188. The Hip Expert's Blueprint: FAI, Load Management, Strength & Hormones | Alison Grimaldi, PhD

Welcome to Medicine Redefined. I'm Dr. Altamusharaja, and I'm Dr. Darsh Shum. Let's put the help back in healthcare. Welcome back to part two with Dr. Allison Grimalti. If you're new, hit part one for a quick primer on hip anatomy and terminology and then come right back so we can talk about FAI and some of the practical takeaways on what FAI syndrome actually requires, some symptoms, signs, and imaging, and why something like a cam versus a pincer lesion, and why these specific morphology matters in terms of hip intracticular pathology. We trace where these morphologies come from in adolescent hip-heavy sports and what to change in the weight room to spare the joint. FAI is something in particular that has really increased in prevalence over the last 20 or 25 years, and Allison is somebody who, as I mentioned before, is an expert in the field when it comes to helping preserve hips before they even get to the surgeon's office. So I was really interested in learning from her and I have learned a tremendous amount from her over the last couple of years, and I'm excited to share that with you guys today. So with her, we map a rehab first path, which includes load management, quote unquote hip-happy ranges, and movement quality, and we also talk about when surgery makes sense with real timelines for return to play versus peak performance. We'll also cover the other side of the coin, which is micro instability and dysplasia, and how to spot them, and this insider out rehab blueprint that Dr. Gamali prefers. Plus where some of these common exercises that you'll see on Instagram and social media such as cars, fitting, and where they don't. Finally, we touch on the big levers beyond the joint, metabolic health, nutrition, and hormones, especially in post-menopausal females. And lastly, we talk about why strength work is non-negotiable for aging athletes. Something I suspect you know damn well if you're an avid listener of this show, but always a good reminder. As a reminder, Dr. Gamali is a principal physiotherapist at Physiotech, an adjunct senior research fellow at the University of Queensland. She earned her PhD at the University of Queensland and founded Hip Academy in 2020 to help clinicians translate complex science into actionable insights. She works with people from all walks of life, helping them optimize their hip health. Without further delay, please enjoy part two with Dr. Alson Gribaldi. Before we dive into today's conversation, I have an exciting update. My new practice refining health and performance is officially launching soon. It's a practice built around health, longevity, and performance. The Medicine 3.0 approach we talk about every week here on this podcast. And here's the best part. It's a telemedicine cleaning, so you can work with me from the comfort of your home. Our founding member in Roma is now live, so if you'd like to learn more or join the weight list, visit refininghealthrx.com. All right, let's go to the episode. We're back here with part two for all the listeners that don't know and are coming here new to this episode. We did a part one here with Dr. Alson Gribaldi about the hip. So please check out part one. You'll get a really good foundation about hip anatomy and some of the terminology. And obviously in part one, when we were talking, we were overly ambitious. We had so many things to try to get through that we just couldn't. We ran out of time. So here we are back with part two, Dr. Gribaldi. Can we start with F-A-I, femoro-acetabular impingement? Can you help us define what that is and what that really means? Sure. So femoro-acetabular impingement is really just impingement of the head-necked junction of the femur against the acetabulum. Earlier in range then would be typical. And so that's usually associated with a couple of different types of bone shapes. And the most common and the most problematic seems to be cam morphology, which is basically an asperical femoral head where we have a little bit more of a bump at that head-necked junction. And so that can become a problem as the hip comes into flexion and internal rotation. And we get early impingement of that bump against the acetabular rim. Then we have another type of impingement that's called Pinser impingement. And that's associated with either a deep socket or a retroverted socket. And so that also can lead to early impingement or we can have a mixed type F-A-I where we have both the Kim and the Pinser together. But yeah, if we go further into that definition, so F-A-I is really just a structural thing that we're talking about. If we're talking about pain associated with that, then we'd usually use the term femorous tabulin impingement syndrome. And that was something that was recommended in the Warwick Agreement in 2016 when they suggested that clinically relevant morphologies that predisposed F-A-I should be referred to as femorous tabulin impingement syndrome. And that requires a triad of symptoms, which is usually groin pain, clinical signs, which is usually painful restriction of hip flexion internal rotation, that impingement type position, and imaging findings. And so imaging findings either finding a cam, so an ACE spherical femoral head, which has variable definitions in the literature, but I usually use an alpha angle of more than 60 degrees, which just measures that bump at the head next junction, or having that sort of overcoverage anteriorly of the acetabulum or a mix of those. But it's important when we talk about F-A-I that we're looking at interventions, that it's the symptoms that make it something that we will intervene within treatment. And so it's having those three things, the symptoms, the clinical signs, and the imaging findings. When you talk about alpha angle, are you looking primarily at MRI or you're looking at CT? Well, the largest data set that we have from the check, chord cohort, was actually just done on APX ray. So we put a circle around the femoral head, and then line down the bisecting the femoral neck, and then we put a line where that femoral head first leaves that circle, and that shows us how much ACE ferricity we have. But certainly if we're looking for that 3D shape of the headnet junction, yeah, either CT or MRI will give you more information. And with MRI, they can do specific sequences where they sort of measure all the way around the headnet junction. Because with APX ray, of course, we're really only getting a good view of that entralateral sort of area, that lateral, entralateral bump. And more recent research has actually shown that in females, that bump is more commonly going to be anteriorly, rather than entralateral or anterior superiorly. And so that means if we're only looking on a pure AP, you might miss that sort of camorphology, particularly in females. So I guess if we want to be really clear about that shape, something like CT or MRI is a good way to go, because we get more 3D information then. Do you have a sense of when the first report of case was, is this early 2000s or late 90s? Yeah, I think early 2000s, I can't give you, and yet they're on what was the first paper that sort of talked about it. But as with anything, it takes quite a while for that information to start trickling into clinical practice and what does it mean for clinicians, and then further research. So that Warwick agreement was 2016, but that paper was published because there'd been like an explosion of information and papers around looking at the shape of that head net junction, particularly. And there was some belief early on, in our journey there with FAAI, that if you had a bump, it's always going to lead to arthritis. So we need to go and do surgery even if there's no symptoms. And that was certainly something that potentially became a problem, because we had patients who were asymptomatic, and then became symptomatic and had very poor outcomes from surgeries that were just based on, let's operate on an image. And so that's why it was great when the Warwick agreement came out, and it said, right, we shouldn't be operating on people unless they have FAAI syndrome. And we're looking at changing symptoms rather than just looking at morphology. Yeah, I asked that question because I see people probably in their 40s and 50s, and they're like, I've never even heard of this. And at this point, it's progressed into osteoarthritis. And that's a sequelae of untreated disease. And they'll mention, well, how come, you know, I've had this issue, how come nobody has said anything? And you know, one argument somebody can make is, well, the prevalence of FAAI or FAAI syndrome has been increasing. But then we also recognized that, well, that's not necessarily true, because this is something that a problem that we've only started talking about, really heavily over the last 10 years, maybe last five years, I'd say. So that's the class of spotlight effect, right? You're, if you're looking for something, you're going to tend to find it. And so I tell them, you know, often times we didn't even recognize this. But I think there's also the other side to that in terms of development of FAAI syndrome. And you know, my understanding is in terms of just early sports blesses specialization and early activity in the adolescent years. So what can you tell us about the development of the disease? At what point throughout the life cycle are people more predisposed to that? Are there certain positions, sports, etc? Sure. So with primary FAAI, so we can have secondary FAAI that might develop, you know, associated with osteoarthritis and development of osteophytes and things like that. But primary FAAI is really something that develops during adolescence. And the evidence so far suggests that high volume activity and particular types of active, so high volume we're talking, you know, more than four training or games sort of sessions a week. And particular types of activity seem to predispose to this bone shape as well. And they generally tend to be what we refer to as hip-heavy sports, which are generally weight bearing, change of direction, type sports. So it's interesting the dramatic difference in prevalent, for example, in ice hockey. Compared to downhill skin. So it's that particular combination of selection rotation, perhaps with body weight forward a little bit, which will really sort of increase that load across the hip joint and, you know, the use of those muscle creating compressive load or stimulus across that epiphysis in the head of the femur. So yeah, any sort of field sports, court sports, change of direction, type sports, but at that high volume. So we know that those things, you know, are risk factors for the development of the condition. And then, yeah, the change usually occurs during that peak height velocity. So in that early adolescence, now there's some studies that have shown even carto-laginous changes, you know, as early as 19, 10, 11 years of age, generally the bony changes. So we start seeing, you know, between 13 and 16. And, you know, for males that might, you know, progress, you know, through, you know, 16, 17. So males tend to, the gross plates close a little bit later. And so we might see those changes still progressing into that age bracket, females. We, our gross plates close a little bit earlier, so 13 to 15. So 15 usually, you know, those gross plates are closing. And so their theory is, at the moment, that those types of loads, particularly flexion rotation loads, create some stimulus in the epiphyseal, the epiphysis. And the epiphyseal, the lateral extension of the epiphysis starts to occur. And so instead of being like a semi-circular arc between the head and the neck, at that super lateral aspect, most commonly, that epiphyseal line starts to sort of change direction and head down the neck a little bit. And that seems to create some change in where the bone grows. So we start getting this outward gross at that head neck junction. There's another theory as well that what we might be getting is some early closure of the posterior aspect of the epiphysis. And so it ends up, you know, ballooning at the front because we're closing early at the back. And that has been linked with those heavy loads across the back of the hip joint there. But it's one of those things that we still probably need to understand more about the condition and the development of it. Can you explain what the epiphysis is? Yep, so the epiphysis is just the growth plate. And so the head of the femur in a growing child is a bit like an ice cream company. So we've sort of got the neck with, you know, the head sort of sitting on it. And we've got this line between the head and the cone, if you like, and the neck. And it's a line where gross occurs. And that's, you know, here are our long bones that grow. Got it. Now I was curious about weightlifting. I think that's one sport that we've been talking now about getting it introduced earlier to athletes. You know, younger kids are now starting with that. Now, especially with the squat, right? This is when I feel that pain in the groin. If I'm doing a bulgurus, let's squat and I'm slightly internally rotated. I'll get that little pinch in the groin. But with, how does weightlifting progress to this? Does that load actually increase the bone density and then cause this type of pain? Or is it that if you're practicing at a younger age, you can get more of a range of motion that actually makes you more comfortable in these positions? We don't have good evidence around weight lifting specifically. And it's certainly a topic that there's been lots of discussion about in terms of safety of weightlifting in, you know, our children and adolescents. I think it's just in terms of safety of, you know, weights in adolescents, it's just, you know, looking at their overall volume and intensity of that weightlifting and then what ranges that they're getting into. And I think it's something that we do need to monitor each individual and be mindful of their range of motion because we're not going to be, we're not going to be imaging our adolescents every year to see, oh, do you have a, a cam morphology developing? But in Australia, anyway, we see a lot of young athletes that have males and females now being put into a weightlifting associated with sports, you know, rugby, soccer, but particularly sort of that rugby and football will often see that going into some heavier sort of more formalised gym training. And that might include not just squats, but things like, for example, a inclined leg press. Now, inclined leg press, you basically start at 90 degrees of hip flexion and then you have a weight pushing your knee to your chest. So I've certainly seen some, you know, mid adolescent, more commonly I've seen in males, but injure their labrum quite significantly by being put into weight training. Perhaps not having been screened adequately in terms of, well, what is their range of motion? What is the healthy range of motion for this individual? Because if they've already got a cam in place and then we start loading them with heavy weights into ranges that are pushing them to their physiological end of range, we might increase the risk of, you know, pushing them from a asymptomatic bony morphology to something that is painful. In terms of the role of weightlifting in development of these bony changes, again, as I said, we don't have evidence for that, but I do think that we need to be mindful during periods of peak height velocity, like the additive loads that our young athletes are being exposed to. And if we know they're in a period of peak height velocity, our peak height sort of change, we probably need to be looking at modifying loads that might be hip heavy loads. And that might include the type of gym works that they're doing as well during that period. Yeah, I think to steal a code from Eric Cressy, he always talks about assess, don't guess. And, you know, I don't remember us starting high school football training or even in middle school when you came in as a freshman, I guess at 13 years of age. And getting any type of screening to see what your hip mobility was. I remember there was a point when my coach told me that, yeah, lower bodies certainly more important for football, Dr. Moldy and I was doing the like press three times a week Monday, Wednesday, Friday, because you know, more is always better. So, yeah, and here I am today. Now, I don't know if you know this, but both Darshan and I were osteopaths, right? And one of the tenants of osteopathy are that structure and functional are interrelated. And really what that means is, you know, what your structure is, it's going to affect how you function and then vice versa. Now, some of my surgical colleagues will say, well, you really need to address a structure because if you have that overgrowth, you know, over coverage with the pinch relation or you've got the overgrowth, but the cam, well, you're not going to have optimal function. And, you know, I remember reading a paper last year, actually, one of my orthopedic surgeon cousins had sent this to me, as he was trying to convince me to get surgery, that this was published in maybe in 2024 over at HSS where they, I think the title goes something to the effect of modern day hip arthroscopy can help prevent osteoarthritis or reduce the risk of progression to osteoarthritis. And that's a really contested hot topic nowadays where you have to address the disease early on. I put that in quotes, or you are going to potentially, or if you don't, you can't alter the course of the disease and they're going to get to early arthritis and they're going to have further consequences downstream, lifelong pain, et cetera, et cetera. What are your thoughts on this? Sure. So there's a couple of considerations there. So first, what are the links with bone morphology, pain in the development of osteoarthritis? There's quite variability in the research in terms of the relationship between morphology and pain. And then the development of osteoarthritis, there is some good evidence that a cam morphology, cam morphology will increase the risk of development of osteoarthritis. But if we look at, again, that earlier check cohort research that looked at shape and the development of OA, we're only talking sort of, you know, up to 25% on the research that's available of people with cam morphology that will actually go on to develop osteoarthritis within a five to 20-year period. Although a lot of the research we've got available still at the moment is on a 45-year plus age group. So we don't have enough evidence yet on the younger population. In terms of pincerm morphology, again, from that check cohort research, they didn't find actually a link between pincerm morphology and the development of osteoarthritis. Actually, they showed a slight protectiveness having that pincerm related to the development of osteoarthritis. So that link between pincerm and OA is still a little bit unclear, perhaps. But everyone agrees that cam morphology is the morphology that seems to be potentially more problematic for the development of pain and osteoarthritis. Let me quickly. What are your thoughts about pincerm being somewhat protective to use your words? What might be happening there? Well, I guess if we compare like pincerm to dysplasia, for example. So if you've got more weight-bearing surface compared to less weight-bearing surface, we know acetabular dysplasia where you have a shallow acetabular, more less weight-bearing surface, a more micro instability than that been clearly linked to the development of early osteoarthritis. Having a deeper socket potentially may have more stability, more weight-bearing surface. Maybe that's what makes it less problematic. I'm not saying there's definitely no links, but what we have from that large check cohort, which was over 1,000 people, they weren't able to establish that link. So it does question the rationale for rim trimming procedures as a joint preservation procedure. But there is clear evidence, as I said, for cam and renti-agricole is more recent paper from that cohort, then put the imaging findings together with clinical signs and showed that if you had symptoms and restriction of range, so 25 degrees or less of internal rotation. So if you had painful limitation of range and cam morphology, then that significantly increases your risk of development of OA. So I think it was like a seven-fold increase or something like that. So I think that's why the FAIS is an important thing when we're sort of looking at preventing OA do we just go off an intervention based on imaging? No, it needs to be the signs and the symptoms as well. But to come back to your question about what evidence do we have for prevention from a surgical side of things, from the surgical side of things, I think the paper you're referring to, that was a paper that was a retrospective paper, or I believe, and so they compared a group that had had arthroscopy and had the procedures to try to osteoplasties to reduce the bony impingement and then compared to a group that they gathered that had basically had not had conservative treatments, so non-surgical treatment. And then they came out with the conclusion that those that had had surgery had less risk of developing osteoarthritis, but there was no difference between the groups in if they were likely to go on and have a total hip replacement. But we have to look at the biases in the study, why not? It was a retrospective. And if we looked at the conservative group, they were patients necessarily who had had an index image, so that had some imaging done, when they first reported their pain, and then they'd had another image done at some time in the future. And so when I read that I went, okay, so we're pretty much self-selecting people that had ongoing symptoms, because if they hadn't had another image, they'd probably done well, settle down, and so we're basically saying, if we compare people who have ongoing symptoms that haven't been able to recover with usual care, whatever care that they had, we don't have information on that, then they might be at slightly higher risk of developing osteoarthritis. But again, retrospective has a high risk of bias, and that paper did clearly call that out. So we really need prospective studies to be able to determine if surgery can prevent osteoarthritis. The only study that I'm aware of at the moment that has done high-quality, prospective research in RCT environment is the FATE study by Palmer and colleagues. And so they recently published their longer-term data, which was 38 months. So again, it's not that long a period of time, but still there was, you know, enough time for there to be changes in that joint space, space width. They compared, again, a surgical group to a rehab group that had just had physiotherapy lead treatment, and what they found was that there was no difference between the group groups in terms of changing that joint space width. And so their suggestion, their conclusion at the end there was that there's, from the data that's available, there's not strong evidence that astroscopic surgery, including osteoplasty, can prevent the development of the disease. And so the surgery should be really more targeted at, are we going to help with pain and function, rather than, are we actually going to prevent osteoarthritis? And that's from the data that we have available at the moment. And it's very hard to do that research, of course, because even that paper that was, you know, high quality, well done, but if we look at the loss to follow-up at that 38 months, I think there was like 50% loss to follow-up, you know, for those who came back and did that imaging again at that point of time, which of course, you know, anything more than a 20% loss to follow-up introduces significant bias. And so it's hard to do those studies and keep track of those people for a long period of time that they did, you know, a good job at giving that a good shot in the fight study. How do you personally determine who's a good candidate for surgery? So I know you highlighted what the evidence suggests with FIs syndrome, pain, chem, somebody might be a better candidate with outcomes, potentially a younger person, better healing. Well, exclude all the other factors like smoking and risk of diabetes and that kind of stuff, frailty and nutrition, when you're looking at movement quality, joint loading, biomechanics control, how are you assessing or advising somebody that maybe surgery is in their best interest? Well, I think we don't have a good answer to that question at the moment, like an evidence-based answer if you like. And that is probably one of the things that, you know, research and clinicians are really trying to determine who is the patient that will benefit from early surgery. We don't know that at the moment, but we know that the larger the chem, the more risk you have of developing, you know, significant pathology and osteoarthritis in your hip. So perhaps those with a larger chem are more likely to be, you know, a better surgical candidate. Perhaps those who have those more concerning control injuries where we actually get delimination of the rim cartilage and that's something that perhaps needs to be addressed, you know, earlier surgically, but the tricky thing with that is that it's often not easy to determine that on imaging all the time. In terms of a clinical, you know, approach to who needs surgery, I would always suggest that we did a trial of non-surgical care first. And the evidence that we have for non-surgical care still at the moment is, you know, still building for that conservative care, but we need to have, like, for example, that the trials at RCT sort of compared, it's, you know, physiotherapist-led intervention versus versus surgery have really only allowed, like, five to six treatments, you know, over a relatively short period of time. But someone with FAI, you know, often they will get benefit from, you know, more treatments or treatments over a longer period of time with that. And I think we can make good changes in a lot of our patients with load management, so helping them understand their condition and trying to reduce exposure to those positions of impingement. And particularly, I reinforced to my patients, it's exposure to repetitive, sustained, loaded, or rapid movements into those positions of impingement. And so we can do a lot of training and education on, right, let's move through this range. This is a hip-happy range for you. So we're happy for you to continue your strength training and it's important to keep strong, but we're just going to, you know, limit the range that you go into so that it's an appropriate range for you. Getting patients to really monitor their own symptoms. So I think inflammation, as we know, is a really important, an important driver for the development of degenerative change in the hip joint. And so that load management piece is really important, managing activity levels generally, and then, you know, managing what they're doing in their exercise therapy or in their gym work as well, so that we can keep that hip as calm as possible. So if they've got ongoing symptoms, and that's the big thing, if you get them stronger, if you get them functioning better, and when I say functioning better, that they're really able to control that pelvic position, because a lot of the people that we're talking about who're going to surgery might be involved in, again, you know, weight bearing activity, change the direction spot, you're landing on one leg, and often when we're looking at them moving, we're seeing that when they land on one leg, they're dropping into positions of adduction and internal rotation. So the pelvis starts dropping towards that weight bearing leg, as they're moving into a flexed hip position. So they've sort of got these patterns of uncontrolled dynamic impingement. So that's something that we try to work on. But if we've improved that, we've improved their strength, they're adequately load managing as much as they can within the constraints of what they need to do functionally, and they're still having symptoms, then that might be a time where they really need a surgical consult. What about, let's shift gear. So you've had a young person who's had arthroscopy, we'll say both the labement has been repaired, you've had osteoplasty, they've shaved down some of that cam, and it wasn't excessive. And they've gone through the earlier phases of rehab. So I want to pick up when we can really start getting aggressive with exercise. And I'm more interested in actually the long-term consequences because one of the things I learned as I was speaking more to my colleagues across the pond, other parts of the world is we do a bad job with expectation management in the US. And I can make some arguments and why I think with respect to our business model and incentives and why we might be doing that. I think that's the case with the procedures in general. But it was really interesting. I think when I came to your workshop over in the UK, when I was talking to everybody else, and you know, it was well understood that really at 12 months out puts our arthroscopy, it's okay. It's totally normal not to have symptoms. What was interesting is my conversations prior to that with people over here on this side, a lot of expectations were a lot of discussions with surgical colleagues, even maybe some sports and surgical colleagues saying, yeah, six to eight months, you'll be good. You'll be returning to sport, performing at a high level. And when you actually dig into the literature and you talk to people, you learn that, you know, return to play, return to performance are two very different things. And lingering symptoms are actually quite high for a lot of people. So I want to get a sense of how you approach those patients. I mean, what are, if you could talk about how you set expectations for patients post arthroscopy in terms of timelines? And how do you progress them through that, you know, if that pain never truly resolves like you were talking about? Yeah, and I think that's something that's really important. And it's really interesting looking at the literature on expectations in that patients have really high expectations of surgery. They have really low expectations of physiotherapy or rehabilitation. So, and I think part of that is because this is sort of perceived as such a structural thing that patients tend to believe that it's very unlikely that they're going to be able to get an outcome without surgery because they have this structural issue that needs to be fixed. And I do think there's a really important role from, you know, both the medical side and, you know, and rehab professionals as well, leading into surgery to set up those realistic expectations of what to expect after surgery. Because I know that patients that I see are usually going into that surgery after seeing the surgeon believing that their hip is going to be fixed after surgery. And they'll be able to get back to running, you know, you know, within, you know, 10 to 12 weeks. And then, you know, they should be fine in six months. But the reality is, yeah, exactly. As you've said, what we're talking about is the literature certainly shows improvements in pain and function for, you know, a significant proportion of people who have that surgery. And so we can give patients that information, but will their hip be cured? Will they have a pain-free full functioning hip back to sport? That takes a significant period of time and not everyone will get there. And so we're talking about like if 100% is, you know, full pain-free hip, what we're seeing is that patients on average might go from 50% pre-op to say 70%, you know, post-op, but they're not usually at that 100%. So it takes a lot of, you know, rehab and effort and training to sort of get back to those higher level sports. And some people, you know, and certainly not everyone will be able to achieve that for various reasons. And that might be the state of pathology that, you know, was discovered when the surgeon went in. We know that if you've already got degenerative change, the outcomes of that arthroscopy are going to be, you know, poorer afterwards. The other thing that I think is important is again that role of inflammation and effusion. And there was a paper last year by Wang and colleagues. And it was really interesting because they tracked that sign-of-itis effusion in patients who'd had arthroscopic surgery after four FAS. And they showed that actually effusion in their joint peaks at three months. So it was more than pre-op at three months after surgery. And by 12 months, 60% of patients still had significant effusion within their joint. And that was linked with poorer outcomes. And so I think it's important that patients sort of understand that they still, even after surgery, they have to learn to manage their hip and control inflammation and do the work, do the rehab and not push too hard too fast because that's more likely to, you know, result in, you know, delayed comes and poorer outcomes because of that role of inflammation and effusion. And then of course post-op we can get other complications that might be related to adhesions in the joint after surgery, which is just, you know, part of what happens in a healing process, particularly if we don't have good early movement after surgery, we can have micro instability of the hip after surgery, particularly if the capsule hasn't been repaired. And that might be, you know, a reason for ongoing symptoms afterwards. So it's quite a complex interplay of, you know, structural issues, inflammation, what they're doing with their hip, how much rehab they're doing in terms of seeing what sort of outcomes we're going to get in the shorter and long-term. Who's job is it to have that expectation and management conversation, you think? Is it the surgeon's job, is it prehab? Well, in an ideal world it would be that we're all giving the same message. And what we see from a physiotherapy perspective is we're often giving different messages. So the surgeons, perhaps not, I don't think necessarily misleading the patient, but perhaps not having enough time to discuss, you know, those expectations in more detail. So from a rehab perspective and we have a little bit more time to perhaps discuss what to expect afterwards. And rehab professionals are also the ones that are living that with the patient afterwards. So it is important for us to set those expectations early. But I think setting those expectations preoperatively is important because that is really important for informed decision making. And so in an ideal world, we're all informing them they're getting consistent messaging and they're going into it being really, you know, eyes wide open understanding that this is not going to be, it's fixed because that bit of bones being trimmed off, it's still going to be work and rehab for a significant period of time after this surgery. What about the joint that looks quote unquote perfect on imaging? You got the X-ray, you got the MRI, there's no liberal pathology, no impingement of any sort, yet they still have pain and it's presenting as true classic hip pain. How do you approach that person? Mm-hmm. Sure. So we're talking about completely normal morphology, so no deflation, no FAAI. And so then we're thinking about, well if we think about what are the sources of no section, the sources of pain within the hip joint. So labelled here is one of the most common capsule labelled structures. The synovial lining is highly innovative. The ligamentum terries is certainly highly innovative and that can be a source of symptoms. And so those are the potential sources and then of course we have like the cartilage itself, we don't really feel in the cartilage, it doesn't have sensor receptors in, you know, a normal cartilage, that sub-chondral bone. So we have to consider bone as well in like a endurance bleat with low BMI or someone with, you know, bone density issues. So but outside of bone, if we've got normal, you know, normal boney structure and we're sort of considering right, well we do think that there's something inside the hip that is painful, why is it painful? So usually it's associated with something that they're doing in terms of their overall loading. So as a, you know, loading their hip in a way that's really pushing it towards its physiological limits. So sort of working at extremes of range of motion. Even without boney, boney morphology that predisposes to early impingement, any hip can actually reach a position of impingement if we put it far enough through range. And so if we're doing things like ballet, gymnastics, martial arts, you know, circus performing, those sorts of things where they're moving to end of range, repetitively or sustained, rapid loaded, particularly with poor control around the hip, poor muscular control, then that might predispose to the development of symptoms over time. Having reduced capsular, capsule labelled support of that hip joints. So if we've got someone who is has laxity of that capsule in ligaments, so that might be just their natural state. So there might be on that hypermobile end of the spectrum, or have some sort of collagen disorder, or they might have focal capsule laxity just related to overloading that capsule. So for example, a throwing athlete who's repetitively like a baseball pitcher, for example, repetitively that backleg is going to be repetitively pushing into extension external rotation, which overloads into a capsule. And particularly if they're really forcing into that end of range, perhaps without adequate muscular control at the front of that hip joint, then that might sort of lead to some issues. So micro instability is one of the conditions that we suspect might be a problem in those people that don't have clear bony issues, but have this pain and particularly those who are on that mobile end of the spectrum. So it's usually what they're doing with their hip and then other risk factors that they might have. Awesome. Well, that's a perfect transition to kind of going onto the next lane, right? So you mentioned dysplasia, hypermobility, micro instability, right? So if we stick down that lane, can you just give us, when you're seeing a patient like that, truly the clinical signs that those patients present with and maybe at what age are they really coming? Okay, so micro instability, we're often, well, we haven't been very good at picking them up, but we're starting to get there. And so there was a nice criteria that was published by because Ken Duja and colleagues, 2023, which published the micro instability diagnostic criteria, which is the first attempt at trying to get some criterion around, right? What do these patients look like? How can we actually diagnose them? Is it just someone who stands on one leg and they're a bit wobbly? That's probably not adequate for a diagnosis of micro instability. So that paper suggests that again, like with the FAI agreement that we need to have a combination of symptoms, clinical signs and imaging findings or if they've had surgery, interoperative findings, but in people who haven't had surgery, then we're sort of looking at imaging clinical signs and symptoms. So it tends to be, pain, if that stability issue is interior, then they'll tend to have that sort of meeting with all pain or seaside, quite pain around that hip joint with dysplasia. We certainly can see that pain around that whole hip and even into the deep butter, even sort of some back pain on the unilateral side with dysplasia. And that is most commonly, or most probably linked with the iliussois and the sois having to work so hard to try to support the joint. And so with dysplasia, we tend to see signs of iliussois related pain and abductor related pain as well because those muscles are working so hard to try to stabilize the hip joint. But unfortunately, that means that a lot of people with micro instability or even bordering on, you know, macro instability, if you're like being diagnosed with hip flexor related pain for way too long because they've got this, you know, persistent pain at the front of their hip. And so I always suggest that if you've got particularly a young female that is, you know, persistently returning, complaining of meeting with all pain or hip joint sort of pain, it's like, well, that meeting with all pain, it's unlikely to be iliussois. Like particularly if there's no injury mechanism that you can find for those hip flexors. And so that's usually a bit of a reflection that the soft tissues are struggling because there's something happening underneath. So if we've got persistent soft tissue signs, we really need to consider what's happening in that underlying joint. And so the other thing that might make you think instability will be like symptoms of giving way or lack of lack of confidence in their limb, particularly in weight bearing, weight bearing rotation and feeling like their hips going to give way. Sometimes they'll complain of their leg feeling heavy when they're lifting it in out of the car or lifting it, you know, when they're lying on their back. So those sort of symptoms of giving way, feelings of instability, sometimes there might be, you know, click snaps, pops, you know, those sorts of things that we commonly see in people with more mobile hips. If they have a known sort of history or family history of, you know, dysplasia, of course, quickly hips or a family history or their own known history of some sort of collagen disorder. So if they've got, you know, they tend to be hypermobile. And then clinically, we tend to see that this population will often have, you know, higher ranges of motion. So very different to the presentation of FAAI in that, well, the same in that they'll both be positive on an impingement test when we take them into flexion, adoption, internal rotation, but the difference being that FAAI, they'll have this, you know, hard bony block and limited range of motion with those with dysplasia or instability, we tend to see more larger ranges of motion. But I do want to just flag there that the FAAI and instability are not necessarily to completely separate things. And more and more now we're realizing that those with FAAI can also have micro instability. And there's some nice fluoroscopic data looking at people with FAAI with cam morphology just walking. So not actually pushing their hip to that impingement zone. So just walking and that had shown, you know, larger gapping between the head of the femur and the acetabulum and aberrant movements of the femur head in the acetabulum, even in sub impingement zones. And so there's a lot more discussion now about that concurrence of FAAI and instability as well. So all that means is that not necessarily going to have huge ranges of motion. So we can't rule out micro instability in FAAI as well. And then we've got tests that we can do clinical tests for stability for various different areas of the hip. So the apprehension tests, the log role test is commonly used, but there's a variety of other tests that we can do as well. And then, you know, imaging needs to be assessed for, you know, signs of dysplasia, the big things we're looking for there. And for that, you're looking at the lateral center edge angle? Yeah, so there are multiple different ways that we can look at that, but yeah, so the basic imaging things that we're looking for is, yeah, lateral center edge angle. So we have under coverage of the femoral head by the acetabulum. And then the other main one is like the orientation of the acetabulum so the upward orientation. So if you've got a roof angle or an acetabulum index sort of more than 10 degrees, then we're going to get more of that sort of migration of the femoral head or translation of the femoral head in the acetabulum. The fear index was also sort of noted in the micro instability guide, but there's lots of different ways that we can actually look at the structure of the hip joint and things that might also impact on stability, things like even the femoral side of things. So the neck shaft angle, so if we've got a more vertical neck, that might, you know, predisposed. If we've got significant femoral anti-version, so the twist in the femur, that's more likely to predispose to entry instability particularly. Even looking at the sphericity of the femoral head, we're sort of used to looking at the femoral head that is ace spherical, that it pushes outside the circle, but actually you can have a femoral head that dips inside the circle at that head neck junction. And that's referred to as the cliff sign. And that population who, you know, doesn't have that nice round head actually, they're a bit skinny at that head neck junction. As they come up into positions of hip flexion and rotation, they actually may lose that vacuum suction because they don't have enough bone. So the stability of the hip joint is that congruence of the head of the femoral and acetabulum is so critical for the stability and that vacuum in the hip joint. So there's there's femoral side of things also. So there can be a number of things. And so I think we need to make sure that we're not just relying on that the lateral center edge angle for that determination. Yeah. What's unique about the rehab approach here as opposed to more of the impingement stuff that we were talking about earlier? Sure. So for this population, getting that, I think there's two really key pieces. One is good function of the capsula muscles. So the muscles that join onto the capsule. So the iliocapsularis and the iliocus not joining onto the capsule, but very important as a sling across the front of that hip as we move into hip extension. The gluteus minimus joining into that superior and enter a superior capsule. And then the deep external rotators of traitor internus and gamelli and of traitor externus that join into that capsule, posteriorly and posteriorly inferiorly. So that cuff of muscles for this population becomes really, really important, particularly if you've got a floppy capsule, floppy ligaments if you like, then those muscles are going to need to do more work and be more efficient at maintaining that the capsule attention through ranges of motion. And so we use a lot of real-time ultrasound to look at those muscles and to optimize that early recruitment in those muscles because what we often see in people with hip pain when we're visualising this with ultrasound is we're seeing a delay in the recruitment of some of those capsule stabilisers. So people with no pain and normal function, when they go to move their hip, the first thing that we tend to see on ultrasound is that deep muscles recruit first, and then the superficial muscles come on to provide that force, that torque production for movement, but that early recruitment of the capsule of the stabilisers is important for joint protection because we pre-tension that capsule and help centre the head of the femur, but potentially also just from an efficiency point of view, we want those capsule stabilisers working to centre the head of the femur so that when your big force producers come in, you're not getting all the energy lost around the hip because the hip's wobbling around. So both from joint protection point of view and from an efficiency point of view, we want that early recruitment of those capsule stabilisers and we often see deficits in that. So that's something that I do think is important in that population and then the other piece that's important. So across both groups strength is going to be important and actually across both groups then pelvic control is incredibly important, but if you've got dysplasia, dysplasia or impingement at both ends of that spectrum, it's important that will be focusing on slightly different things, but with that micro instability or that poor control and if you've got dysplasia, you've got less weight bearing surface and so the labrum will take more load naturally. So in someone with dysplasia, the labrum you know goes from taking one to two percent of your body weight to four to 11 percent of your body weight so it's naturally taking more body weight, but if you are weight bearing in a way that overload those rim structures, then you're much more likely to have symptoms. So for example, if the patient is functioning in relative posterior pelvic tilt, so if their pelvis is rotated back, so that will take like reduce the end to a coverage of the head of the femur by the acetabular and so we'll have less acetabular coverage that will put more load on the edge of the acetabular. Now surgeons talk a lot about edge loading, you know, with hip replacement and things like that, but in the native hip that edge loading is also really important. So making sure that people get that control, getting that acetabular over the head of the femur, so that pelvic control piece is incredibly important and then we need to do graduated sort of strengthening, making sure they're controlling that. But I think that the two key things there is that good deep muscle function and then good pelvic control and then graduated sort of strengthening and functional loading. Right, that inside outer push that you speak about. What are some go-to exercises that you like to start with that you've found in your experience that are better to get some the recruitment for the deeper muscles? Sure, so we would usually start with some isometrics for each of those deep muscle groups and so that would be taught as a like a preparation for movement. And so for the hip flexors, for example, we might be lying on the back with a couple of pillows underneath the knees and the patient is just preparing to lift their knee but they're not actually going to lift their knee and so they keep the more superficial musculature relaxed, particularly TFL Sartoris rec fem and they just prepare to lift their leg and they should feel a deep tension sort of in that meeting when all region for that Iliacus Iliocapsularis. For the external rotators and abductors there's various different positions that we can do that in but for example you could do side lying with a couple of pillows between the thighs so that we're sort of neutral abduction rotation. They can do a preparation for lift into abduction and again keeping that TFL relaxed and just working on that low general recruitment into abduction for the external rotators we work on just a little heel push like an ankle push down into the pillow in that position. But other things I like, for example, for the hip flexors even just practicing something like pelvic tilting is really nice in like a high sitting position for example. So sitting on a high planche or a table or something like that and just working on slowly bringing the pelvis into into a pelvic tilt and back to neutral position without moving the chest so we don't want that happening sort of through the Serapha lumbar erectus biny but we've looked at this with ultrasound and we get really nice recruitment of Iliacus and Iliocapsularis actually doing that nice little pelvic tilt and that sort of is a bit of a win-win because we're also teaching them to get your acetabulum over the head of the femur particularly in that population that tends to be more posterior pelvic tilted sway type population where they stand with their pelvis sort of out the front their pelvis translated anteriorly to the base of support and so this gets nice recruitment in those deep hip flexors while they sort of work on that motor control of controlling the pelvis over the femur as well. It's funny you said that and I could see that dorsh was doing his pelvic control while he's seated and I'm standing and I did simultaneously. What about cars? I just this morning early this morning I was on LinkedIn and actually believe it or not one of your Aussie colleagues he was a physiotherapist I just saw somebody talk about the performance and then jamele and I clicked on it because you know everybody wants to blame the performance for everything but nobody ever talks about some of the other short external rotator so I figured I'll check this video out just because he gave the the superior infrage of my little shout out and he was just talking about how cars are going to be the fix to stiff hips so to speak. I actually haven't heard where you stand on that I know this is really getting to a lot of and ranges but there is a lot of motor control there so what are your thoughts on that specific exercise? Cause the controlled articular rotations when so I guess if I was to describe it really you can do this with really any joint and actually dark why don't you describe it because I know you you did that DNS thing right with this. Yeah cars is just so if you do like a 90 90 with the hips and it's really isolating just the hip joint and trying to make all your other muscle static and all your other joint static while you are taking let's say the hip from internal to external rotation. So I'm trying to actively do it right now over the camera but yeah it's a really it just controlled articulation of the hip joint I think that's where most people I think that's the most favorable joy that I've at least heard from you know people doing cars people will try it with the shoulders too and really just to have a controlled articulation from you know one range of motion to the other so I don't know yes if I was to describe it for the hip right so let's just say we did in a standing position you probably wouldn't start that you would have somebody come up into full flip active hip flexion as high as they possibly could then you would take it all the way out to external rotation as far as you possibly could then you would do deep internal rotation and then extension and then bring it back to neutral and then you would reverse that motion seems like that's not something you've used routinely I know I thought you're actually talking about a vehicle all right so there is value in the concept of control smooth rotary sort of training but but yeah you won't be able to if you're doing a full range active range of motion you're not going to isolate that to the deeper capsule muscles if you like yeah so you're going to use all muscles around the hip but you're just going to use them in a control way and so really it's just a motor control exercise but if you have dysfunction already I'm not convinced that that alone is going to you know solve your dysfunction and one of the things that I see is particularly open chain exercise if we're trying to deal with dysfunction and imbalance if you like between some of those superficial muscles or muscles like your TFL sartorias and you know your glutes for example and those deep rotators I find that you are much better off having your foot in contact with the ground so as soon as your foot is off the ground you tend to seem to get a lot more recruitment or upregulation through that entralateral corner musculature and it's not like there's any exercises that you know a muscle you know this muscle will turn off completely and this muscle would be doing all the work it's not like that anywhere around the body but around the hip included so it's not like we can do a completely isolated exercise for one muscle or one part of one muscle but the principle of slow control weight bearing sorry slow control rotation is good in that flexion rotation position I guess you just have to be careful in terms of if they have rim pathology and you're sort of rotating in at that range of motion is that provocative for the patient so maybe just considering the range of motion but yeah there's no there's no one easy answer to this is the best exercise and this is bad and this is good so there's there's different elements that are likely to be useful and for some patients particularly who already have dysfunction perhaps not as useful in certain exercise you know types that I we don't have enough evidence for the moment in terms of what is the best exercise for you know xy or z but yeah slow control rotation I agree is not a bad idea but wherever you can get your foot on the ground when you're starting to talk about those you know after we've done that early isometric phase I would generally do weight bearing exercise weight bearing control training and we can do that slow control of pelvis on femur but in a weight bearing situation where you'll tend to get a lot more stimulus of those deep rotators and glutes relatively to that entralateral hip so I think yeah go with the exercise that you think makes sense with what you're trying to achieve but make sure then that what you're trying to achieve is actually what you're achieving so ask the patient where they're feeling it put your hands on you know we have the benefit of being able to use ultrasound as well to sort of check it's happening in some of those deeper muscle groups as well and that does make it tricky for the hip because you know you can't easily sort of palpate any of those different muscles so a lot of it is a leak of faith that we're hoping that what we're doing is you know what we're trying to achieve but at least we can you know have a feel of what's happening in the superficial system I'm tempted to to ask you about the clamshell but I know I'm not I'm not going to take you there I think people if they want to get your thoughts on that then we'll plug some other podcasts that you've spoken about that length before let's make a somewhat hard turn here maybe not too hard that we get dizzy but we talked a lot about on our first discussion with respect to tendon health and you know I think we just think about pain in general as you highlighted so eloquently earlier on this is a syndrome right it's not just structure we're looking in isolation you have a variety of factors you're looking at one of the things that we're starting to appreciate is the role of metabolic health hormones and just homeostasis of the individual and how that plays a role in tendon healing tendon pathology to begin with and perhaps even pain I recognize just from following some of your work this is something that you've been talking about a little bit more as well so how do you first of all evaluate that in part of your assessment processes and then you know what strategy are you using to implement to have discussions with that stuff in in terms of getting better outcomes yeah sure and I do think it's incredibly important and I think it's I think there are you know areas that yeah certainly rehab professionals I know from a medical perspective you're probably much more likely to perhaps go yeah and look at those and discuss those more global factors I think from a rehab perspective if we're seeing the patient as first contact practitioners we need to be monitoring and you know taking a look at these factors and and referring on for additional assistance are we're required with those factors metabolic factors for some individuals I think will be incredibly important and so we're looking for the person who is you know lawyer BMI hyperliplidemia and diabetes so those factors have been linked with tendonopathy but not just with tendonopathy with joint conditions as well we need to consider that that global systemic inflammation now with tendons tendonopathy now we recognize that we rarely see a true inflammatory process an acute inflammatory process in the tendon but systemic inflammation may certainly be involved and we see with tendonopathy higher presence of you know TNF alpha and interleukums and things like that so we need to consider that that more global inflammation piece and so yeah tracking yeah BMI you know so asking patients you know they're wait looking at their BMI for gluteal tendonopathy carrying weight around around the hips around the middle seems to be linked with that risk of gluteal tendonopathy as well so those are things I think we need to have a discussion about and not be perhaps afraid to have that discussion as rehab professionals because carrying extra weight will have both a physical effect when you're standing on one leg for gluteal tendonopathy for example but then we have the metabolic effects as well so doing a good history asking about general health you know asking weight or weighing the patient themselves looking for that that gynoid adiposity around the middle and then you know if we think that's not yeah if they're sort of flagged as having some risk factors there it's something that I think we should start talking about earlier than we do because if they start getting onto that early together with you know the education exercise program they may get there a little bit more quickly or have better outcome and we don't have the evidence for that at the moment but it makes sense from a clinical point of view and like diet will feed into that as well so nutrition will feed into that in terms of that systemic inflammation as well and so those peering those two things together like strictly sort of you know reducing the intake of sugars and high GI carbs will be really important trying to sort of minimize processed foods take away foods things like that they're good healthy you know green leafy vegetables and you know your good fats in your fish and things like that so there's that nutritional piece but that might require you know referral onto you know a dietitian or a nutritionist to feed into that if there are other issues involved in weight that might involve a multi-discipline multi-discipline team that might involve you know even an endocrinologist depending on what what's happening with that weight a psychologist if there's a psychological sort of element took that weight and so I think those factors are really important and then we have yeah the hormonal piece and certainly for tendons like gluteal tendinopathy we know that the the prevalence is so much higher in post menopausal females so hormones seem to have a role their estrogen is important in the the health of the collagen tissues so when we start losing estrogen then we're more likely to see these tendon conditions come out and that's something that we should be really mindful of and be able to educate patients about even in the first instance in normalizing or helping them understand that you know that we often see a lot of post menopausal women who are very distressed because they might have multiple sort of areas of pain so you know gluteal tendinopathy maybe some plant of fascia maybe a little bit of you know shoulder elbow symptoms they'll feel like their world is falling apart their body is falling apart they'll usually end up seeing a rheumatologist because it looks like a systemic illness the blood don't support a systemic illness but there's something happening systemically and you know hormones are you know you know a big player in that and I think there's still a huge under recognition of the role of hormones and interventions for hormones and I think we've been through just at least a decade or more of females being and general practitioners being really fearful of prescribing hormone therapy for post menopausal women because of one poorly executed and poorly interpreted study and so we need to move past that and start giving females you know assistance from that hormonal perspective as well yeah yeah I definitely appreciate you bringing up all the lifestyle factors right every the all go hand in hand when it comes to metabolic health and you know recently I've just been finding the conversation around the world about metabolic health I find stops prematurely just when we talk about weight and then what does that weight lead to okay we know ill hell but explaining actual disease processes right affecting the joints of the hip the plantar fascia it is or whatever it might be whatever organ system that you might want to pick so I think that's an important discussion that needs to be had a little bit more when you work with high performing athlete let's say right somebody who has all these lifestyle factors dialed in however let's say they're aging will take a 60-year-old triathlete for example what are the type of discussions you're having with that type of patient when it comes to maybe risk benefits still trying to perform and achieve whatever their goals might be and whatever sport they're having but also knowing that their body you know has taken on a lot of clinical feeding throughout the years through just the different types of movement patterns that they've been going through sure and I think there it's about yeah throughout the ages I'm always very proactive in terms of trying to get our patient not reliant on us so they need to be self-monitoring their own bodies and understanding when they've pushed too hard so monitoring response not just during exercise but that night how they're feeling that night next day making sure they're attending to recovery it takes us a little bit longer you know to recover potentially and then the other thing is really just about you know natural stark opinion that is more likely to occur with age and the need to ensure that there is adequate strength training resistance training you know being incorporated so a lot of triathletes and runners for example aren't doing enough strength training and particularly when we're sort of you know entering those older age groups that's going to become even more important so strength training to maintain adequate bone density and muscle strength and with that being able to maintain metabolism because metabolism starts to reduce as we age and part of that is associated with the sarcopenia the loss of muscle bulk and so we need to make sure that our older athletes but all of our older population understand what they need to do to maintain weight and maintain health as they age is to make sure they're including some strength training so for our endurance athletes often they're going now I'm just going to run I prefer to run a cycle or swim but that's not necessarily going to be adequate to maintain muscle size and metabolism and so I think that's incredibly important and for females particularly postmanopausal strength training is incredibly important for maintaining you know health of their bones and their muscles and their tendons and so I think the way athletes train may have to slightly change as we age and a little bit more attention into resistance training a little bit more attention into recovery you know looking after their body as well listening to their body yeah love it I think that's the biggest thing as well I mean you've touched on this a couple of times in terms of identifying what works for you and that's what makes it so challenging I think it's funny for me you know I had a at least I thought that I understood the hip really well until I took a couple of your courses and it's the same goes you know the further you get out from the shore the deeper the water and you start to realize that how complex this really is right when we're talking about the twist and the femur you're talking about the variety of different factors that we have to look at and there is a tremendous amount of overlap right that lucky person that you said who might have instability and impingement simultaneously like that they really hit the lottery and how do you help that person I at the same time you know it's I'm overwhelmed when we have these conversations and when I learn more about the hip but I'm also super excited because we've learned so much just in the last decade you know I was like no since 2016 so you know just coming up on 10 years I remember at the time surgeon saying hey listen hold off as long as you can because hip arthroscopy it's it's infancy and you don't want to do that right now and but you would know better than I but I tell people like it's probably in the toddlerhood now is what I would say probably not much more than that but the future is really bright because we're having these conversations you know you present at some of these meetings worldwide your your colleagues would surgeon some of the world's experts so my question for you is you know given all that you know all that you're learning and you seem to be the person who's learning every single day what are you most excited about with the future of hip and pelvic pain care and maybe we'll keep it focused to over the next five to 10 years I'd love to know what technologies you're looking at innovations diagnostics what are you excited about sure well I'm excited at the moment that we like surgeons and rehab professionals we're definitely coming closer and starting to talk more of the same language which is fantastic so 20 years ago talking about instability of the hip joints that really wasn't a thing you know outside of trauma or frank displays just instability was not accepted you know but we were you know from a rehab perspective we thought well you know it probably you know makes sense but it was interesting in the last issue conference I went to the hip preservation society conference in Washington last year there was so much conversation around instability and and the relationship of instability and impingement and there was more much more discussion from a surgical medical perspective about pelvic position and even movement and posture and it was incredibly exciting because it's like yay we're finally talking the same language and understanding that it's more than just a single bone shape it's a complex issue that we're dealing with with all of these hip conditions so that's particularly exciting for me and I actually love going to the arthroscopy conferences because our surgical colleagues are actually doing a great job with taking up the reins in trying to really understand these conditions I think we still need to go broader but at least there's a lot of research that's happening which is exciting and we're understanding more every day which is great in terms of technologies I think we need to the big black box I suppose certainly in the rehab world is still being able to identify, measure and adequately show changes in movement at the moment it's sort of like a bit of a a dark art it's something that you know we look at with our eyes and and sure we can take a camera and we can measure some measures but they're not it's not highly sort of you know accurate but there's some technology that is coming out of Brisbane here that I've been involved in some feedback that technology they call it smarty shorts so I'm a bit excited this is Laura Diamond's project and they're basically like bite pants with sort of accelerometers in them and they're developing like an app that you'll get real-time feedback of how you're moving and and joint loads and so the long-term look at that is understanding how people are loading and giving them immediate sort of via feedback on how they're moving so that we try to change at movement and see if that you know helps with their with their joint symptoms there's still a long way to go there but I think we definitely need better ways and I've played with lots of different you know technologies trying to see if we can measure and the pelvis and the hip is incredibly difficult to measure movement and so that's one technology that I'm excited about and I think there'll be other technologies that will get better and better hopefully but accelerometer technology that things that are wireless and that are much more you know practical for use in the clinic or even as a biofeedback tool outside the clinic I think that's exciting we've still got a long way to go with you know matching the you know movement patterns and you know whether that's going to be problematic or not and I guess that sort of goes to the other thing that I think is where we're heading towards in individualized care so really sort of understanding what's their body shape how are they loading their hip and it's something that I I teach a lot we don't want to just throw someone on a bed and you know do some clinical tests we want to understand you know how they're loading how they're moving and you know where that where's the area of pain what structures are being overloaded and understanding you know what mechanical factors might be contributing to that but then as we've just talked about looking at the pieces around hormones nutrition metabolic health and trying to bring that together in a very individualized treatment package for the person and I think that's when we really start going to start getting some good traction with some of these presentations that have just got you know persistent pain we're probably not getting quite on top of a lot a lot to look forward to I'm still shocked that most of this hip development is like from the early 2000s and then you guys are all talking about tolerant and infancy I mean I was squatting 10 years ago and I'm like this hurts this must have been like found out way away before so if this is all new to me and it's crazy because I mean you know this all too much for us like can't pincer these are all just like the words that we have to learn even though I'm not in sports medicine but for our board exam and all so I feel like to most of us is kind of things that we thought were you know established but to speak along the lines of timelines what is something that you've changed your mind on let's say in the last five 10 years in regards to hip and everything that you've learned. What have I changed my mind about? Well I guess well if we eyes one of the interesting things like when we first started talking about F.A.I the physio approach to F.A.I at that time was okay we've got restricted hip flexion we're impinging at the front so what we want to do is stretch out the back of the hip so that we can try to give them greater range of motion we now understand that it's not such a great idea because those who have impingement and truly are at risk of actually posterior instability and even subloxation or dislocation at the back of that hip joint and do we even want to give them higher range of motion certainly if it's a bony block we don't want to try to increase range of motion for F.A.I because if we do manage to get that cam deeper into the acetabulum what are we going to do? We're actually going to create more sheer force and more damage around a larger rim of cartilage and so I think that's been a significant shift in the terms of when we first you know we're talking about F.A.I and what we would do from a rehab perspective you know and we are very perhaps you know rehab professionals are often very impairments focused and like restriction of range of motion is an impairment right so let's try to you know restore that range of motion we now understand that you know you've got a bony limit and that's what it is and so we have to give them education around looking after your hip this is your hip you know it doesn't like going into that range so we're going to have to modify that so I guess certainly there's been shifts in in understanding around that sort of mechanical side of things and then the other shift for me I suppose is just you know more and more that that metabolic hormonal you know dietary aspect that previously you know you know rehab professionals probably you know have looked oh well that's not my role I'll just sort of leave that over to the side there but I think more and more now we need to become more holistic and you know certainly you know bringing other health professionals in for multi-disciplinary care we're required but at least being more mindful of those so I guess that's a couple of examples of changes that I'm saying awesome well and thank you so much again I've said this time and time again I'm a big fan of learned a lot from you not just in these conversations but also offline or conversations and attending some of your workshops I've plugged in multiple times so I'll plug them again here I think that when it comes to elevating you know my knowledge to to learn more about the hip and not just the hip but just movement and pelvic anatomy and the complexity of that and how to actually implement that practically bring it back to our patients that's been very helpful in fact your masterclass paper that I highlighted last time I've made that required reading for a lot of my mentees that I work with respect to a lot of a hip pain so thank you for everything that you've done I know you're flying all over the place I see you coming up in Hong Kong New Zealand you got conferences so where other than Dr Alison Grimaldi.com where else can people find you working they connect with you what's a good place for for you for them to reach out. Great yeah my website is probably the best place to find and there's heaps of free content on there in the blogs there's lots of sort of detail in the blogs there then I have individual courses that people can do or they can join our hip academy so for hip lovers or hip learners and you can really dive into the detail in hip academy and we do live meetings and master classes case studies Q&A sort of sessions in master in the hip academy as well as just access to a heap of you know video and you know quick quick reference PDF downloads and things like that so there's probably the best place and there's a contact form there but I'm also on all of the main social media channels so either at Alison Grimaldi or at Dr Alison Grimaldi you'll find me on most of those social media channels. Excellent we'll put all that in the show notes any other parting words of wisdom Alison for the hip learners or hip lovers or anybody with hip hip. I think know your anatomy around the hip that really helps that's a really good starting place for assessing and managing hip conditions and be a detective I think our role is very much asking questions and sometimes we're so excited or perhaps you know time poor and we're sort of heading straight to those clinical tests but what you get from your patient interview is so incredibly important that I don't skip that part you know ask those extra questions because you just get so much great information there that will help direct your diagnostic process but also direct your management process as well so don't rush that patient interview be the detective asks lots of questions and it will reap your reap the rewards. Amazing last question Alison that we ask all of our guests now I don't know about the healthcare system down under but here it's much more of a sick care system and so we always like to ask our guests is how do we put the health back in health care? How do we put the health back in health care? Well I think we've talked a lot about that today haven't we and I think putting the patient at the center is really critical there and asking patients about you know their goals and what they want to achieve and so moving away from very much an impairments based model of just the clinician looking for impairments and looking at and trying to see how how we're going to fix these impairments we really need to be looking at what the patient wants to do what's their goal and really tailoring our treatment to get them back to full health but full health is for the individual unit we need to understand what full health looks like for that individual. I love it Dr. Alison Grudemaldi thank you so much thank you thanks very much thanks for listening to the other episode of medicine redefine if you enjoyed this episode please be sure to check out some of the additional resources in the show notes please also check out our social media platforms where you can find more content like this you can follow us on instagram twitter and tiktok at med redefined we also want to thank our team for the production of this podcast specifically Ethan Joo on video Harita Yekorean social media Zanablegmani on research and Sarah Han for newsletter also if you enjoyed the show please be sure to subscribe review and share with anyone who you think will gain value from this as well now time for the ever so important disclaimer this podcast is intended for general public use and is for educational purposes only it does not constitute the practice of medicine no should be construed as medical advice no physician patient relationship is formed and anything discussed in this podcast does not represent the views of our employers we recommend that you seek the guidance of your personal physician regarding any specific health related issues