medius muscles of your pelvis and hip to help with your anterior hip pain. Have the back of your ankle and heel pushing back on the front low side of a big ball against the wall. In side lying, make sure that your torso is not too far back or bent too much forward to avoid your hip being in a flexed position.

With your spine and hip in neutral position push the back of your ankle and heel up to the top part of the ball maintaining contact on the ball the entire time. A few key things to look for is to keep the toes pointing forward and towards your own nose so that you’re not rotating the hip and the toes upwards while you push the ball upwards. Bring the ball back down and repeat this 10 times for 3 sets on each side.

This is a great exercise to build more functional posterior core strength to help offset the muscle imbalances that contribute to anterior hip pain. If you have any problems or questions with this exercise consult your local Physiotherapist before continuing.

This is a great mobility exercise for the hips to help improve what we call the motion of abduction so that you can move the lower extremities more into the outward direction.

Start by securing a belt or a solid strap around something solid and unmovable like the leg of a couch. Check your position by starting with your knees open wide in a “V” and bent. Make sure your lower back is nice and straight.

Next, hold on to the strap and gently pull yourself forward to take up the slack of the belt to reach the barrier of your hip flexion while you maintain a straight low back. Then begin to straighten the knees to the floor and gently pull yourself forward on the strap by flexing at the hips even more until you feel a more moderate but comfortable pulling on the inside muscles, or the Adductor Longus Muscles, of your thighs.

Hold this for 30 seconds doing 3 sets 2x/day. If you have pain that doesn’t feel like a stretch, or are unsure about what you are doing consult a local physiotherapist before continuing.