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Getting to know Mehmet

David: So first off, where are you based? Mehmet: Yeah, so I live in Devon now, so it's like southwest coast of England have done for the last few years.. Grew up, though my whole life I was born, raised and lived and worked my whole life in London. The last five years have been a bit of a change, so I've gone from a city life to raising kids and living, with kids and wife down in the south coast in a rural area now, which is quite nice.

I've been a physio for about 15 years now and specialised in hip groin type physio specialty, probably for about 10 of those. So I I knew what I wanted to do pretty early on. I had a very, really distinct insight and it stemmed from my own experiences. I had that at FAI, which was at the point of when I was qualifying and I didn't know anything about it. I had surgery, didn't work out too well.

And then basically at that point, I was really keen to learn, just become a physio, I was thinking, I want to know what's going on with my hip. And on the other hand. I was wanting to use all the opportunity I had for like in service training, CPD development, to just correlate with what I was trying to understand about my hip. And that took a while and then obviously what happens is as the years go on and then I was doing like a post-grad masters, again, anytime I had to do any kind of research or review, whatever, it was all hip-related.

Years went on and I've basically spent all my time trying to learn about hips pretty much from the day dot. Don't get me wrong at the beginning, you don't really know anything, do you? I was just winging it for the first two years, but but pretty much that stemmed an interest. And then after a few years, I realised actually, I know what I want, what I have a passion for when it was hips pretty much from an early period of time. My hip's fine now. So it was all sorted out.

And that's what's led me to doing pretty much what I do now, really, which I'm very grateful for.

David: It's funny how those experiences shape you and it can be, sometimes injuries you experience yourself or, different patients you see that sort of shape the direction that you go in. So it sounds like it was a bit of a journey of self discovery at the same time as you were looking into how to treat hips and getting a real interest in it at the same time.

Mehmet: Yeah, definitely. I'm pretty happy with how things transpire and how I've got to this point now.

I wouldn't say necessarily everyone who's a hip specialist or shoulder specialist or knee specialist has to go and have an ACL reconstruction or a shoulder replacement just to get some sort of like insight or empathy, but it's useful. It certainly helped shaped my perception and awareness and more importantly, the passion. And I love it now. A huge, like I have such a huge passion for hips and share some like decent information. I think that's what I'm most passionate about. It's quite a complicated area. I just want to share. There's much good information because, unfortunately, because it is quite a difficult area, sometimes misinformation could be rife, especially on, online outlets and social media and stuff like that. Glute myths and misconceptions - Can patients have "gluteal amnesia" or "switched off glutes"?

David: There seems to be lots of myths and misconceptions and glutes seems to be one of the big ones where there's a lot of myths around glutes. Tell us a little bit about some of the myths that occur around glutes particularly to start with..

Mehmet: The amount of traction that some of these myths get, it's fascinating. It is almost like the more obscure, random and simple like these myths are, the more people hook on to them. But I get it because ultimately who's the audience? The audience is someone who's in hip pain and realistically someone who's in hip pain, they just want a quick fix because ultimately you're in pain, you just want to resolve it. Something that was so common was this glute amnesia situation that come up.

The actual term amnesia and glute together doesn't make sense. It's like saying a happy teapot, like those things don't come hand in hand.

Glutes and weak glutes have inherently been blamed for everything that's wrong with the world, but for people who have hip pain, it's such a oversimplified approach to take one person's one muscular weakness and strength deficit. One is not going to correlate with their pain. But it certainly isn't going to be the singular blame for someone's experience. But trying to explain what I've just said It isn't as sexy as a term like gluteal amnesia that seems really straightforward and that you could fix by doing this exercise that you'll find on this person's Instagram page or this person's YouTube channel, so unfortunately those are one of the things that I've probably come across.

And there's, I get like how sometimes it's explained to try and simplify what's going on, but also you don't want to giving patients information that's flawed just with the hope of that's easier for them to understand because that's not the case, you've got to make sure that we're giving them right information.

But equally, you don't want to bombard them with science either, but it doesn't mean that you lie to them and just say things like your glutes are switched off because they aren't. If you're walking about and you're sitting and you're standing up and you're putting your shoes on and you're going outside or upstairs, they are on, it's impossible for it to just like, all these other muscles are working, but one of them is just asleep or switched off, and that's a little bugbear of mine.

David: Can glutes get switched off or get amnesia?

Mehmet: No, I think no, I think there's some glutes that any muscle could certainly become deficit in their strength or kind of functionality, but ultimately if you have motor loss of a muscle which is the fact that the you know the muscle is not firing because there is some sort of like input that is inhibiting its function, that's a quite unique and significant scenario. So in regards to the common theme that we see with these patients, and often when people are being told this, that's not what's happening.

Actually, to be honest, I would hazard a guess the majority of the time, the glute strength probably hasn't even been tested to then be able to say, it's switched off. So at that point, I'd say no, for me, gluteal amnesia is a term that's been made up that doesn't have any kind of like decent clinical validity or applicability.

I'm quite lucky to be at the coalface of like hip physio. I probably should also point out that my opinions, I try to base them on evidence based background and research and understanding. I appreciate not everyone's going to agree with me. When I'm talking to someone, I'm like, look, I'll tell you, I'll be open. I'll be transparent. I'll be pragmatic.

I'll tell you what I know as it is, but also understand that there's I don't know everything, none of us know everything. There's going to be like limitations and levels of ambiguity to all of this stuff, but if I feel a little bit more certain on something, I'll be a little bit more assertive with those thoughts.

And this is probably one of those, where I'm saying, switched off glutes or gluteal amnesia, I think is something we probably need to just steer away from a little bit.

David: Have you had a patient come in and say to you that they've got their glutes switched off or their glutes have forgotten how to fire or they've got gluteal amnesia?

Mehmet: What's the first thing someone does? They go on Google, they'll type in, "What is my hip pain? How do I get rid of hip pain? Why does my, side of my hip hurt or whatever?" And then they might come across that and then they come to see a physio and that physio is sitting in front of them thinking, I've just listened to Mehmet talk. I've just gone on his course, blah, blah, blah. I know that this thing isn't even like really like valid, but the patient comes in, and they say to me, like in my clinic, and they say, Mehmet, you know what? I've got a problem here. My glutes are switched off. Or I went and saw someone and they told me that I've got gluteal amnesia and I've still got this hip pain.

And I know that from talking to them, that hip pain is probably going to be a little bit more complicated. It might be a hip joint pathology, gluteal tendinopathy, deep gluteal pain, whatever. What you don't do at that point is then just absolutely slate the other clinician that's told them, slate the other physio, all disregard what that patient is telling you. I think that's a really important thing to, for any clinician to understand is just, you've got to show a level of respect and professionalism across the board, even if they're telling me stuff. And I think, geez, that's honestly bonkers. Like whatever you've been told makes no sense, but you don't want to confuse the patient. You don't want to make them leave thinking, okay, I've had now two quite conflicting bits of information. You have to put yourself in their shoes and think how can they leave understanding better what it is that I need to do. And a lot of that comes down to saying, look, I understand their thought process.

I understand what you've been told. There might be some gluteal involvement. What we could do is probably try and refute that for your assessment, or even, if there's involvement, we can integrate that into your plan. But also if you've been doing stuff and it's not gotten any better up until now, there might be something that's been missed.

So we'll go through that with your assessment and see if that's relevant or not. And just trying to educate the patient, but like bit by bit.

When and how to test & improve glute strength

David: And, you want to gradually challenge some of these beliefs, particularly if they're, a little bit maybe wild beliefs, but you're also not looking to straightaway just hit them with that's absolutely, not the right way to think about this. We figured out glutes aren't getting switched off or getting amnesia. When and how do you test glute strength?

Mehmet: I think any hip strength testing is quite vital. But I think it will be relative to the individual in front of you. I think one of the pitfalls that often clinicians they associate contractile muscle testing with strength testing. Like those things are really quite different. If you're pushing someone's hip against resistance or abduction or hip extension with your hand and you're just resisting a resistance, that's not really strength testing.

You're just like testing the fact that muscle can do something like it's active, that it can resist resistance from a contractile perspective.

That doesn't give you any data, like just ranking something four out of five or five out of five, that doesn't tell me anything. It doesn't tell me if it is weak, how weak it is.

It doesn't tell me what plane of movement is a problem. Doesn't tell me really from a rehab perspective, where to focus, right? So if you're testing someone's glute strength and you've, using handheld dynamometry, if you've got them prone, if you've got them upright, if you've got them supine, whatever kind of like hip type strength test that you're doing to elicit some sort of response.

If you do like maximal voluntary isometric contractions and you're trying to get some data Then I'll have that discussion like if it is weak, how weak is it in comparison from left to right? What's the asymmetry? Is there an asymmetry? Because the thing is as well Dave, like that's going to help guide your rehab like this is a thing that I tell all clinicians whenever I'm teaching is you have got to answer me why, like you have to answer my why question.

Let me ask you this, for someone who's got like weak glutes, what would you commonly see as an exercise given for someone who has, for glutes, that we all know?

David: Hip thrusts are a pretty common one..

Mehmet: They use loads, and I, when I'm talking to physios, I'm like, let's talk about rehab, and they're giving a hip thrust. Why are you giving that to that patient? Because you're giving it to that patient for their glutes. Or if you're looking at like EMG recording data studies and you're saying, I know that step ups are great for glute max.

I know that side planks are great for glute med or whatever. Why are you giving it to them? Bicep curls are great for bicep. But like, why does that bicep need to be worked? If you're telling me though, that you're looking at the data and there is a deficiency or real notable deficiency. And you feel like that may be playing a role in that symptom, that patient's presentation, then great. Then we can funnel that from their assessment into their treatment. And then you're selecting exercises based around that. But also loads of things will contribute to that weakness.

One exercise that focuses on one muscle, isn't going to be the answer. They, all these muscles do slightly different things. They all work.

You have synergists as well. They work in different planes of movements and angles. That's where rehab for me gets quite exciting. And often patients recover better if your exercise prescription is really clinically reasoned. So in a roundabout answer to your question, manual testing is useful to see if there is an inhibition or an inability to resist manual resistance or gravity or whatever. but actually getting some tangible data is what will then help you.

Now, you don't necessarily need to do that for everyone because if you've got an athletic individual who has hip pain and on the other hand, you have less active patient who maybe just has some, let's say, gluteal tendinopathy, 55 year old patient, gluteal tendinopathy, who isn't really that active but has a high level of pain.

You start to create the question of is it worthwhile your time trying to do a full kind of hip screen for that? But then again, and this is almost like a paradox. It's I'm like contradicting myself, but I'm purposely just trying to demonstrate the level of the situations where it might not be relevant for everyone. So I think, again, you'd be able to answer why though, if I said to you why you'd be able to have that argument.

Functional glute testing

David: Handheld dynamometry sounds like it's a pretty common. You use that a fair bit within your clinical practice. Any other sort of tests you tend to do when it comes to testing gluteal function, strength, that sort of thing?

Mehmet: We have a lot of normative data for calves, for example, singular calf raises to failure relative to age and gender. We don't really have that for the hip, to be honest, there's some more data coming out. But it's very specific. It's almost asymptomatic high level female footballers.

That's the most recent one. But, we don't have it as generalised for the other stuff, but we still get information. For example, if we're looking at glutes in isolation you could get them to do pelvic thrust, but, some people would struggle with that if they had hip pain anyway, or they might be able to do too many for you to get a good insight.

So you could say if you've got a chair, you could do, single leg, high box step ups to failure. See how many of those that they can do if they can, and if they can't. And also just trying to understand that, just trying to understand how many that they can do, but also the quality of their movement.

And then it's using that same principle for other things. Adductors, you could do a straight long lever Copenhagen, single hold to failure, an isometric hold. You could do the same with a lateral plank, side plank on one leg. Maximal hold endurance tests. Same with the hamstrings, single leg hamstring bridge on the chair, 90 degrees at the hip, 90 degrees at your knee to failure.

But there's loads of opportunities for you to get, it might not be as accurate, but it's still, you're getting some information. I love a single exit to stand from a chair. I think loads of people can't do it. You get people with hip pain that are still training in the gym and I'm like, great.

You're still training and you're still doing your, compound lifts or whatever. But, you can't do a single leg sit to stand from a chair, but you can do it on the other leg for 20. What's going on in the gym when you're lifting and doing heavy deadlifts still now, if you can't do one leg raise from a chair?

So I think that starts to paint a bit of a picture.

Mehmet's favourite glute exercises

David: You mentioned there's some really nice ways to test it when you don't have a handheld dyno. You can use some of those more functional sort of tests and check what their, either time to failure is or how many reps they can do when you're comparing side to side. If you've identified some deficits, tell us a little bit about some of your favourite exercises that you tend to use. If you identify that they've got a deficit, you. Where do you tend to go? How do you tend to structure someone's rehab?

Mehmet: Rehab is easy to get right if you just have the right principles for what you're trying to do. But those principles will start from not necessarily the best or the sexiest exercises. Some of the, some of my most effective exercises are the most boring things in the world, that, but there's an important element to that, that we need to make it not boring for the patient. So I think rehab is really important from the perspective of making sure that the patients are adherent to it, right?

So it doesn't matter how much information that you know, how much knowledge, how much information you've gathered from in service trainings or CPD. If your patient doesn't do the rehab, nothing happens. The hip's not going to get better on its own. To get that output, you need to dose it, perfect.

You need to make sure that it doesn't irritate the pain too much. If it does, you've educated the patient on how to manage it themselves, how to regress, how to, within that week, just tailor it a little bit. You need to make it fun. No one.. I can't be asked to do rehab if it's boring. If you just have someone has a sheet of 10 exercises that they could have got off the internet. It's boring. No one's going to do that for four weeks if you're asking them to do it. So the length of the rehab set or session is really key here. So sometimes I would probably pick four is my sweet spot, four exercises, but even that can be a bit boring. I say, look, this is what I need from you, 20 to 30 minutes, three times a week. That's what I need from you to start with. That's almost like an hour and a half of your life a week. For the next few weeks for us to start to see some sort of change and they say okay fine I can do that.

My job then at that point is in those 20 to 30 minutes to make it effective, clinically reasoned and fun, but also the fun comes with a lot of my patients want to exercise. They want to feel like that endorphin hit. They want to feel like they're training. So I find circuits work quite well. So I can normally say look you've got four exercises you do one, two, three, four, have a little rest. Time your rest, two minutes, three minutes, do it again. And we do that two or three, four times and you, I want you done in half an hour, max. If it's taking any longer, let me know, drop it down, whatever. And what that does is it facilitates like positive reaffirmation in the sense that they get to the end of week one, week two, week three. And they've done it. They've done Monday, Tuesday, Wednesday. That's so much more empowering for a patient who has hip pain than the complete antithesis of that, which is I've got an hour of exercises that I've been told to do every week. I've got to end of week one, I've done 50 percent of it. I've got to week two, I've done 50 percent of week three, I've missed the other two weeks.

It's probably not going to get any better. I'm already struggling. What's the point? I'll leave it. And then they move on to the next thing. And I think that comes down to us. That's our responsibility to just understand that person and that individual so that we keep them adherent to it. Now, the other thing as well, you said what's your favourite exercises?

Things that are boring and simple sometimes are most effective, but we also can't do them forever. The step ups, the side step ups, the single leg box squats, the single leg RDLs they're all great. Many patients benefit from challenging lower limb strengthening exercises. And I find that for my cohort of patients I work with who are often a lot more active benefit better than the lower level bed based like Pilates, clamshells, pelvic bridges and stuff like that. For some, that's great. Don't get me wrong. There are some patients that are too irritable, too painful. That for them is great. But also we need to elicit a response and to elicit a response, you need to do stuff that is going to be effective. So although some of the boring stuff at the beginning works quite well, you also need to change it and adapt it.

And that's when the assessment findings come into play. The selection of exercise for me also comes down to thinking, these are the things I need to work on. These are the exercises, but also understanding that these exercises, we can tweak and change with angles, weight, dynamic movements to then take it to the next level so it doesn't get stagnant. And I think that's quite important.

Greater trochanteric pain syndrome/gluteal tendinopathy

David: Say we were looking at a gluteal tendinopathy, what's the sort of exercise that you tend to avoid or that you tend to include with those sort of patients?

Mehmet: Yeah, glute tendinopathy is surprisingly quite a challenging condition to manage, on paper you think it's just the tendon, we pretty, we're pretty good at tendons, healthcare practitioners, we know a lot more about it, we know how to manage it, but GTPS, greater trochanteric pain syndrome, which is the umbrella term, eight to nine times out of 10, you're dealing with a glute tendinopathy is the main culprit, to be honest. It's a challenging cohort i n the sense that there are not the most simple, directed, tendon risk factors at play. We've got other factors intrinsic as well. So things like.. People have got like systemic, inflammatory, hormonal changes that might have put them at risk or playing a role in their symptoms in particular.

But also a patient cohort that not all the time, but sometimes maybe are less active. Maybe are a bit more sedentary and don't do exercises in comparison to the FAIs and the hip dysplasia of the world. It does mean that where you have someone who has a high level of pain, high level of irritability, and a duration of symptoms that have probably persisted for months and months, you do have to tailor it because actually the way that we manage GTPS in particular is twofold. You could give someone in this patient group, the absolute creme de la crème exercise rehab plan that you think should work within, six to eight weeks. But the important thing here is if you're not also educating the patients on some of the things that will provoke it and behaviours that might not allow them to recover as well, I don't think it works as well. Like when you look at the key paper, the leap trial that was published years ago, that was like a great demonstration of how well physio can work to manage people with GTPS.

It's three groups. It was wait-and-see and steroid and the physio group. It isn't just physio exercises for eight weeks. It was a program on load management, education and exercise and that education, the reason it works so well is because consistently, you're educating, they did almost two sessions a week for two months almost.

You think if you're telling a patient and educating them that much, they'll remember it. Remember I said before, like normally in that first session, they forget most of it. If you're telling them again in three days and then again in four days and again in three days, they probably are going to retain it. And I think that education piece is really important. So although we've got, exercises that we would use, yeah, you probably would do, they probably would fall into the category that I said before. Lower level, maybe bed based, a lot, just general activity, getting someone walking a bit more, just trying to functionally get them moving.

But also on the other hand, we've got to educate them on some of the stuff that might provoke it, which unfortunately is the first thing that they would do because they would go on Google and they would, like I said, search for something and they end up coming in telling you that they're doing foam roller, tennis ball release, trying to stretch their IT band or doing like absolute savage glute stretches because that's what they've seen or someone's told them to do and then we're thinking, well I actually like that glute stretch that you're doing is also the same as a diagnostic test that I've just done to elicit your pain. It doesn't really make sense because I'm trying to get your hip to hurt but you're doing it as a treatment.

It's not their fault it's just what they've picked up so you're trying to unpick that and those things from a management perspective have to come hand in hand.

You can't do one without the other and that's why it's quite a difficult patient group because we're trying to progressively load a tendon at the same time with a patient who probably doesn't want to, not all the time but like majority of the time and that's a challenge. But I find it a good challenge. I enjoy it.

Stretches for lateral hip pain?

David: That Education piece plays such a large part of it.. I've had patients come and say, oh, yeah, you're asking them, do you do any stretches? No. And then you find out a little bit down the track when they say, Oh, I normally sit at night and, just in front of the tele and I'll just be, just sit with my legs crossed like this and pull my knee across.

And you're like, okay, these are some of the things that we need to explore. And you start to find out some of the things that are actually contributing. Or like you say, they've, done some research and they just yeah, they love to stretch or they've picked up some exercise and someone said you need to do this piriformis stretch or whatever it might be that they then go and aggravate their lateral hip tendinopathy with.

Mehmet: Yeah, and he thing is with this and I think it's worthwhile just one of the..That's not a debate. I try not get into debates online and stuff like that, but I see it. I see it happening but one of the only debates probably I've had is this concern about educating patients on things maybe to avoid, now, I get that everyone in there should be able to do everything. Yeah, compressive load is normal. Yeah, you should be able to tolerate it. I get it. But also if you're with a patient who can't tolerate a compressive load, like with the stretches that you mentioned there, it doesn't make sense to just hammer and knock on the door of pain all the time because it doesn't help.

It will increase their sensitivity. It will reduce their mood. It will reduce their compliance. Loads of knock on effects to that stuff. But it's the understanding of the patient that you're not going to avoid it forever. I'm not telling you not to stretch. You just, it's just now for a few weeks, just let's see if it makes a difference. The interesting thing is what you said before, some patients do stuff that you think shouldn't help. And it does. And I've had patients come in and say, That's the only thing that gives me some pain relief. And I'm thinking that's the only thing I probably don't want you to be doing. At that point, I don't turn around and say to them you know what, look, actually, when you're doing that, the excess compressive load at your tendon insertion is probably going to exacerbate.

They don't care about that. They're just like, it feels nice. So I'm like, okay, continue to do it. But do my stuff as well. And if you're not getting any better, because ultimately you're here with me now, and it's not better. So whatever you've done hasn't been enough. But if you love that exercise, do it, but do my stuff as well. And if you're not getting any better by, and then I'll set a date, I'll say, give it five, six weeks. If you're not even a little bit better, and I'll refer to it as like a net gain of rehab because this isn't going to resolve in six weeks. I'll just say, if you have a some net gain in rehab by six weeks, then we'll have to probably drop that one thing that I think might inhibit our progress. And if you're not and you're progressing, then we'll keep it in. And I think that's really important to consider, but it comes back down to the thing that I said before about people are sometimes doing stuff that you think, I wouldn't have advised that, but they love it. And they saying it helps. Who am I to tell them to stop?

Should patients perform hip mobility exercises?

David: We've talked a little bit about glutes and you've mentioned there, stretching and those sort of things. Now, hip mobility exercises, on social media there's lots of people, demonstrating all sorts of different hip mobility exercises as such.

Tell us your thoughts on, hip mobility and, whether the patient should be doing different hip mobility stretches and some of your, the misconceptions around that.

Mehmet: Hip mobility for the general population who just have a bit of a slight stiff hip but aren't in debilitating pain is fine. If it helps you, you're doing. Then great, there's no problem at all. For some, they love it. For someone who's got hip pain and they've got hip joint pain that is specific to a hip joint pathology, that is presenting with a stiff hip, which is often when this is used because no one's going to go and look for reduced.. Improving their hip mobility unless they think my hip mobility is diminished.

And often that is a cohort of patients that fall into like hip impingement or Femoroacetabular Impingement syndrome, FAI syndrome. Because with FAI syndrome, often those patients are the ones that do have a stiffness of the hip, either into deeper flexion or internal rotation at 90 degrees, or even, into external rotation as well.

So they have that stiffness. Now, is that stiffness because someone has a morphology of the hip of FAI that's restricting their range of movement? Does that someone, does that individual have a version or an acetabular version of a hip profile? So you've got obviously ball and socket and then there are varying different versions to how that socket may sit and also the profile of that hip in regards to how much it rotates. So if you have a retroverted profile, your hip will rotate less into internal rotation anyway, and if you had an anteverted profile, it'd be vice versa.

But then equally, if you have someone who has a CAM related FAI syndrome, they'd have loss of internal rotation too. So you're thinking what are you trying to gain there? You're trying to push against a structural restriction, like a bony restriction that I actually will probably precipitate more problems later down the line. On the general kind of what I've just said there, like when you're searching, people are searching for stuff on hip mobility or whatever, like none of this stuff would get mentioned.

It's not sexy, and someone who isn't necessarily aware of that when they're giving that also to the patient might not be aware that restriction might not just be a soft tissue stiffness that they've got.

Actually what you're doing there is probably just jarring the hip. With that unfortunately what it could lead to is things like joint effusion or even in some extreme cases like iatrogenic instability of the capsule because essentially you're stretching it past its capacity to tolerate that range of movement and I think that's where my limitation to it is.

I think I'm not against it but I rarely use it. And where I would use it is if I have an athlete who requires these real extreme ranges of movement for the sporting, performance that they're trying do, and they're possibly recovering from surgery, then I would at that point, utilise it.

Or if I'm utilising it conservatively, trying to get as best, because it is a challenge clinically, but getting as best an idea into what they're profile is and working within those means rather than trying to find the endpoint restriction and then pushing past it.

Improving hip range of movement

David: So if a patient comes in and you're testing them and they have got restricted, say, internal rotation at 90 degrees, And what's your thoughts here on trying to improve that? Is that something that you'll work on if it's just the person's coming because they they might have some hip pain or some hip stiffness and probably a combination or something like that.

Or maybe they've come in with low back pain and they've also said, oh, my hips are pretty stiff. Tell us a little bit about how you might approach that range of movement, movements and things that you might avoid and things that you might include. Mehmet: Yeah, I definitely wouldn't focus too much on the avoidance perspective, but it's going to be really hard to refute that there isn't these morphological causes that are restricting the range of movement. And that's the same for me as well, like there's a degree of I'm not really too sure why that's restricted. And I think that's not the only reason why it's not my top priority, but also there's many situations where if it was a hip, condition like the, like for example, FAI, like I mentioned, the patients who do well from it that you manage conservatively have to have an understanding that we have to work within the means of what the hip allows us to do, condition it, strengthen it throughout whatever planes and angles of movement that you have access to, but also just be mindful that It might still be a bit stiff afterwards, but you might have no pain.

You might still be able to play sport. You might have no pain. You might have full function, but you might just have less internal rotation still on that side. That might just be normal for you. And I think they need to appreciate that when trying to manage it. That doesn't mean you avoid moving into those angles and positions actively.

But you probably would avoid someone sitting on the edge of a bed holding their thigh and just doing loads of internal rotations repeatedly because it doesn't increase it.

You might increase it transiently, like for a few hours, but I suspect that's probably not actually like the morphology of the hip that you're addressing.

So from my perspective, it's not my priority, which is surprising for people because I think someone who specialises in hips should be obsessed with like mobility and range and majority of the time I'm not, I'm like, I just want to get people physically more robust and actually, making someone emotionally and psychologically resilient is on par with getting them physically robust for me. Like those two things come hand in hand. Everything that I do with patients from a physio perspective, when it comes to exercise and rehab, I'm doing not just to make them physically stronger, But I want it to have a knock on effect. I'm trying to make them like psychologically more like resilient to like the tasks that they want to do. And that kind of comes with obviously reduction in pain as well.

David: Hip mobility exercises as such, they're not tend to be something that you'll include too much in someone's program. For instance, you mentioned they're not just sitting on the edge of the bed doing internal rotation on their leg to try and improve that. Say someone has maybe a bit of hip joint irritation or their hip joint's involved in their pain.

Have you found anything that does help to improve it? Obviously, we can't change morphology, but are there any, is there anything strengthening or, manual therapy, any of that sort of stuff that you found actually, can help to improve someone's comfort with their, and potentially their range of movement.

Mehmet: Yeah. To be honest, like that's a kind of a very common approach. We know when we've got someone, young adult population, FAI hip dysplasia who do have. Although, albeit from two very different structural drivers to their symptoms, do have a structural driver to them, ultimately, if you've got one that's got instability from lack of coverage and one that's probably got either too much coverage from a pincer or this kind of cam morphology, we have a joint condition.

A common question that a patient might ask you is, how are you going to get my pain better if the CAM is still there? How are you going to get my pain better if the pincer is still there? Because I'm educating them on morphology and then they're asking me like, how the hell are you going to make that better for exercise?

Same with the hip dysplasia, educating them, explaining it to them as a possibility, not a definitiveness because it is hard clinically to diagnose these things, but there might be an instability or, a lack of coverage.

And then they say how are you going to manage that? Because if there's a shallow socket, then how's exercise going to address that? And the argument is like, none of this stuff has just happened. Your cam has been there probably for two decades. Your pincer has been there since the same time when you've developed in adolescence, same with the hip dysplasia. Like either happens, infancy or, secondary ossification during adolescent development. If you're presenting with symptoms when you're 25, 30, like they've been there a while, like you're just getting symptoms in the last six months to 10, 12 months, whatever. But those things have been there, which means that for a significant amount of time, your hip has tolerated it, managed it and been absolutely fine.

What we need to do is create a program that allows your hip to do that again. All right. And create a program that allows it to have the strength and the conditioning and the stability and whatever it might be to allow you to get back to where you were before. And I think that's really important because often patients, they might come to you with an X-ray or an MRI scan and it might say labral tear, it might say cam, it might say pincer, whatever.

And then they don't know that sometimes is just normal, people just have those things. It doesn't equate to pain. So then your program has a little bit more back into it.

Because then you're like, look, what we're going to try and do now is focus on trying to build your strength, tolerance, whatever it is, physical, function, tolerance, whatever it is that we're trying to address.

But also be mindful that there are circumstances where it's fine. Don't worry, you're not going to need surgery. Like I think that's what patients really get concerned about is that like when they hear structure and morphology. That the only way to fix that is to go in and shave it and repair it.

But I'm just educating them on the fact that loads of people have these things and have no pain and may never have any pain. Don't worry, let's just focus on this first. And then normally that helps, but again, that's why it comes back down to education. I'd say some of the most valuable outcomes I get from patients is when we have a really successful session on like education and reassurance.

I think those are like the most powerful. They're not like the sexiest things in the world. No one goes on a course about how to build rapport and how to communicate. And I'd say those are probably our strongest skill sets. Anyone can learn to do an exercise. Anyone can read a sheet or go on an app or whatever. Like the ability to really communicate, listen, articulate your thoughts and just treat someone with genuine respect and like care is so powerful. There's loads of people who have hip dysplasia, FAI, ankle sprains, knee, meniscus tears, like they don't go to a clinician.They just carry on with it. So we're seeing a group of people that might not have any history of anxiety, stress, depression, whatever.

But they are bothered about it. I'm lucky to not have those things, but I know when I've had an injury, I have got worried about it.

I thought, oh geez, am I going to be able to work? Am I going to be able to do this? So there is that underlying level of new anxiety that we have to respect and address.

And a lot of that comes down to just education, reassurance, and that's really quite vital. And it's easier to do with rapport.

David: Definitely is, yeah, it's a major part of what we do. And you mentioned there that education part. That's come through pretty strongly a few times. It's helping patients understand what's going on with their body. And that, even if there is that morphology, like you described, whether it's a cam, pincer, anteverted, retroverted hip, whatever it might be, that doesn't necessarily mean that they're going to need surgery, but you're going to help to work to settle it down.

And you can help patients improve their thoughts and their attitude towards it as their pain improves as well. That's all going to be a big part of the treatment.

Mehmet: Yeah, for sure. I agree and I think as soon as they're on board and it might take a little bit of time to get them on board, but as soon as they are and they understand that I think you can have real good outcomes.

When to test hip range of movement

David: Definitely. Alright, let's have.. We've had a chat about gluteals now. We've talked a little bit about the hip. I want to chat to you about hip flexors in a minute too, but while we're talking about hip mobility and range of movement, Internal and external rotation testing and range of movement testing around the hip. Obviously, it sounds like people come to you, they often think that, you're the hip guy, you're going to help, you're going to be really interested in their hip range of movement. When do you test hip range of movement? And when do you find that's actually relevant to what's going on?

Mehmet: Yeah, I would test it for all. I'd say even though I might not necessarily give individual exercises specifically to a range of movement deficit like the things we mentioned, I would assess hip range of movement for every patient that presents. In whatever capacity, I think it's really quite valuable.

I think there's ways to do it. That are probably better than others. And we spend a bit of time when I'm doing this on my course just to explain to clinicians the reasons as to why I do it in certain ways, because I think patients can present with levels of irritability that kind of can tarnish the insight that you're getting, so I think that's really important.

But I certainly would assess it. The reason for that is it helps you build that clinical picture. If you're having someone that presents.. Let's compare those two patients, right? So we had the active young adult. And we mentioned earlier the gluteal patient. So we had young, active, very fit, healthy adult. And then we had maybe more sedentary, less active gluteal tendinopathy patient, decades apart. I'd still want to understand their hip ranges of movement. On one hand, I'm trying to understand, is there a hip morphology that would correlate with a potential hypothesis like the things we discussed dysplasia FAI. And on the other hand I'm trying to understand with the other patient is there a another underlying hypothesis differential like for example an arthritic hip that might be co existing with a glute tendinopathy or actually do they even have a glute tendinopathy?

Is it an arthritic hip that's masquerading or presenting like that? Or are the two things coexisting? And I think that starts to give you a little bit more.

So I look at all of it to help, what I call a hypothesis, roar a rumble, right? Because when you're talking to a patient, you're thinking it could be about 10 things.

I've got 10 differentials in the ring. I've got to try and, barge out a few of them by doing my assessment and that's what your assessment should be. The assessment is trying to understand what I don't think it is to see what's left because it's hard in clinic to diagnose stuff.

If you're seeing someone for the first time, clinical tests are real limited. We have loads of restrictions and limitations. So that's not to say that when the patient's there you think. You say to them, oh, I can't tell you what's going on because none of these clinical tests have a high specificity or likelihood ratio.

You just say to them, I think it could be this or this, and that's in your head. Then you've got to that point by nullifying as much as possible. And a lot of that comes when you mentioned about hip range of movement, that will support that rationale and thought process.

Differentiating hip osteoarthritis (OA) from GTPS

David: You brought up a good point there. So oftentimes patients come in, they might have a couple of conditions going on or they might suspect that they've got a, their hip joint is involved and actually it's their, they've got GTPS or vice versa, or maybe they've got a combination of that.

So tell us a little bit about some of the clues. So if clinicians are listening and they've got a patient coming in with hip pain, what are some of the clues that are going to help them to identify that whether their patient has got GTPS, or whether the hip joint's involved and how they can go about differentiating that.

Mehmet: First and foremost, the subjective is key. Subjective is absolute paramount because not only does the narrative and the story paint a bit of a picture, the patient has all the answers. You shouldn't be jumping to get them on the bed and doing clinical tests to try and diagnose something.

You should have a real strong suspicion as what's going on before you even start like touching them. But with that in patient in particular, it can be challenging. So for example, if you've got those two hypotheses, OA, Osteoarthritis of the hip and GTPS and gluteal tendinopathy. You could argue and say well for OA we have real obvious textbook signs and symptoms in the sense of you've got an age and a demographic that increases your suspicion, you've got the time frame which is usually a bit slow and progressive which increases your awareness of it.

You've got the standard like difficulty putting shoes and socks on, difficulty washing legs at the bottom, difficulty walking, difficulty getting in and out of a car. You've got like real, like normal, obvious OA signs and aggravating factors. And then with your GTPS patient who has symptoms probably in a different place, lateral hip, but also that lateral hip might be so sensitised that they've got symptoms then going into the buttock or into the thigh.

You think, actually the OA hip could also present with the symptoms there. So all of a sudden you think, the locality of symptoms now is off. Now I can't use that to differentiate because it could be both. And then the GTPS patient's saying to you, actually I can't put my shoes and socks on. I can't reach down or put my shoes and socks on or cut my toenails because, I can't reach down or put my shoes and socks on or cut my toenails because they can't rotate the hip because it hurts. They've got a contractile or compressive intolerance of the tendon, which means they can't do it.

So now you're thinking can you not do it? Cause the joint is stiff or restricted, or can you not do it? Cause the tendon is so painful that it stops you doing it. That's why passively looking at the range will help you with that. And you think, okay, fine. Can you lay on that side. No, it hurts.

Can you lay on the other side? No, that also hurts. And then you have to dive into that and think are you unable to lie on that side in bed because of a, again, contractile or compressive intolerance of the tendon? Or is it just because the joint is painful? But it starts to paint a bit more of a picture because it's unusual for the joint to be painful.

If you're laying on the good side, because really if you're knees are together, the hip isn't going to be that provocative. You'd be like unlucky if the joint was that irritable. But this time the patient's telling you distinctly, I've got pain here on the side of my hip when I'm laying on the good side.

And then when I'm laying on it, it's distinctly painful on that greater trochanter. So then you're starting to subjectively separate these two things out a little bit. And that's when the kind of thought process of trying to understand a bit more about the patient in regards to GTPS is fairly pertinent because we've got some key factors and risk factors that we mentioned.

I think that the menopausal status of a patient is fairly pertinent to understand. The fact that those hormonal changes may have a catabolic effect on tendon health is imperative to understand but also highlights the need to have good rapport for patients as well Because it's a sensitive topic to discuss, you know I'd get a black eye if I just asked someone if their menopausal 20 minutes into appointment when they're coming with hip pain They're not going to understand it, but I would explain why, you know why I'm asking it Why we being quite thorough with it So those things are quite important and that will start to lead your thought process.

Now it may well be that subjectively, you're finding it hard to differentiate between the two. It may be that then clinically you also will struggle to differentiate between the two because again, they could coexist. They commonly do coexist. So it's a challenge at that point. And what you do there is embrace the ambiguity.

I think it takes a good clinician to understand that working in that gray area is really quite a skill, to explain to the patient that, again, because they don't care too much, they just want to get better. You say, look, there's a couple of things that could be going on. We're going to address it by considering all of those factors.

Then you carry on. All right, and I think that's a real real important lesson. I think sometimes physios are just so keen to has to just be one thing. It has to be only, it's not sometimes there's a bit of both. There's a bit of both and that's really quite important.

Hip objective assessment - OA vs GTPS

David: So you pick up the clues from the history like you would with all things, then you're going into that objective going, okay, maybe we have both things going on or you're still a little bit unsure because they're getting pain when they're lying on their side, they're getting pain putting their shoes on, like you mentioned, bending over to, put their socks and shoes on or getting dressed.

So what are some of the tests that you then like to use to help to identify which of those, might be involved or if there is both? Mehmet: When you've got someone who has, hip joint pathology specifically, the OA, you're not necessarily going to have the degree of specificity that you would do when you're testing for the glute tendon. So if you're doing a cluster of tests for the glute tendon, things like, single leg stance, palpation, FADER resistance test, sideline hip abduction with resistance, they're all looking at the compressive and contractile tolerance levels. So whether you can stretch it and it hurts, whether you can contract it. in its most stretched position and it hurts, or in a range resistance and if it hurts.

You wouldn't necessarily elicit that level of distinct response in a local area when you were thinking if it was just the hip joint. So then you're starting clinically to be able to separate these two things out a little bit.

But the difficulty is when you're doing a, so a fader resistance test is my favourite one because it's one of the rare tests that we have that has a high level of specificity, meaning that it's specific. to this. You bring the hip into full flexion, adduction, external rotation fully. So you're basically doing like a glute stretch, like piriformis type stretch, right?

Fully rotated the hip. And then you would get the patient to resist back into their starting position, which is obviously mainly going first into internal rotation, extension and abduction. So when you're doing those tests, And you're trying to refute OA, where you're thinking, is your OA hip going to let you come into full flexion, adduction and external rotation?

Probably not. Which means you're going to struggle. And then you're thinking actually there's a passive inability to do that from the hip itself. It's not an intolerance from the glute tendon. Do you see what I mean? So it might, that's when it starts to paint you a little bit more of a picture specifically.

The cluster of tests that were great, the Grimaldi test, I think are really useful to consider. And then from the OA perspective, I think, looking at quadrant restrictions and range are the only things that really are going to be able to give you a good indication if that loss of range is there as a result of an arthritic hip.

GTPS diagnosis

David: So you tend to use those tests from Alison Grimaldi and it's good to dive into some of those because we've got people that might be familiar with them. Maybe they're not super familiar with the cluster of tests, but you mentioned there some really nice ones that you might not expect the patient to have pain if they just have hip OA.

And so if they GTPS but not hip OA, you might expect it with that pain on single leg standing.

Mehmet: It's like standing on one leg for 30 seconds to see if they can tolerate that level of position so you see if that was painful.

That's quite a good sensitive test, which means that if it's pain free. You can't 100 rule it out But it's starting to paint a picture that you might be able to rule it out. Now palpating the side of the great trochanter which often patients get told that it's bursitis commonly it's not, I'd say bursitis is there a very minority of the time, certainly in isolation, very minority of the time, let's say nine out 10, it's the tendon pain around that area. And then bringing the FADER resistance test, which is the one that I said is when you bring in a hip to your chest across your body and rotating it, like how you would do a glute stretch, puts the glute med, so glute med, which is the most commonly impacted tendon muscle, with this.

When you're bringing the hip into full flexion adduction and external rotation, it becomes the most stretched position of it. And this is kind of an interesting thing to people for people to consider, especially when they're doing like clamshell exercises, which commonly get prescribed.

When you do a clamshell, you're on your side, your hips are flexed. Feet and knees are together, right? And then you bring your knees apart. So you're basically in hip flexion and you're going into hip external rotation.

But when you're testing the FADER test, The reason why it's so specific is because it's specific to that muscle and tendon, because that's the thing that we're dealing with.

So if you're in a flexed glute stretch type position, and you're having to resist internal rotation, and that elicits the pain, and it's a specific test, that just reinforces biomechanically what the glute med does in hip flexion. It does internal rotation. So if you're doing a clamshell, you're putting it under compressive load repeatedly, which is why often patients find it painful to do because it looks like it should work the glutes, but it doesn't, if anything, it would irritate it.

So that's again, a demonstration of just flowing your assessment into your management choices from a rehab prescription. And those are the first three and the last one would be like a side lying hip abduction. So just laying on your side, bringing your leg up, seeing if you can do that. And often I would do that passively first and getting the patient to just withstand that leg hold in mid range.

No one can effectively resist when the leg is halfway up your ear. Like you've got to be able to just like hold it and then resist it at that point. But again, it just gives you a little bit more understanding in regards to those lateral structures and what they can withstand.

Return to running with hip dysplasia

David: We've actually got a great question from Tom Goom that I want to just run past to get your thoughts on. And Tom asked, what's your thoughts on return to running with hip dysplasia?

Runners tend to get a lot of conflicting advice, so it'd be great to hear your take on this.

Mehmet: I think if we're talking about someone managing it conservatively, I'm the biggest optimist. I think until someone, or there is a real obvious reason why someone can't get back to the stuff that they love doing, I'm all for them doing it. Hip dysplasia is no different. Like I said, people who have hip dysplasia would have had that level of hip morphology throughout their life. It's not just happened. So we have to consider two facts. Is there such a deterioration in hip health that has caused them to have that level of pain that is inhibiting them getting back to their sport.

And have they done enough rehab to get back to running? Okay. What we can't do is focus on someone having significant hip pain as a result of hip dysplasia, have low quality rehab and then just try and get back to running themselves. Often what we would have to do is consider, let's try and gradually, progressively get them to that tolerance that they can withstand running.

And if they can, then that's absolutely fine. People have characteristics and levels of hip dysplasia and have no problems and that's really important to consider. Unfortunately, there's still that misconception that running is bad for joints. Impact is bad for joints. We're great at adapting and tolerating these things.

This is no different scenario. But I guess if you've got an individual who has significant pain, is rehabbing quite well, but really struggling to get to the point of where they can tolerate running consistently without the risk of their symptoms flaring up again. I think that's when you just have to be a bit more pragmatic and say look, if we're going to manage it conservatively, like that's the only thing that we're struggling to get you back to, but that's not us telling them to stop.

That's just their lack of ability to tolerate what you're doing. What I wouldn't want someone to say is. You have X, you can't do Y. I think like it takes a lot to be that descriptive and decisive with that. And you look, you could argue, you could listen to this and say, yeah, but Mehmet, you just said about clamshells. Don't do this. If you've got this as an issue, it's a complete contradiction. But again, if someone could do clamshells whilst they have GTPS crack on, once the GTPS is fixed, they can go back to doing clamshells, much like the same with this. If they have dysplasia, you manage it, they go back to running and that's absolutely fine.

I see it a lot with the hip replacements as well, don't run. You can run like it's fine. Life's too short, man. Let's just get on with it. It's fine. Just manage it. Make sure that individual can tolerate it and help them, get back to that point. But it's still, there's a lot of information out there. If you've got a hip replacement, don't do this. Don't do that. You can.. Physically you can. There isn't evidence to tell us contrary and there isn't evidence yet at all that shows that it will have a negative influence in the long term. Until there is, then I'm thinking, life's too short. These people have been in pain. They're not having these treatments to live with more dysfunction or limitation.

Hip flexors - what are they responsible for?

David: Let's have a chat finally about hip flexors. They cop a lot of bad press, there's lots of stuff that they get blamed for, everything from back pain, knee pain, and everything else. Tell us, is, why do hip flexors cop such a bad rap?

Mehmet: For some reason the hip flexors just get blamed for a lot, mainly just, I think, location of where the symptoms are. Then on the other hand, they do become irritable with other conditions.

If you have FAI, if you have hip dysplasia, yeah, you can get irritability of the iliopsoas tendon and other hip flexors, but not the main problem. That's a symptom. Same with patients who have femoral neck stress fractures or bone stress injuries get blamed for hip flexors just because it's there .There's just a locality of symptoms and where anatomically this muscle group is. I'd say it's getting up there with the weak glutes. When someone walks in and they say, Oh, I've got tight hip flexors or my tight hip flexor hurts. I just feel it's probably the joint. Even if it is painful at your hip flexor, it's probably something else that's causing it or it's not the hip flexor. Or as my good mate, James Nokes would say, it's never the hip flexor, but sometimes it might be in some unique scenario.

Do hip flexors get tight from sitting?

David: Everyone that thinks they've got tight hip flexors always blames the fact that I sit a lot, so my hip flexors got really tight from all the sitting. What's your thoughts on that? Mehmet: I think it comes back down to the fact of things will feel stiff if you don't move. So it could be the joint that's stiff. It could be the hip flexors. Yeah, sure. Muscles all get tight if you don't move, no one complains about, Oh, I've been sitting too much.

My Achilles feel really tight. My anterior ankle feels quite stiff when I've got up from walking. No one really says that stuff like.. It's just normal. Things get stiff if you don't move, it doesn't have to be pathologised. It is just normal. What isn't going to happen is if you're sitting at your desk that your hip flexors are going to shorten and become, you get like some sort of contracture.

I think people will think that, like we're way more fragile than we are, but it's the perception, if you're stiff, you sit, you get up, it feels tight, you think it's short, and it probably hasn't. And we certainly are not going to get like contractures of the hip flexors just because people work office jobs.

Hip flexors - objective assessment

David: When patients come in and they say, I've got tight hip flexors, or if you suspect that there's hip flexors involved in their pain what sort of tests do you tend to do.

Mehmet: If I think that they've got iliopsoas type groin pain, I would probably do two things, I think, and it falls again.. Because if we're dealing with a muscle, muscular tenderness or tendon dysfunction, I'd want to do similar to what we've said before.

Some of the key things, especially with those who have hip instability who have secondary iliopsoas pain I quite like doing a plank and a three-point plank at that as well. So the iliopsoas acts as an anterior femoral head stabiliser especially in the first 15 degrees of hip flexion. So often people who have instability. And this is the.. And I need to caveat this heavily with this is probably the only time that I would, this is more my opinion and approach. This isn't based on evidence, but often when you have someone who has an instability of the hip, they have an intolerance to do that three point plank.

And certainly, as you go from a plank into a pike, where you increase the hip flexion through a trunk or pelvic flexion or rotation often they struggle or are intolerant to do that. So that just gives me a little bit of insight into resisted anterior load or those structures with hip flexion to see if they can tolerate it.

And often they can't. So it just gives me a little bit of information there to then help with my rehab further down the line. Looking at range of movement, Thomas tests are great, but Thomas test has to be done really well for it to be effective. So this is one where you're sitting off the edge of the bed, hugging the knee and the other leg is dropping down.

That hugging of the knee that restricts and limits the pelvic position is what the test lives and dies by. Like it has to be in that position for it to be effective. If it is, then it gives you a little bit of specificity into that flexibility of the anterior structures. But again, at that point, I'm not like overly stressed about trying to do some sort of like passive treatment to loosen it up. I would just maybe encompass that with some of the exercise that I choose. And also in that fully stretched position, I would often get them to resist as well. So I can get some insight into the contractile tolerance in a fully stretched position in that Thomas test position also.

You can probably gauge from the prone hip extension, but difficulty looking at that. It's not you much to play with anyway for most people. So I want to look at those two things. And then I will just go a little bit further to assessing the contractile intolerance when they're on their back with short and long levers, mainly for me to just figure out like how irritable it is. So then when I'm picking exercises, I'm picking the ones that are pitched at the right point. Not so much to think. From a diagnostically, we've got as much as we're going to get. If it's painful to contract it, fine. If it's painful to stretch it, like we're getting some insight. That's not the diagnosis.

That's just like part of a clinical pick. The main diagnosis is the joint. This is just like something else that's going on that we have to just still encompassed within our rehab but not put just all the focus on it.

Hip rehab exercises

David: You mentioned there a three point plank and moving into a pike position. Can you just clarify that a little bit about how you might, get a patient to do that?

Mehmet: Say you get someone in a plank, right? Normal plank position on their elbows, on their toes, like good form on two legs. And they say to you, yeah, I can do that. It's not too bad. Let's say their right hip is the painful one and you say, okay, cool.

Can you lift your right leg up? So you extend the right leg. So you're basically doing a plank, but just with the left leg. And they say, yeah, that's all right. The right one's a little bit stiff to hold up, but I can do it fine. And then you say, swap around and then you get to swap around. And what often will happen is they just can't do it.

They can't lift the left leg up because it's too painful and they can't withstand that force and load going through the hip on that right hand side. So they normally just can't do it. They can't lift the left leg up. So I'm thinking that's quite a big difference from left to right, first and foremost.

Now it doesn't just give that stability in neutral. It goes as you go through flexion. So what I would normally get them to do, let's say they could lift the left leg up. The right one is a bit painful, but they can do it. Then I would progress it to starting to lift their butt up into the air. So you keep your legs straight and then you just start lifting your butt up.

So into a pike position, but not too much. And then dropping it back down to neutral and even just slightly past as well to see if it causes pain, like if they can or can't tolerate it. It's just trying to paint a bit of a picture in regards to what's going on, especially in those like first degrees of flexion.

And just being mindful that's in a long lever. So then when I get them on their back and I'm doing other tests for the hip flexors in short lever, like I said, I'm just trying to figure out where their level of irritability possibly would be.

David: Yeah, so you're getting them to lift one leg off the ground so they've got three points of contact on the ground instead of four. And then within that three-point contact, you're then going into a pike position. So they might have one leg still off the ground, then moving towards a bit of a pike position coming up a bit and then coming back down into like neutral or maybe a bit past you mentioned there.

Mehmet: Absolutely. Yeah. Just to see how it responds to it. And, but I would say, often, if it is irritable, like that first hold is normally a big problem. Unfortunately, like it's not a standardised clinical test. It's not.. I've based this around like anatomically what's has a high prevalence and iliopsoas tendinopathy and overactivity of those structures, especially for hip dysplasia is quite commonly correlated.

And there is a causal relationship between that as well. And equally biomechanically. That's what these things do. So I'll just try to merge them together. And these are one of the things that often you can pick up. That's not to say if they can do it, there's no hip dysplasia. That's just, I'm just trying to, my main focus on that is.

If they can do it, then I know I can use that within their plan, because I know that's still helping with the stability. That means I can still use that as an exercise potentially.

David: So if they can't, you're maybe suspecting that there might be, there's well some hip flexor involved, but there may be some hip dysplasia in what's going on.

Mehmet: I would want to know if there is, I want to look into that. Yeah. And I'll just be mindful of that. Or if not, I would just say well, it's unusual to get that level of, you know, so it's irritability just randomly as a primary diagnosis, unless you're like, a sprinter, hurdler, long jump, whatever, like someone doing explosive work or a dancer where they're kicking their leg at the top of range every, repeatedly for three hours on end. Like most people aren't doing that. So it's unusual for it to be a primary diagnosis. So that then does raise my index of suspicion. At that point. Then I'm thinking okay, we will use that as part of our rehab journey for that individual at whatever level that we think that they can tolerate it.

And it might be that they can't do that at all. You might give them a dead bug, you might go from short to long lever and just use the weight of the leg to start to load it, if so we're not doing it against resistance, we're just using gravity and the lengthening of the leg and the weight of the leg essentially to just gradually load it from that eccentric property of the muscle.

David: Nice. You mentioned there some really nice starting exercises. For instance, if they can't cope with the long lever stuff, that dead bug might be a nice place to start to help to get some eccentric strength there. What are some of your other exercises you like to work through or progress through when it comes to hip flexors iliopsoas related groin pain?

Mehmet: Once that irritability has settled, so if we've gone progressed a little bit, some of my favourite things are using that kind of plank position. So sliders I use quite frequently, so like double or single leg sliders into full pikes, or if people don't have that they can use a Swiss ball, exercise ball. And if the pike is too difficult, doing things like knee tucks also are really useful to do because they can like just do a shortened lever. For me, I find that really beneficial as things are then continuing to increase and improve. I try with all my rehab to start doing 2 or 3 for 1s.

So 2 for 1 is like, I've got 2 good movements in 1 exercise. So for example, you could do like a psoas march. So if you're laying on your back, right? Laying on your back, knees are flexed or hips are flexed to 90 degrees and you've got a band around your feet, right? So psoas march would be like you push one leg all the way down, bring it back up, And then straighten all the way down with the other leg and bring it back up. And basically, as you're moving one leg, the other one is so rigid that it's, you're holding it against the resistance of the band. Now, my two for one with that would be to get them to do a hamstring bridge. So laying on your back, heels on a bench or a box, 90-90, lift them up. So purely isolated hamstring bridge. And then do the service march at the top of that. So you work in your hamstrings cause they're statically having to hold you in that position. And then you're doing the hip flexor march with the band as well. So you're doing two front. That's tough, but just an example of where I would sometimes try and do I guess like multiple things at once.

It's quite intense. Quite hard work. Another example would be if you've got someone completely supine on their back and you've been doing the leg raises, that's easy, right? So if you put a medicine ball between their legs or a Swiss ball. You do an isometric adduction squeeze and then do the hip flexion raises with two legs. That's quite tough. You get them hanging from a bar and doing toe taps, toe raises. Just imagine someone hanging, swinging, and they've got the Swiss ball between their ankles, and you're squashing the ball, and then you're doing straight leg raises. Then you've got abdominals, adductors, hip flexors, so three for ones, two for ones. I'm being quite hard to this imaginary patient, but you get the point I'm trying to make.

David: Definitely working through from short lever to long lever, then incorporating like different muscle groups at the same time, so you can actually, get a little bit more bang for your buck, or intensity. I think that's a really nice place to wrap it up. We've covered a lot of great topics. There's a lot of myths and misconceptions and we've explored a lot of those and how physios out there can share accurate information with their patients and take an evidence based approach to assessing and treating the hip. So really appreciate you coming on and sharing all that with us today, Mehmet.

Mehmet: Yeah. Thank you for having me on. It's been great. And yeah, I really enjoyed it. And hopefully people listening find it useful. And, if you've got any questions, just feel free to reach out.

David: Where can people find you, Mehmet? What's the best place to get in contact with you or to see what you're doing and you've got going on?

Mehmet: For patients, I would say my website, which is just thehipphysio.com. And then my main social media platforms are Instagram, YouTube, and X or Twitter. If you search for @the.hip.physio, you'll find them. My main one is Instagram. And at the moment on YouTube, I'm starting to create a lot of patient-centric videos. Because I get a lot of referrals from physios, and what I want it to have is like a place where patients can go and just learn a bit more about their problem, how to manage it, and just to cut out all the BS that they might find out online. Yeah, that's something that's developing and that's growing.

David: Perfect. So check you out on Instagram and Twitter, or X, and YouTube as well, eh? We'll have links to all those in the show notes.

Mehmet: Thanks, buddy. Thanks a lot. Yeah, thanks for your time. Great questions. Thanks for having me.

David: Thanks for coming on, Mehmet, and sharing all that with everybody. We appreciate it.