In Your Pants with Dr. Susie G - Causes of Hip Pain with "The Hip Physio" Mehmet Gem

Starting point is 00:00:00 on this episode my hip hurts or my achilles hurts and then we're trying to navigate like how to manage that so there are links though when we look into the evidence if you have someone who has you're listening to the in your pants podcast i'm your host dr suzy gronski your penis friendly pelvic health physical therapist sex counselor and educator helping you get in the know down below In a world where hip pain misinformation is all too common, it's time we debunk the myths surrounding body asymmetries, pelvic tilts, glute amnesia, and hip labral tears. Welcome to another episode of In Your Pants, where we're going to unravel the misconceptions surrounding hip pain, delve into the biological sensible causes behind it, and empower you

Starting point is 00:00:55 to become your best advocate if you're dealing with hip or pelvic pain. Joining us today is the hip physio, Mehmet Cem, who'll break it down for us in ways that is easy to wrap your head around. Mehmet started his higher education journey at the University of Hertfordshire, where he received a bachelor's in science, in sports, and exercise.

Starting point is 00:01:15 He shortly went on to complete a pre-registration master's at the University of Essex, and has since completed his postgraduate diploma in advanced neuromusculoskeletal physiotherapy from the University of Hertfordshire. Mehmet initially started his career working in football and rugby throughout Essex and Suffolk, predominantly with young elite athletes and also within women's rugby. Over the last 11 years, Mehmet has specialized in musculoskeletal physiotherapy,

Starting point is 00:01:43 while specifically developing his special interest in hip and groin injuries over the last 10 years, specifically specializing in FAI syndrome, femoral acetabular impingement syndrome, alongside his role as a regional fcp lead for pure physiotherapy memet has his own private hip consultancy clinic where he sees patients both locally to devon and also with zoom consultations for patients who are based all around the world in addition to his clinical role memet has his own course called simplifying the hip which he teaches to healthcare professionals all around the world both remotely and face to face memet has a strong belief in using evidence-based practice to direct his treatment approaches and feels that empowering patients with the tools to

Starting point is 00:02:29 prevent injuries from reoccurring is imperative. Mehmet, welcome to the show. Thank you for being here. Thanks for having me. I'm pleased. And I was a few minutes late, people. I was a few minutes late and I've managed to just about make it. So thanks for the invite.

Starting point is 00:02:47 Looking forward to diving into having a chat. Yeah, thanks for having me. Yes, and we are going to dive right in. in fact to talk about some of the misinformation out there about the causes for hip pain i'm sure you've heard this and i've heard this but also some of our patients about asymmetries labral tears popping clicking hips etc so please enlighten us about what is it that we should really be believing when it comes to hip pain where do we start suzy where do we start i mean this we could be we're going to be here all day but I think a lot of the stuff look you know we we met

Starting point is 00:03:27 through um social media obviously you reached out through that and that's my avenue to try to share things on online that's you know decent information I think the problem with information online is it can get diluted by people who probably don't know as much about stuff if I by no means know everything yeah I've been a physio for 15 years and specialized in a deck for a decade in this stuff and I still don't feel like I know anything so I think when there's a lot of people giving advice sometimes patients get confused and unfortunately the thing on social media is and online is that patients are being told like really simple things are there to cause their hip pain and it's never that straightforward like the human body isn't it's not a car you know

Starting point is 00:04:12 it's not like something is broken and we'll go and fix it or you can have an MOT or whatever like it's such a complex system about the brain and nervous system psychology physiology so my biggest bugbear really is when i see patients and you know people online or whatever it might be um really trying to ascertain hip pain because of a tight muscle or something is a little bit weak or because the asymmetry stuff bugs me i'm like we were all asymmetrical why is it just like all of a sudden for some people it's irrelevant so I've got that balance of like the passion of what I'm trying to put across and then not being rude like I don't like like being a an account who is just jabbing people online or whatever I'm not really about that but

Starting point is 00:04:59 also it's frustrating because I have to kind of rein it in sometimes can I actually like you know people read this and they're quite desperate for help and none of it is is true so um yeah in regards to kind of the stuff that could cause it there's so many different different types of hip pathologies but it's just about trying to navigate that often you just need the right person to help you understand really what might be going on um with with hip pain really yes thank you so much for sharing that because you're right there is often people are very desperate to get help and in a world where we have so much information readily available at our fingertips it's often that folks do get confused and frankly there is no unless you know how to sniff out bullshit

Starting point is 00:05:46 you wouldn't know otherwise and so I think it's a huge disservice when we really are myopically looking at a situation that actually is quite complex as far as hip pain or that connects to the pelvis I often tell people that you know your hip and your pelvis and your lower back and everything else is all connected including your brain your environment your context as you mentioned so let's go back to some of the misinformation and you know stuff that's circulating out there as far as maybe pelvic tilting is something that I usually hear a lot as far as anterior pelvic tilt or posterior pelvic tilt as a cause for hip pain or low back pain or pelvic pain for that matter can you speak a little bit about the pelvic tilting

Starting point is 00:06:34 the pelvic tilt in suzy this honestly like if i could write like what is the bane of my life there's the top three and i say this is up there this is sometimes the top one sometimes it's two or three it's always there or thereabouts because that is one of those things that is almost like bastardized to the point where people are like well look if you have it that's the cause of your pain look for some people there is some occasions where it is relevant but even when it is relevant you're like it's never relevant in isolation but unfortunately there's a narrative where people have someone has a pelvic tilt it will give them back pain it will give them hip pain go away and do this stretch or go away and do this exercising or somehow change it the human body has variations

Starting point is 00:07:21 and that changes from gender to ethnicity to all sorts and that will also be present in those who with their pelvic pelvic positions and tilts and angles that will then mean that for some what seems excessive is actually normal and for others the contract the contrary now unfortunately there's also then that dialogue of well actually this is a quick fix you go and do this and it's going to get rid of your pelvic tilt you go and do that and for some and it's always the ones who seem to be shouting the loudest unfortunately on on online it's it for some it can help but it's the conversation is sort of what actually is it that that's helping is it just the fact that you're getting someone active and moving is it the fact that you're re-educating and reassuring

Starting point is 00:08:04 them and actually that's the most important element of what you're doing but unfortunately for me like it's a it's a big bug bed because when you have a certain pelvic tilt position if let's say the the common one is you know an anterior pelvic tilt that's what you know everyone finds is a sexy topic of pelvic pelvic tilts we should never knew there was a topic of pelvic tilting that could be sexy apparently there is now but um that for many people is fine doesn't cause an issue asymptomatic isn't even a problem at all but of being told well if you stretch this if you strengthen that it's going to change the position and it won't just because it's on a picture because someone's posted there before and after and it looks a bit different don't be kind

Starting point is 00:08:52 afford you know don't be fooled actually what you have to do is look at proper evidence-based literature and research and see well even in populations where you are doing repeated long-term static stretching for hamstrings or hip flexors or whatever it might be you might see a change for an hour but it's not going to change it consistently and it certainly isn't going to be the fundamental reason why that individual has pain but unfortunately when that conversation happens it trivializes that person's experience and when it doesn't work or last then that patient is then left with thinking i've got pelvic tilt issue and i can't fix it what do i do next and then they go to the next person and then they dig their thumbs into whatever or try to release whatever it might

Starting point is 00:09:37 be and then that doesn't work and then often a lot of my caseload um are patients with quite complex hip issues that have seen all these different people giving these little bits of advice and that's frustrating for me and also but primarily just because it doesn't support the patient's you know recovery at all absolutely and it's quite fear-mongering and also just saying you're just you're broken you know you're broken and if it doesn't fix this way or if you don't notice it in this particular way is how your body you know looks or feels then there's there's no true and you know what says you know the other thing is always like when you then got like such an extreme thing here where it's just like you've got pelvic tilt or you've got an anterior

Starting point is 00:10:22 pelvic tilt that's the cause of your pain and it's almost like that real negative connotation around it then they can't see me and it's like so like the opposite but then I'm like but then I'm like actually it's almost sounds like I don't give a shit because I'm just like brushing it off so much I'm actually I need to show that it's not that I'm disregarding your problem or your pain it's just that that ain't relevant like that's not like it might be in certain situations part of the picture but it's not the only cause of it um but you know you could only do what you can do it's a delicate balance right you you you i've heard a uh that marty smith is an occupational therapist and i was just on an ot pelvic health conference and she she said something that really

Starting point is 00:11:03 stuck with me is match the cadence but not the dysfunction when you're working with someone right meet them where they're at but don't get enmeshed with the dysfunction and and this is just totally hitting home our conversation about that it's like we need to meet them where they're at as far as their knowledge what they feel is going on and also trying to dismantle little by little some of this misinformation or these beliefs which we know play a role in how we feel about our bodies and even our recovery process because beliefs thoughts feelings etc what we're told our environment context all of that are they are physical processes right like we we we kind of almost disregard those as potential factors but you and i know that's the thing those factors are

Starting point is 00:11:52 huge and that's the problem and i think often where patients don't benefit for those patients and also clinicians there's no value any even if i had someone who came to see me who said to me oh i've been told all this stuff like are you sure it's not that that i need to be doing like even then when i think geez you've been told so much shite like none of that even makes sense i'm still not going to tell them that i'm saying oh okay cool well it didn't work because like you as a clinician us as a clinic clinicians like the number one thing that we need to try and do with our patients is build a trusting relationship and rapport for me i feel like that's paramount it's almost like number one if you then start that relationship by slating someone else it makes it

Starting point is 00:12:37 kind of dampens your credibility from my perspective a little bit so even when i'm in my head i'm like crying in my brain and my said my inner monologue is like what in reality i'm just like okay cool let's not work let's try something else and do something like so different they benefit from that better absolutely absolutely let's let's move to scans so so the topic around around labral tears hip labral tears uh i i know a lot of my my patients even in the pelvic health world because again it's all connected labral tears are often blamed for pelvic dysfunction pelvic pain again hip pain etc help us unpack labral tears what are they what happens if you do see it on the scan uh yeah so labral tears i think people are far more aware

Starting point is 00:13:27 of them so the labrum is potentially for those who have hip pain a nociceptive source a painful source within the hip joint there are certain factors that may lead to someone having a labral tear but there's always that ambiguity in regards to well is that the thing that's actually even causing their pain if we kind of like go into first maybe some of the causes that may lead to it then i'll go i'll circle back and reaffirm why even at that point you need to kind of critique can question its relevance even if it is the problem now the labrum doesn't necessarily as a structure just randomly tear if we're talking about young active individual young active adult we're not going to just develop a painful symptomatic labral tear just spontaneously

Starting point is 00:14:12 having not done something there's often a cause and and two of the common causes of that would be FAS FAS syndrome so femoroacetabular impingement syndrome and hip dysplasia two of the probably most like like common causes hip pathologies that would lead to a label set the the complexity around those two things come with their own issues and also they coexist which is a different conversation but nonetheless if you have a hip with either of those two characteristics one would potentially be a shallower socket for those who have hip dysplasia others with let's say a can morphology from FAI syndrome may have an impinging type hip um that could cause a labral tear both of those in different ways can cause that to develop now at that point even if you

Starting point is 00:14:58 then have a patient who has FAI syndrome or dysplasia or a labral tear it then brings up that conversation like I said before the the ambiguity around is that actually the thing that's causing the pain because one people have FAI syndrome or characteristics of it and have no pain people have hip dysplasia and manage well if you look at ballet dancers and elite dancers have a degree of you know laxity or hip dysplasia actually desirable for them and equally those who have labral tears 50 60 percent of us will have it and never know so even when you know and you think you know you still have to question if you really know because that's the difficulty here and unfortunately when you have on paper labral tear let's go and have surgery to operate on it because

Starting point is 00:15:47 it's like black and white it's almost like right screen version of the pelvic tilt right it's like oh this is broken let's go fix it right and they don't get better you're like well actually was it that was it something was it your back was it something else was it like pelvic fluorated was it viscerogenic all these different things really should be the fundamental first thing that you're thinking about and when i'm with my patients i'm and when even when i teach i'm thinking look this is what it could be like trying to refute as much of the other stuff as much as possible and then if you're left with that then you're thinking well it could be that and then you treat as you would do um but unfortunately and it's probably like more um prevalent i'd say nowadays

Starting point is 00:16:28 patients just want a scan because if they get a scan then they know what well you know what the problem is um but it's a difficult conversation and also the it kind of it's almost like more helpful when patients don't have access to some of these scans immediately because they don't have those expectations if you've got private health care then you're like right i want to scan let me go and see whoever because then you can treat it um i'm like no we can treat it without the scan we can manage don't worry we need the scan every time but um you know it's just like the joy of managing patient expectations is never a direct simple road though right oh this so do you find that those who have that scan that that that confirmation that there's a tear there's something

Starting point is 00:17:13 here versus those that don't have the scan like in your clinical experience compare and contrast those those for me who who which one of those actually may perhaps do a little bit better i'm bias here i'm fishing for the answer i'm biased it's interesting it's interesting though because if you've got a patient who has had the scan right yeah and they come to see they're like oh look i've had x-rays mris and i've got this and this often they'll then turn around and say it depends how they've got to you obviously if someone's referred them if they've come under duress which not many people do they kind of want to come and see us but let's say they're in our room um then i turned i said well how are you going to fix my labral tear because the labrum's

Starting point is 00:18:02 torn and you've got a i've got a bony bump because of that my fai syndrome why are you giving me like squats and deadlifts and lunges because like that's not going to help and then you're like well i'm trying to explain that actually we still don't even if the surgery is the right option long term right but this is the stuff that we control this is the stuff that actually may well enable you to physically be a bit more robust physically be a bit more resilient to this to the activity and load that you want to put through the hip and also you may have had this scan result 10 years ago if you scanned it and you would never have known but it's only when you start taking the pictures and you start seeing when actually things inside your body also change

Starting point is 00:18:43 you know i don't always had a white beard you can't see too much on camera but i have got some white beard there right but and you can see that and you can just see that's just as you age and you grow older things change you know people get wrinkles people get gray hairs but they also have changes to their joints and the internal kind of system as well but like until you get that scan um you don't know about it and i'm a big believer right like i'm not against scans i think the problem is like when a scan is then re like like the way it's interpreted the way it's related to a patient so if you're with an individual like yourself or someone who's experienced and you can say look I kind of trust that that's being relayed on in the right manner and the patient's

Starting point is 00:19:24 getting the right information the problem is is when they're told like oh actually you've got FAI syndrome I'd go and have surgery because you'll need a hip replacement if you don't because it will cause it and then you're like well that's we'll pick the bones out of that you know that's the tough one to kind of navigate does that fit your bias is that what you definitely podcast if we're clashing i know i know i know i know it does fit my bias because you're right it's it's not the scan that's the issue it's the narrative around the scan that could be helpful to the individual or harmful to the individual and also their recovery and how they perceive their own body and their own resilience you know that that can really be damaging and at

Starting point is 00:20:09 that point i mean no amount of surgery is going to ever take away that seed that was planted of you you're you're broken you're not enough your body's not fit for purpose and forever having to be afraid to to to even access perhaps the potential that that person might have yeah definitely and i think with with pelvic pain patients and with men's health women's health and with with hip patients in particular I do feel and you know I've not seen just hips my whole career I've seen everything and there is all there is definitely that similar cohort to lower back pain patients but there's that slight increase in prevalence of anxiety catastrophization you know like self-efficacy issues that you'll come across and all of those things when considered

Starting point is 00:20:59 can sometimes be negatively impacted by the wrong management by the wrong person and often if you then just manage it correctly with fairly simple but like directed guidance things can change so yeah it's just yes just the right place at the right time really for some patients with that stuff it is absolutely absolutely another interesting conversation around muscles firing or not firing something that i see prevalent i'm sure you do as well of my glutes just aren't firing or my core is weak or etc or my it you know my it band is too tight can we can we maybe can you share a little bit about your experience with with that and what does the literature really say so we started off with number one on my bugbear list of all that hall of famers now we're

Starting point is 00:21:49 on to number two which is great which is kind of muscles and the thing is whenever i try and kind to dive into this on any kind of social media platform I didn't always get kickback from like anyway it could be clinicians or patients as well and they'll say oh you know that's not what people mean they don't mean that it's not firing I guess like just to kind of clarify the thing that we're talking about here is often my glutes aren't switched on gluteal amnesia which was coined by you know some name job or someone you know so historically he's got like a reputation of back pain and try to associate those two which we know is flawed completely and then also things like muscle um tightness or you know like you said with the it band as well now ultimately there are

Starting point is 00:22:36 going to be patients in instances where someone will have under activity you know if you have someone who's had hip surgery as an example there are going to be muscles that aren't working as well that's just part and parcel of it you're also going to have individuals who from a sporting environment might not be utilizing movement patterns in the right way but nonetheless it's still the muscles aren't inactive I think it's really kind of a difficult scenario to be discussing something that is inactive or um underactive or sorry or with amnesia or whatever you want to call it um but unfortunately when you start trying to fix that narrative then it's like oh it's just semantics they don't mean that actually it's just the case of that they mean it's a bit under it

Starting point is 00:23:20 that's the different story though you know things must muscles can't be switched off right unless you're dead or like if you're have some degree of paralysis which happens but that's such a different level of like insight it's a complete different pathological course of those things you know if you have any kind of neurological cause that drives it then yeah then you're dealing with something that's really is probably not like firing and you have that ability to kind of address that but from a musculoskeletal perspective when you're assessing somebody especially those who have hip pain we often give exercises strengthening exercises in particular makes the forefront of most of our kind of management tools and then the question is well

Starting point is 00:24:02 like when we do that why are we doing that because the patient isn't in pain because their muscles are weak you know the patient is it doesn't have more pain because they're weak but then why are we giving them exercises because they're coming to see us because they're in pain right no one no one no one no one walks through our door and goes man look i really need your help my gastrocnemius is really weak like no one says that right like no one does that like oh my my adductor longus is like super weak can you help me out like they're just coming there like oh it's it's my hip hurts or my achilles hurts and then we're trying to navigate like how to manage that so there are links though when we look into the evidence if you have someone who has adductor related pain

Starting point is 00:24:43 and they have a tendinopathy for example always recovering from a tear then we know that actually that there is a risk factor of having a a weaker adductor group or an asymmetry from adductor to abdominals can predispose to an adductor injury so you're like okay we'll test we'll do kind of physical tests wherever that might be handheld testing or whatever and you get some data and then you try and treat the data that you're given to try and improve the symptoms by looking at the whole picture of that patient in that respect then you're giving exercises to strengthen specifically on the test that you've done but then by saying oh you've just got back pain or hip pain because your glutes are switched up when you really you've not tested it other than

Starting point is 00:25:24 push against my hand you're like well that's not really going to tell me anything other than the fact that you can just push against gravity and my hand i can't really measure that you know that's Oxford scale measurement and stuff that you get taught is fairly fairly redundant low level stuff so from that respect I kind of like it frustrates me I kind of get sometimes how people try to use that information when sharing kind of stuff online or whatever it might be or to patients but it's so dated you know and all like we even know now you know like I think going back you know years we used to kind of hammer like transverse abdominal like and that's still thing in pelvic floor and that's the whole thing in pelvic yeah none of it goes right it doesn't

Starting point is 00:26:07 matter how much you bend don't bend your back when you're picking things up you think like how much more can we like yeah we're moving away from it but then it's still like there yeah it's quite frustrating so um i think often for patients they don't they don't care i mean often patients don't care about much of this stuff it's just about like when they're trying to navigate it and look up information or listen to things um for every one podcast you and i do there's going to be 15 podcasts or 20 podcasts of someone saying the opposite and unfortunately sometimes it's whoever shouts loudest gets heard and then they kind of attribute that to well they may be there talking the most sense but that's not always the case you know you're opening a can of worms

Starting point is 00:26:49 i know i am i i have been looking forward to this conversation for a very long time because like you I also have my own inner monologue that goes on when I when I when I see such misinformation, just I think it really is a moral injustice. It's health care injustice to have this information circulating without having any fact checking any anyone to vouch for who is released. Are they really using up to date evidence and leaving room for uncertainty? Because a lot of what we're talking about is around is it has to do with uncertainty. Yes, it may, it may, it may not. Every individual is different and every case should be individualized and tailored as you're saying. So, you know, there may be some things that are potentially the cause of that person's hip pain or pelvic pain, but there's also individuals who show, have data or diagnostic tests very similar to someone who's in pain who doesn't have symptoms, right? And that's where the uncertainty. We don't like uncertainty. Nobody likes uncertainty. We want to have the answers. You know, we want to have the answers. I think, you know, as clinicians and also as people, as humans, it's embracing uncertainty, not waving the white flag and saying, OK, well, I'm not going to do anything about this because that's not what we're saying here. we're saying is maybe taking a bit more of a balanced perspective and ultimately a biological

Starting point is 00:28:16 sensible approach that also has some science behind it yes yes times a million basically to everything that you've just said i'll echo that and you're far more articulate than i am which is great but with that kind of stuff and i think often when i talk to clinicians who are younger and more kind of upcoming um there's always that immediate insight into like i have to know what's going i need to kind of say it's a rotator cuff problem i have to say that the problem with the hip is sometimes you kind of have to know there or thereabouts what it is that you're dealing with because like there's a little bit more specificity to it but also like you can never definitively say clinically because even if you suspect pathology x is the problem really you need more of an in-depth

Starting point is 00:29:03 workup when it comes to the hip sometimes it even involves in diagnostic injections to really understand the painful source in some of these issues and not everyone has access to that so by by like you said embracing that ambiguity or uncertainty doesn't demonstrate a lack of understanding actually demonstrates more of an awareness of reality so often when you're trying to teach someone that you're like well it's fine it doesn't mean go to the patient and pretend like you're completely unaware and like just say look actually it could be this it could be that it's not going to change how we manage it but if it's not improving we can then look into it by doing this this and this but unfortunately patients want answers they just want to say

Starting point is 00:29:45 what's the problem what's the label so you kind of have to appease them sometimes but look sometimes sometimes it is needed that's just how you kind of like kind of manage it i think absolutely and to your point about you know what the data shows and exercises i'd like to go back to that as far as talking about function right so so we can strengthen or isolate a particular muscle and do exercises but ultimately I think in my point of view is how do we get back how do we help them get back to the thing that they're they're wanting to get back to whether it's a sport whether it's going up and down the stairs whether it's having sex you know it's how do we get high function right tying it back to the functionality of helping that person move better

Starting point is 00:30:32 in their body with less pain and more confidence really that's the thing though and I think like from from my perspective I think that's always like when I'm talking to individuals or whatever like sometimes that can be overlooked for fear of coming across like you don't know specifically what you should be doing and what I mean by that is when a patient is being told that we're going to do this exercise because if you do it it's almost like that over coaching situation again where you're giving an exercise and you're giving them 100 bits of information because that exercise works muscle x and actually if you do it this way it will kind of do this that never patients don't give a shit they're just like i just don't want to have pain you know

Starting point is 00:31:16 they don't care that like the adductor has multiple functions exactly so when we're giving them stuff to do though like it's almost like like you said you've got a group of like tasks that you want to get back to whether it's sport or not and then our job is to try and kind of we've got this goal here we're here and we're trying to think well how can i get to that how can i bridge that gap with clinical reasoning of the exercises and treatment you know it's not you know i know people do manual therapy and stuff so let's say clinical reasoning of the treatments that you're doing with this goal in mind and then also the understanding well look sometimes it's going to be a bit like this as well it's never going to be a direct like linear like improvement

Starting point is 00:31:56 so trying to kind of like get from one point to the other by doing those things is um is a tricky thing really but you just need to kind of like reason it whereas sometimes where the downfall is when individuals are like well we're going to do your adductors because we do this or like and it just complicates matters further often if you have an athlete sometimes that's needed like if athletes like i need to get back to sprinting and last time i you know i mastered injury was when kicking or sprinting or change of direction and you kind of have to manipulate that variable a bit more specifically but if it's just general population and they're like i want to go to crossfit i want to go to pilates yoga and you just want to get them back to that point they don't

Starting point is 00:32:39 necessarily need to know your clinical reason you need to know what you're doing but you don't need to go crazy about telling them what it is because they don't care and unfortunately when you start going mad with it and then you see that look right when they glaze over right right oh did you not hear about this article about like how if you load up your like blah blah blah and they're like wow and you in your head you're like oh i know so much but in reality they're like thinking about what they have for dinner just tell me what i need to do so i can go on you're boring me go away you're boring me no that's fair exactly it's true though and i think that's where patients obviously like often benefit and it's um it's

Starting point is 00:33:21 interesting so i'll give you an example like sometimes i'll have with my private caseload i'll have patients who have had hip issues for years like two three four five years and have done tons of stuff often i'm like bottom of the pile but it's just because they've only probably just found out about me and i want an appointment so by that point i've seen tons of people there are so many instances where people immediately get what I say immediately in the following months improve quite quickly having had it for so long having just done the most simple stuff like and they're so surprised that I get patients because I sometimes will give a patient four exercises and they've just done they've had like millions of stuff and I'm like

Starting point is 00:34:03 you've got four exercises but I want you to as a circuit I want it to be time these are the reps I want you to do these amount of reps and sets per week that I want you to do I don't need to see you for six weeks and all of a sudden they're like okay this is a bit worrying now because I've been going back in and out every day every week to the chiropractor whatever like for ages now you give me only four exercises for six weeks I'm like yeah but like also you are a biological human like you know there's only so much that you can speed up these adaptation and changes we can't do everything at the same time and if you give if I give someone like five well seven eight nine exercises it's boring it takes too long they're not going to stay

Starting point is 00:34:43 compliant to it it takes up too much time and you're never going to be able to get as much out of all of those things whereas if you from my experience if I give them four make it fairly tough and intense clinically reason those four I know that if I talk to you in four five or six weeks you've done maybe 18 20 24 blocks of that exercise I don't have any reps and sets you've done and I know that actually we've done enough then I can move on to the next bit and that shocks people sometimes because then they're like oh that's not enough like surely I need to be doing more or like is it enough but I'm like look that's just if you're doing the simple stuff and I tell them I said look if you do the right things at the right time for the right amount you'll see an

Starting point is 00:35:23 improvement I don't want you to come back having had it for five years I don't want you to come back in four weeks and expect it to have gone if you're doing great please leave me a google review i'd love to please come back it'd be great but like if you come back in four weeks and say it's not as bad we're winning that's right if you're if you have if i give you a million more and i'll give you a thousand thousand dollars see i've like put it in the right thing i was gonna say pounds a hundred dollars and i say go and invest in some shares you're not gonna look at that and think oh i just want it to go like this linear direct increase you'll think oh it's gone up a bit it's gone down a bit but it's going up over a period of six months your quids in and

Starting point is 00:36:07 rehab is similar to that so if you're getting better slowly then you're probably doing it right and if you're having a bit of a setback but the grand scheme is an improvement you're probably doing it right yeah yeah but if you but if it's going backwards it's quite clearly you're doing it wrong but then even at that point it's like how long has it gone on wrong for because like i said if you're having these little dips that's not a regression that's just part of it that's just about saying well look how can we manipulate the variables to then continue on that right trajectory but if you're then if it's like the trend is like negative negative negative negative then we've got a problem we need to do something different yeah yeah no that totally makes sense

Starting point is 00:36:48 and that that's very wise advice as far as skillful recovery you know and understanding that adapt adaptation does happen but it does happen over time and like you said with the right with the right uh pacing and like the goldilocks principle of not too much a little you know finding your sweet zone that's so interesting someone i interviewed someone this morning and they said that so um yeah twice i've heard that today but that's true though right it's just kind of again giving patient that that is all about just a patient's self-efficacy to self-manage their awareness their education and so much of that is is is vital really right right and and being open to the trial and error process right if somebody hasn't been doing a particular activity

Starting point is 00:37:29 or exercise in a very long time for whatever you know many reasons obviously pain is one motivating factor for to avoiding things it you're you're you may do too much too soon too quickly that and that happens and we don't freak out about that we learn from that right it's if pain can change in that direction then pain could pain changes that's really just proof that pain does change absolutely absolutely and that's just part of it like it's so complicated right it's just it'd be so much easier if it was just straightforward but it isn't i wish you explain that to the patient then it just it makes it easier and also i just feel like it helps that trust yeah absolutely absolutely oh my gosh so many gems no pun intended because that is

Starting point is 00:38:13 yes i was just waiting on the tip of my tongue um there's one there is one topic because you mentioned the fais femoral acetabular impingement syndrome and hip dysplasia as potential as potential reasons why someone might have hip issues. What is your knowledge around sports hernias or athletic pubalgia? It has several different names in the literature, but those are some of the, I would say, diagnoses that in the pelvic health world we may see, but often underdiagnosed or misdiagnosed or just lacking of knowledge in that area because it it is really you know tied to the pelvis the hip i mean it's a very complex very very and i think part of why um especially in sports medicine and hip and groin cohorts in particular there is much

Starting point is 00:39:20 more of a push towards like more of an umbrella terminology because it's so difficult to specifically identify causes so obviously we've got it's almost like you've got hip inguinal pubic adductor and you kind of like and even that even when you've got something like with the doctor where it's so so more so much more common we know kind of the muscle groups that are more prevalent but even then you're like well there's other things that coexist with that with pubic related pain with inguinal related pain as well it kind of there's that overlap the semantics of that for years was so so confusing because you had sportsman's hernia gilmore's groin inguinal hernia insipid hernia like there was so many things as a clinician that's why often there's

Starting point is 00:40:06 like this real under overwhelming feeling when you get someone who comes in with like that we've kind of we're talking and we're talking like inguinal pubic pain because there is so much around that and even now when we there's more research coming out in regards to that the PLAC like pyromodulus ligament complex like people still are even now finding out more causes that might be attributable to especially those who have persistent groin and um pubic pain whenever whenever i'm seeing a patient whenever i'm teaching there's such and i'm not saying it's just because i'm on this podcast but there is such a uh a missed opportunity to utilize women's health and men's health specialists when it comes to this stuff um one of my go-to questions within

Starting point is 00:40:54 my subjective now that i'm always asking especially for female patients is pregnancy type of pregnancy birth number of births because i know about the risk of prolapse and all those kind of things that might play a role the role of pelvic floor muscles as well but that's not me saying then i'll know the best way to manage it myself you know i know my skill set but then i know actually if there's something else that might be playing a role we need to understand who to signpost to and often those things when i explain it when i'm teaching people are like why are you asking about that because either way consistently if you don't really know much about that it's like oh if you have sij pain i'll ask you about like you know like the generic stuff but actually

Starting point is 00:41:36 there's so much that like i wouldn't even know where to start learning when it comes to like deep pelvic floor stuff that plays such an important role and even in men's health as well where there's an overlap where you know things like things that have caught me off guard you know hyperactivity or pelvic floor muscles you know things that present with like also like accompanying neural um neural type symptoms that masquerade as inguinal or like testicular pain from the hip whatever it might be you think actually there's a lot going on around there so that's why when we're assessing it it's a case of well look systematically let's try and refute is it the hip no is it outside the hip let's try and look into that and there are like

Starting point is 00:42:17 the the doha agreement and the consensus around trying to identify the the cues the subjective and the physical um ways that these would manifest you know the hip joint wouldn't give pain if you cough and sneeze the adductor complex doesn't cause an issue if you do valve salve or a sit-up but might be uncomfortable because an adductor injury could coexist with an inguinal and there's like you know the hip won't potentially could be a bit stiffer but you wouldn't get that with an inguinal or pubic so there's like subjective and physical cues that often which I would refer to as USPs like which is like a unique selling point like in business you'd have a USP like a unique thing characteristic or a pattern of how it would present that if you start to identify those

Starting point is 00:43:00 unique patterns you can start to navigate it but you it's the difficulty is when it's like trying to be specific um and often that's when the imaging can be helpful when you have like kind of trying to figure it out the just another point on top of that i'm trying to kind of give you like i'm trying to talk and say a million things that's in my brain and trying to like articulate and convey it smoothly the other thing as well is often especially in a young active athletic population so many of these different structures when they're problematic will manifest with multiple different entities at the same time so there'll be characteristics of it being in green but they'll have some pubic related issues as well even some adapter pain so it's although

Starting point is 00:43:40 you're trying to like work through it and navigate one to the other they also do overlap as well and that's where like that pubalgia athletic type presentation can be um somewhat overwhelming but then the more that you see the more that you understand um it kind of becomes a little bit more easier to manage right and so what i'm hearing is really that there's multiple different causes that could be contributing to having this these symptoms there's a cluster of symptoms essentially and and they're all unique and individualized as well for for that individual so taking the subjective and you know doing your objective data and testing etc and taking it into the whole picture essentially the same principles that we've been talking about as well for everything else

Starting point is 00:44:24 right and then like you've then got like all the other stuff that you obviously would always want of just like kind of if there's any inflammatory you know inflammatory visceral gyne related issues always if you're talking about someone who has inguinal related issues and you know aren't screening for potential gynecological risk factors or causes familial history all those kind of elements might overlap um so yeah it's just about subjective for me is like the the number one i'd say you can kind of pretty much be on the right track you could solid uh subjective i agree wholeheartedly definitely one last question around this uh pubalgia or athletic pubalgia or what is like what is the term now i mean is there pubic pubic pubic related groin pain i'd

Starting point is 00:45:08 say okay pubic related groin groin pain what does the literature say around surgery because this is a population that often is again like let's let's repair the abdominal wall let's do hip surgery etc etc and and i do have quite a few of individuals that i've worked with who've had several surgeries around this issue yeah what are your thoughts about it's it's a um a lot of it is down to the type of patient i think if you're an elite sports there's no time to waste so whether you're it depends on what level of sport but obviously if you're trying to get back as soon as possible it's it's it's actually more difficult for a clinic clinician like us to manage because they're going to go and see an orthopedic consultant surgeon you know that orthopedic

Starting point is 00:45:56 saying well look this is potentially an issue this or you know may not be but then they're kind of suggesting that equally similar with inguinal as well if there's any potential like hernia that's not evident but still something that's being suggested to our surgery the the evidence is there to show that sometimes surgery can be beneficial the difficulty is making sure that it's the right decision especially I think with inguinal stuff as often people can have surgery and get back and do quite well you know there's quite a kind of there's a lot from a rehab perspective that we can do with pubic related and inguinal to get back post-operatively but it's not something I would I really try and avoid it to be honest I really try and avoid it

Starting point is 00:46:40 as much as possible because there's so much that you can do without it but the problem is like if you're then with an individual who's an elite athlete that's trying to get back to something as quick as possible or even if they're younger and they're worried about risk of time off development and you're like well do we have six months to trial it probably not and then they go down the surgical route and but that's just sports that's just elite sports of how it is um i wouldn't say it's my first port of call sometimes you know sometimes it's needed but yeah certainly for pubic related issues unless there is a a distinct you know we're talking like a rupture or something that needs repair right yeah for sure like stay away from it

Starting point is 00:47:23 especially with things like you know even if it's like a tendon tenotomy or something like that i'd probably avoid it you just because you never know you never never know that's the thing you could kind of go and see the best surgeon in the world you just never know how you're going to respond to it so I would just say kind of like trying to like offset it for as long as possible is for me my personal opinion um but I'm biased if I was a surgeon it would probably be the complete opposite I'd be sitting here saying operate on all of them just surgically repair with a lot but you know it's just kind of experience I guess right exactly exactly oh my goodness so I have one more question for you as far as well not a question but maybe to summarize for our listeners and viewers out

Starting point is 00:48:03 there if your top three takeaways or if there if somebody is struggling with hip pain what are the your top three pieces of advice for them first bit of advice would be go to www.thehipphysio.com shameless plug don't don't you worry we will have that in there that will be the final question i think the thing like i can't see the things i can't see everyone and often like i i think the number one thing would be if you have persistent hip problems find a decent hip specialist physio or sports medicine doctor who deals with it because then you can rest assured that there'll be no bullshit you can be rest assured that what you'll be told is the right thing for that that would be my number one thing my number two thing would be don't be scared to move and exercise

Starting point is 00:48:56 within what your hip allows you to do now there are going to be certain things that people would probably listen to this and say yeah but you're telling me not to do 1990s or not telling me to do clam shells on your page well and then you'll hear saying number two don't be scared to exercise i never say those things to make someone scared i'm just saying if you've got hip pain like do things within reason that makes sense and those things don't make sense for people who have persistent hip pain hence why i say don't do that so i would always suggest um trying to you know focus on that for the third for the third point i'd say and a slightly different thing here for a clinician listening to this because no doubt you've got like patients and clinicians i would

Starting point is 00:49:37 say if you're unsure of how to manage the hip issues because there is so much that's confusing and can be overwhelming don't be scared to admit it don't wing it because unfortunately the patients that don't do as well that persist for so long are often seeing individuals who are like giving advice or exercises or management or whatever that's with good intent like well intended but poorly clinically reasons if you're unsure just learn about it seek support reach out ask questions ask me ask anyone but just like kind of have a different approach to managing it cohesively with other people so then you can get the right outcome for that patient um i also yeah you asked the three you guys three thank you thank you mimet that those are beautiful and now shameless plug

Starting point is 00:50:24 away for our listeners and viewers out there where they can connect with you find you and any other projects on the horizon that you have oh thank you well i um so the social media is my main thing so you can find me on instagram or um twitter so you can just type in the hip physio you'll find me on that my website's thehitphysio.com so I see patients on zoom majority of them are in America coincidentally and and around Europe so I do online consultations um and a lot of my work is teaching so I teach in like do like face-to-face courses and online courses um I don't have any in America but I've got a ton in Europe where I go kind of and do a weekend course and teaching so if there's anyone in America that wants me or Canada wherever like I'll come and do it just

Starting point is 00:51:12 if you host me i'll be there but also if you're a patient and you want to help my website and if you just want some decent advice go on my instagram and see and hopefully i don't you don't get sick of me talking about hips but look you know what to expect there's nothing else on there it's just going to be hips there's not going to be pictures of me like gallivanting around dubai showing you what i had for lunch it's probably going to be not like i'm in dubai having lunch often you know but like just i'm just giving you anyway the hip look in summary susie the hip physio and just you'll find me in summary there you go all right thank you thank you I love it I love it yes and I can vouch I can vouch for I follow you on Instagram and it is really good stuff so if you

Starting point is 00:51:53 do want to gain some quality knowledge and weed out the bullshit please follow him Mehmet again thank you so much for being on the show today for your for your wisdom your playfulness and and yeah much respect to you and the work that you do. Thank you. Thanks for having me. It's gone time to fly by. So it's great. Thank you. Thank you. And to all of our listeners and viewers out there, thanks so much for watching and listening as always and loving wellness for your pelvis. This is Dr. Susie G. Thanks for listening to today's episode. Be sure to visit my website, drsusieg.com for show notes and related resources on today's topic. If you like what you're hearing, head on over to youtube and subscribe to my channel on my youtube channel you'll find

Starting point is 00:52:43 content related to sex pelvic health and expert interviews for men if you got a question or a topic that you'd like me to answer on my channel be sure to type it in the comment box below

In Your Pants with Dr. Susie G - Causes of Hip Pain with "The Hip Physio" Mehmet Gem

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