Other potential causes for PHT pain with Aidan Rich

: today's episode, Other Potential Causes for PHT Pain with Aidan Rich. Welcome to the podcast helping you overcome your proximal hamstring tendinopathy. This podcast is designed to help you understand this condition, learn the most effective evidence-based treatments and of course, bust the widespread misconceptions. My name is Brodie Sharp. I'm online physiotherapist, recreational athlete, creator of the Run Smarter series, and a chronic proximal hamstring tendinopathy battler. Whether you are an athlete or not, this podcast will educate and empower you in taking the right steps to overcome this horrible condition. So let's give you the right knowledge along with practical takeaways in today's lesson. start this episode with an apology. I have just realized that the PhD course that I offer in almost every episode that I've put on when I slap in the ads, the link doesn't work in the show notes. And so I was talking to A listener of the podcast today and she mentioned that the link doesn't work. And so I went back to the links and went back to all the episodes and other links work. And so I have rectified the situation. I have changed all the links in all past episodes and have changed it in this one. So apologies if you have tried to sign up to the course through the show notes. And I can assure you now that everything's in fully functional order. Today we have Aidan Rich. Aidan is a sports and exercise physio. He is currently attending his master's at La Trobe and has ambitions to go on after that and do a PhD, particularly around proximal hamstring tendinopathy. So he's doing a, he wants to do a PhD in PhD and he currently works at Life Care and Advanced Healthcare in Ashburton and Boronia. Today we talked about what we call differential diagnosis, which in the physio realm is like, is there something else that it could be? And when it comes to PHT, there are a few diagnoses around that sort of area that might masquerade as PHT. And so I thought I'd do an episode on it. And Aidan was a great guy to have on. So we dive into exactly that. We'd look at our Psyduck nerve, we look at some sort of impingement, some muscle tears, other fractures or referral patterns that could be going on. what are some tests that physios might do. And we also delve into things like scans and how there might be some false positives around that. So we really enlighten a few things. When it comes to a diagnosis, anything else it could be, why you probably should get it checked out if certain things are happening, if you're not responding to traditional treatment. And yeah, it was a good discussion. Hopefully we have simplified it enough that anyone can understand without having a medical background. It is quite a tough topic or tough content to try and communicate through audio, especially when it's quite highly technical and quite physio jargon. But we tried our best. Hopefully you still enjoy and get a lot of takeaways out of it. Aidan is also recruiting a few people with PhD for his La Trobe study that he's currently doing and we'll have another one in the future. And so you'll talk about that at the end. And if you're interested, if you're in the Melbourne area, then we'd love to have you participate. So I'll leave all the links in the show notes, especially links to Aidan if you want to reach out and see if you're interested. And that's all the things I have to say. So let's dive into the interview with Aidan Rich. Welcome to the podcast. How are you today? Hey Brody, I'm really good. Thanks for having me on your podcast. You're very welcome. I'm happy to have you on because we're gonna dive into all things, differential diagnosis and I will... mentioned to you as well, most of the listeners for this podcast won't have like a health professional background. They'll mainly be like weekend warriors or athletes of some sort. So we might have to try and keep it quite brief or simplify a few things if we get too technical with our, um, with our physio language, but yeah, talking about all things, differential diagnosis or what else proximal hamstring tendinopathy might be, uh, and what some characteristics might be for each condition. Um, so. I've got a couple, a list of a few things here, particularly from Tom Goom's paper that I mentioned in a past episode. He tend to mention a lot of other issues that might be going on kind of masquerade as a proximal hamstring tendinopathy. So the first one I kind of wanted to talk about was some involvement of a sciatic nerve irritation. Could you maybe just dive into that and talk about like how it might represent what symptoms might be? to think that it might be more of a sciatic nerve involvement rather than a classic proximal hamstring tendinopathy? Sure, sure. I guess the first thing to mention with the sciatic nerve involvements is they're relatively rare. So you won't see a lot of them, but it's certainly an entity that can cause lower buttock pain. And I guess lower buttock pain's the main presenting feature we see with proximal hamstring tendinopathy. So it can be challenging and a term that was really popular in the nineties and in the next decade or so afterwards was piriformis syndrome and there was this kind of theory that some people would have an entrapment or a compression of their sciatic nerves as it passed through the piriformis muscle which is one of the muscles at the back of your hip and your buttock. It's probably a lot less common than what we thought that long ago but something that certainly does exist and there's other locations to where the sciatic nerve can get caught or compressed or irritated and we know if you compress irritated nerve it can can cause pain as well. So that's the background there. So in terms of how we diagnose it, scans or imaging can actually be quite helpful when we're looking at sciatic nerve irritation. So normally an MRI is the scan of choice, at least here in Australia. And what you'll see on the scan is some fluid that sits around the sciatic nerve, often very close to where the proximal hamstring tendon is on the maybe a centimeter or two centimeters away, which can, I guess it shows why it can be difficult to diagnose. Also, you can sometimes see, again, it's quite unusual, but you can see in some situations where the part of the sciatic nerve or the entire of the sciatic nerve passes through a muscle and you'll see some edema or some fluid where that edema, so you see some edema or fluid where that nerve passes through the muscle. It doesn't always have to be piriformis, but that's a common cause in terms of entrapments. it's challenging in the clinic. It's very challenging. So we do what are called neurodynamic tests. And one of those tests is called a straight leg raise, which is basically a length test or a stretching test for the sciatic nerve. And we can modify that by doing some different things to change the length of the sciatic nerve, like bending your foot up and down or bending your head up and down. And if those tests are positive, as in they reproduce the patient's pain, it makes us think there may be a nerve or a sciatic nerve or a neural involvement. Okay. The tricky thing is those tests can also be painful with proximal hamstring tendinopathy by itself. So it's not always a black and white situation. Is there any presentation or characteristics or location of the pain if someone comes into your clinic where you're starting to suspect, okay, this might be more of a sciatic nerve involvement rather than a proximal hamstring tendinopathy before you do tests, just not. building up an accurate diagnosis, but something you might lean towards suggesting that it might be something to do with the sciatic nerve? Yep, that's a very good point. So we talk about pain mapping or getting the patient to explain where their symptoms are. And more often than not, if it's stock standard proximal hamstring tendinopathy, the location of the pain will be quite localized. We talk about the area of a tennis ball or smaller in the lower buttock at the base of the pelvis there. Here there's a sciatic. nerve involvement, often the pain is more radiating and it can radiate down into the back of the thigh and even below the thigh into the calf or foot. Um, but pain is a bit more diffused or a bit more spread out compared to this localized pain location that we see with proximal hamstring tendinopathy. Yeah. Which would make sense based on what you're saying before. If the, the nerve is involved, sometimes the symptoms might travel to where that nerve travels to. And we do know that with a tendon, if a tendon does get irritated, When it's really irritable, sometimes it becomes become a little bit more widespread, but doesn't usually get larger than like you said, that tennis ball size location around the buttock area. Okay, so that makes a whole lot of sense. And then you said you might do some nerve tests in the clinic just to test out the ability, the durability, the length of that nerve. And if that triggers pain, especially if it triggers pain like down the leg and would reproduce their normal leg symptoms, then you might start to suspect that the psych nerves involved, whereas potentially if you do that stretch test, and the symptoms are coming quite localized to that area, that might be a false positive, that still might be an irritable tendon if you stretch it. Yeah, yeah, I think with proximal hamstring in particular, that the tendons often saw when you stretch it, as people with this conditional know, if they do a hamstring stretch often that brings on the symptoms, but doing things that lengthen the nerve, which is a little bit difficult to explain with, with audio only, I guess, but you can lengthen the sciatic nerve by moving your foot up and down or by, uh, um, moving your head up and down in some situations and those tests shouldn't increase pain if it's coming from the tendon, but I can often increase pain if it's coming from the nerve. Yeah. And I guess that's what the physios or health professionals are really good at doing, trying to do certain tests that would bias one thing compared to the other and then combine a whole gambit of tests, layer one on top of the other to sort of hone in on more of an accurate diagnosis. Yeah. It's, it's a look, it's a challenging addition to diagnosis or can be a challenging addition to diagnose, as you know, and the tricky thing with, with PHT is there's no definitive gold standard diagnosis unit. You might think, you know, someone falls over and break their arm. That the way to diagnose the fracture is to get an X-ray or sometimes a CC scan, but with proximal hamstring tendon, you can. you can do an MRI scan, it may show some changes, but we know somewhere around 60% of the population has changed anyway, even if they don't have pains, you've got to be careful interpreting change on MRI, because they don't always tell you the answer. The next one I wanted to talk about was ischiofemoral impingement, and we could probably explain a bit more layman's terms, what that actually is. And it- wasn't probably a common diagnosis that I was used to when I was working in clinics. It seems to go under the radar for a lot of health professionals. But I'm curious to know your answer, like exactly what's going on and how does that represent compared to PhD? Sure, again, it's one of those ones that's relatively uncommon, also relatively new that's been the century for hip impingement. The more common hip impingement many people will have heard of is FAI or femuro. acetabular impingement and something that probably 30 or 40% of the population have. But again, the term didn't exist until about 2003. I think it was there was a Swiss surgeon who started describing that impingement term. So ischiofemoral impingement is a different term. It's where the femur or the thigh bone can compress against the ischium, which is the sit bone more or less. And there's only a small space in there and it varies in different people. And there's a muscle in there, one of the lower buttock muscles called... quadratus femoris and that muscle can get compressed. And there's probably some other pain generating structure in that area that can get compressed. And if you compress that area, it can present as lower buttock pain. So it's another differential cause of lower buttock pain, but again, relatively uncommon compared to PHT. So you've got two bones, one being the sitting bone, which is where most people would experience their PHT, cause that's exactly where the tendon attaches. But then you've got this other bone, the thigh bone that can kind of squeeze those two bones together and everything that's involved in between those two bones can get irritated. So the psych nerve maybe being one of them and a couple of other muscles. Exactly right, exactly right. So the location physically is only a couple of centimeters away, so it can be quite hard to kind of, with a pain mapping, I guess that concept we talked about before, the pain location with ischiofemoral impingement can be very, very similar to the pain location that you see in PHT. And then just based on the nature of What's happening there, I think, yes, the location might be quite similar, but the ability to produce pain might be extremely different because the PhD would just be what we do is just load the tendon and that just gets worse and worse. Whereas if this is an impingement issue, maybe we just put someone in a position that squeezes those two bones together. And if that produces pain without loading the tendon at all, then if pain is created, then you might start to suspect it might be this impingement rather than PhD. Exactly right. It's a very good way of explaining it. position of impingement, pre-ceo-femoral impingement, we think is hip extension. Hip extension is when you bring your thigh bone back behind your body, if that makes sense. So the opposite movement to doing a kick is when your leg goes behind you instead. So in the clinic, we test that and we condition a few different ways, but either with a participant or the patient lying on their side and taking their hip back into extension. The other one that's been the other test that's been talked about, it's a bit of a funny test called long stride walking test. And basically you get the person with buttock pain to walk with very, very long steps. And in that last little bit of the walking movement before their foot comes off the grounds, if they get pain in that part of the walking cycle there, it makes us think more of ischiofemoral impingement. And you've got to be able to tease it apart. If the pain happens with their foot added in front of their body, that's more likely to be a PHT because using your hamstring there. But if the symptoms happen at the back part where your legs get behind your body, that's more likely to represent issue ephemeral impingement. I might get a little bit clear on this one because if someone is doing hip extension, let's just say if they're walking or they're running, a lot of times the hamstring tendon might grab as soon as that foot leaves the ground when the foot is like, when the leg is straight and the legs behind them. Um, because I know some swimmers or I know just some people with PhD, if they want to lie on their stomach and keep their leg completely straight and lift that up off the ground towards the ceiling. Um, they can get a bit of a grab in the hamstring tendon there, but, um, some of the tests that you were suggesting is quite passive. So the, the body itself is staying completely relaxed and the therapist is actually moving their leg up into that hip extension, um, in some of those tests. And if there's pain there, then there's no work to be done with the tendon at all. And so if pain's produced, then that's most likely to be this impingement. Yeah, it's a very good point. I think the passive tests are probably more likely to elicit the impingement signs. There's not much out there in the literature about the best way to diagnose ischiofemoral impingement. So they're the two tests we're using for one of the research trials that we've got going on. that makes a lot of sense. It can reduce the active component or the contraction component of the hamstring tendon. It's less likely to elicit symptoms from the hamstring tendon. Yeah. Or someone, if they want to do it at home, I don't recommend trying to self-diagnose you, but if someone was to just walk around at home and do those long strides, probably try and hone in on, okay, does the pain come on when, just before my leg leaves the ground, so that the tendon is quite in a passive kind of state? Or is it just as my leg lifts off the ground? Because if it just lifts off and you feel that grab, that's probably when the tendon will most likely activate. So if the pain's coming on before the leg leaves the ground, then there might be some sort of impingement going on. Yeah, the other way of doing it, which we don't use regularly, the other way of doing it might be to do a hip flexor stretch or the standard kind of kneeling hip flexor stretch. Oh yeah, that's a good one. The back leg would be the leg we're looking at in this situation. So that's a passive test. in a similar position to the long stride walking test or the long stride walking. And that could be used for differential diagnosis as well. Yeah, perfect example. This podcast is sponsored by the Run Smarter series. If you want to take your knowledge building to the next level, I have built out a proximal hamstring tendinopathy video course, which complements the podcast perfectly. Sometimes it's tough delivering concepts and exercises through an audio format. So the course brings a visual component full of rehab exercise examples graphs and visual displays to enhance your understanding. Even if you sign up now, you'll have access to all current and future modules that I create. Sign up through my link in the show notes, then download the Run Smarter app, and you'll instantly have unlimited access to all the course resources on any device. And to say thanks for being a podcast listener, I want to give you a VIP offer. There will be a link in the show notes in every episode that will provide you 50% off the course price. just click on the link and it will automatically apply your 50% discount. The next one I have written down here is a deep gluteal muscle tear. I'm not entirely sure how often that would happen, but could you maybe just delve a little bit further into that? Again, I think it's a relatively uncommon cause and one that we probably don't pick up very often in the, in the rooms, because a lot of these muscles are very, very small. And sometimes there's no history of those being injured. If you injure a hamster normally there's a story behind isn't it? You know I was sprinting and I felt something go or you were to injure your calf you were running or walking up a hill and you felt something go but often with these small gluteal muscles you don't have that history so much and often just the athlete pulls up fatigued or sore or disabled after a run or after a match in soccer or football for example. You can do tests to to look at these muscles in the rooms, but the tests are not, especially with these small muscles, they're not super duper accurate. And the palpation, in terms of pushing on the muscle, can be quite challenging there, because there's lots of different structures in that area that can generate pain. The good thing is with a deep blue seal muscle, to most of them will settle down quite quickly. So, you know, maybe one of those things where, you know, you treat us, but you don't have a 100% accurate diagnosis, but they get better anyway over that next week or so. Yeah. And I think it's worth mentioning to the listeners as well, that around the hip, around the glute area, there are a lot of little fine muscles that can be subject to strains and I guess tears. Um, but if a physio starts doing all these tests, trying to hone in on, if it is PhD, it just won't fit the pattern. Will it? There'll, there'll be a couple of tests that it just won't fit into a nice categorized pattern of it being PhD. They'll just be like, Um, pain doing other tests and pain, like maybe just standing on that, that single leg stance, trying to hold that support or things that just won't fit. And that's when you can maybe start to suspect another diagnosis, like a muscle tear around that, the hip region, because it can be, if it is deep gluteal pain, the location can be very similar to PhD, but all those strength tests, like you mentioned, just might be a little bit off. Yeah, I agree. The diagnosis, as you kind of pointed out, is often made with a detailed history taking or subjective exam. And then there's kind of a barrage, a variety of objective tests or clinical tests that we look at. And then you form a often form a best fit diagnosis after that. And sometimes when I'm talking about those differential diagnosis things, I remember the outcomes raising, you know, common things happen commonly. So you're more likely to see. if it's a runner with gradual onset of lower but it's more likely to be a PHT than one of these obscure diagnoses. But if they don't improve with a period of treatment as you would treat for PHT, you start saying, gee, am I missing something here? Am I missing one of the unusual diagnoses? And that's often when you can pick up these ones. Yeah. And I think another way of, oh, well, another reason to maybe suggest another diagnosis, if you're not responding to a classic treatment of what say, PhD might be, which we know from previous episodes, what that actually entails. But if you're just not responding, if it's getting worse, or, um, if it's just not fitting, maybe we need to suggest other diagnoses might be at play. But I'm glad that you're clarifying this every single time. These are very rare. And I know a lot of people will listen to this and be like, that's me. I have that just. I think it does require first of all, a professional assessment to get it professionally diagnosed instead of self-diagnosing, but these are very rare. And speaking of the next one that I have down here is somewhere to do with like a stress fracture around the hip. So there can be stress fracture around the sitting bone or around the say the hips, that sort of thing. How might that present differently to a classic PhD? So I've seen a few of these actually. So I treat quite a lot of runners and quite a lot of distance runners. And this is really a distance runners injury, almost without exception and much more often a female distance runners injury. So that's normally the background. If you have a distance runner coming to the clinic and starts to describe pain in this location, lower buttock pain, you start thinking, you know, could it be an unusual? stress reaction. Normally it's, they come in with a limp. That's one of the differentiating factors from pH too, which can cause a limp, but it's much less severe, normally much less common, but they have a limp. They often have a lot of pain at rest, you know, cause you've got a stress reaction or a stress fracture in the bone. They've often got a history of quite high mileage running. So high volume running. And then the other thing you need to look at is signs of. energy deficiencies. The old term was that the female athlete tried. Now the term is reds or RADS, which is relative energy deficiency in sports. So features of, you know, weight loss or rapid weight loss or in females, amenorrhea or absence of, if those kind of features come up in the history, you start thinking more of a bony kind of injury. And I think you say, not often would a PhD person limp into a clinic and I think just doing some loading tests, what I do, if I suspect a tendon issue is I'll do a gradual loading test, like a gamut of tests where the loading requirements that tend to becomes harder and harder and harder. And usually the pain levels will match that level. So if you're doing something quite low, like a double leg bridge, pain comes on a little bit. If you do like an arabesque pain comes on a little bit more. If you were to do like a deadlift with weights, it will get higher. Like the more demand you ask of that tendon, the greater the pain response should be. Whereas I think this might be a little bit different if someone's just doing something, depending on the level of reaction, something doing quite low levels can spark quite a high level of pain. If the stress rate, the bony stress reaction is quite irritable and quite high. But yeah, night pain was another one that sort of vague, remitting sort of pain at night is And like you said, pain at rest can be quite common with stress fractures or bony stress reactions and usually with a tendon. As long as it's not really irritable. If you rest the tendon, it settles down. If you're lying in bed or if you're just like, yeah, lying on the couch watching TV, it can be quite settled. So a few things to point out there, which is really nice. And is there anything else, any other tests that we might do? Any other maybe scans that we might get if we're suspecting bony stress? Yeah, just one more point on that. I guess that the palpation can be very valuable with these. And normally you'll have a push on the proximal hamstring tendon and see if that's tender. And then we're just not, you know, a guaranteed test by itself. If you go a few centimeters higher, you saw over the actual bone itself. And that's quite exquisite tenderness. When you're pushing the bone itself, you start thinking, gee, is there something funny going on with the bone here? Like a stress reaction or a stress fracture. So scans, yeah. So X-ray. is not that often used in these. You'll rarely see any change on x-ray unless the bony injury's been there for about three weeks. Because after about three weeks, you start to see some new bony formation or some kind of sclerosis, thickening of the bone or scarring of the bone on x-ray. I've seen a couple on x-rays, it's not unheard of. But MRIs, at least in Australia, is the scan of choice, easily available here in Australia. The cost is not outrageous. No radiation, no ionizing radiation. But it will also be seen on a, you'll see a stress fracture, but not a stress reaction on a CT scan generally. And then the nuclear bone scan is what used to be used a lot more even when I started working about 15 years ago, cause it was more easily available. A nuclear bone scan will generally be hostile, will show increased bony uptake in the presence of a stress reaction or a stress fracture. Yeah. But MRI is the scan of choice normally. I do know that stress fractures are often misdiagnosed for a long time before they're eventually picked up. And so I think, yeah, just going off what you're saying, if someone has a history of very long mileage and also has a history of say that those red S symptoms, poor nutrition for quite a while, um, weight loss, um, if they're just really skinny, um, that can sometimes produce a well, sometimes be a category to start at least maybe getting it scanned and then seeing it. Because we want to pick up on these stress fractures quite early. If there is one instead of, you know, months down the track of trying to rehab something and then picking it up later, it's very hard to manage the later it's picked up. The next one I have on our list is a partial or complete rupture of the proximal hamstring tendon. And so not necessarily talking about a reaction of the tendon like PHT usually is, but in fact the attachment onto the bone has produced some sort of tear. How can we differentiate the two and does management like this management different? Does it matter if there's a rupture compared to a tendon reaction? Yeah, good one. So the, um, the, the main point with these proximal or complete ruptures is there was a moment in time that the person with this problem will be able to say exactly what had happened at two 30 on Saturday, I was out walking the dog and I slipped in, I felt something go, you know, it's quite a dramatic story. Whereas, whereas with PhD it's, um, It's often it's generally more gradual onset of lower buttock pain. Um, but so yeah, so there's a moment in time and often they kind of, they're slips or kind of forced stretches or it's a common water skiing injury. Actually we see a few with water skiing where they're got these big long leavers on their feet and they're in this thick water and then their arms get pulled forward and have this kind of over-stretching, uh, where they're also trying to contract the hamstrings and see themselves. So you see a bit with water skiing. I've got two at the moment. If I've got that partial tears, one was there. walking a dog and slip. And the other one was actually at boogie boarding at the beach and went to push off and jump over a wave and felt something going, he's up a hamstring. So they both had partial ruptures of the tendon on MRIs. It seems like it'd be quite hard to rupture a healthy tendon. Like it's either, like in my eyes, it might be a movement that's quite violent that actually has a rupture. or it might be something that's not as violent, but the tendon itself, maybe they're very deconditioned or maybe the tendons undergone some sort of pathology in the past anyway. Have you seen a link there? What do you, can you shine some light on that? Yeah, so most of the ones that have this injury when you MRI and they've got significant degenerative change in the tendon already, but most of them have no real history of pain there. And you always reflect back to what do we know about other tendons? I think with Achilles, which is where the... majority of the researchers being we know the people who rupture their Achilles about two thirds of those people have no history of pain. They rupture their Achilles on a Saturday and you say you ever had pain your Achilles before and they say never not one day ever. But if you look at their tendons in surgery when they're having a repair or an MRI when you're doing a scan or an ultrasound, there'll often be significant tendinopathy or degenerative change in the tendon. So we don't have that data for hamstring yet only anecdotal data. So I've got two anecdotes there, I guess, but there's not much published on that for hamstring. Obviously there's the ones where there's exceptional, exceptional force and you can probably rupture a relatively healthy tendon, but that's not really proven, but most of them probably have significant tendinopathy. And then sometimes it's, you know, regionally innocuous. I saw one two years ago who was playing table tennis and just, you know, lunged to a backhand or something and he had a complete rupture of his hamstring tendon. Okay. Yeah. Quite strange, but I'd say that that'd be relatively rare. Um, I think it was, I think I listened to Jill cook who's a famous like tendon researcher. I think she mentioned a few years ago that no tendon could or should rupture unless there's some sort of pathology in that tendon anyway. And like you said, there's like, it could just be totally pain free, but there's some degenerative portions of that tendons is very, very hard to rupture a tendon. Yeah, it's probably the opposite of what you think in a way, isn't it? Especially when you look back at an Achilles, you think for an Achilles to be sore, a bit worse, a bit worse, a bit worse, and then pop and suddenly erupt. But it's the opposite often. It's nothing, and pops. So the way Jill explains it, she's one of my research, the way Jill explains it is that pain is protective, you know, it sends a message to your brain to offload the tendon and makes you use it less. And if you use it less, you know, for powerful explosive things, you're not likely to ruptured, but I think it was some of the Scandinavian research that showed that I think it was 90% of, of Achilles ruptures had significant tendinopathy before they ruptured here. Yeah. Good to know. Um, the other topic that I have written down here, which, um, wasn't in that Tom Goon paper, but you suggested, which I loved was the referral from the sacro iliac joint, so that the joint around the sacrum at the back, um, and other referrals like from the lower back or from the hip. And so it'd be really nice to dive into that. So let's start with the sacroiliac joint. Is it common like to be referred from these other areas and to kind of masquerade as a proximal hamstring tendon issue? I'll just make one more point on the complete rupture actually before I move on. If it's okay, just one thing you say with these complete ruptures is often there's dramatic, dramatic kind of bruising and the whole back of the thigh can turn black with bruising over the next few days after. That's one of the things you see in the clinic. Good point. It normally stands out. But on to sacroiliac joint. Yeah. So your sacroiliac joint is where your sacrum, so kind of your tailbone or just above your tailbone meets your pelvis. And it's a pretty stiff joint. It doesn't move a lot, probably a couple of millimeters, and it gets a bit stiffer over your lifespan. And there's things inside the joint that can cause pain and things outside the joint like ligaments that can cause pain. And it's a very common pain generator in pregnancy, actually often women who are pregnant would develop this kind of buttock pain and a bit of a waddle. And that's normally from the sacroiliac joint. So it's not as commonly seen as lower buttock pain, but it certainly can be. Not more often, it's more kind of vague, can't quite. put your finger on it kind of fleshy buttock pain they call it, but it can refer to a few other locations as well. There's a variety of tests that we can use to examine the sacroiliac joint. The five of the more common ones are called Laslet's test. He's a, I think he was in New Zealand, New Zealand physio. He had a group of tests that he used to diagnose sacroiliac joint pain. I think it depends on which test you use, if two or three of them are positive and they reproduce the symptoms, these tests it starts. starts making you think it's more likely to be coming from the sacroiliac joint. The other tests we can do in the clinic are sometimes you can compress the joint with often called maternity belts or sacroiliac joint belts often compressing the joint can clearly improve the symptoms particularly in that kind of pregnant prenatal post or even postnatal kind of situation. So that's what we see for sacroiliac joint and then in terms of what makes, makes a sacroiliac joint kind of issues worse. It can cross over a little bit with PHT, you know, running can make them worse. Going upstairs can make them worse. Sitting can sometimes make them worse. But the main thing that you'll see, you'll hear when you're having a talk with them is that it's more vague kind of buttock pain and a bit more widespread than this kind of localized lower buttock pain than we see with PHT. Yeah. It seems like the, what the person might experience Uh, can be quite similar to PhD, but some tests can easily differentiate the two because if you do some tests for this joint, um, and it produces pain, we're doing nothing, we're not doing anything to the proximal hamstring tendon. We're not loading it up. We're not stretching or doing anything. And if it produces pain, then, um, it's. Very unlikely to be a PhD. Uh, would the same thing be said for the back? If it's, if, if you've got a, um, if the pain is referring from the back. could we just do some back movements or some back tests and see if that produces pain? Yeah, absolutely. So this kind of, you can break referred back pain into two main categories, I guess. The first one is they call it somatic pain. So it's referred from joints in the back, like facet joints. And there's a variety of tests you can look at for facet joints, basically when you compress them. So if you're suspicious of a right-sided facet joint problem, you can get the person to lean to their right-hand side or lean backwards. will compress the facet joint. And if that brings on buttock pain, it starts making you think, gee, is the buttock pain coming from the back? And the other thing you can do is push on the joint. You know, if you push on the facet joint and go, gee, that's sore and it's reproducing my buttock pain. It's something that makes you think it is a facet joint. Referral there. So that's kind of category one. So somatic or facet joint pain, I guess. And the second category, we kind of covered off a bit before with this sciatic nerve irritation, but you can certainly have sciatic nerve irritation coming from your. low back and that's kind of generally known as a disc protrusion or disc extrusion, sometimes a disc protrusion where some of the nucleus, the central part of the disc is pushing out at the back of the disc and touching one of the spinal nerve roots that forms your sciatic nerve and runs down the back of your thigh and that can cause lower buttock pain or deep buttock pain. But it normally causes nerve type pain, you know, burning. sometimes pins and needles tingling and often symptoms further down the leg as well, as opposed to just isolated buttock pain, often it's more widespread symptoms, but not to be missed certainly, it's not unheard of. I know low back pain is very common amongst like the whole population. And if someone does have a classic proximal hamstring tendon issue, what are the odds they also might have low back pain? to say almost have the two conditions can be like not uncommon. Is there any way to kind of work out if what the two, whether they have the two or whether the pain is actually referred from the back? Yes, you can do a treatment of one or the other. So, you know, if it was a facet joint problem, for example, you can do a treatment and treatment might be mobilization. So mobilizing the joint. We just do a mini treatment for a couple of lots of 20 seconds and then reassessing the hamstring tendon tests. And if the hamstring tendon tests, you know, significantly improved by treating the back, it makes you think, well, maybe it's not hamstring tendon. Maybe it's a referred tendon from the low back. So you might explore the, the back as a cause of symptoms more, you might treat it more aggressively or more, more thoroughly if you've got positive response from a short treatment. Yeah. And I guess if you're doing a test to try and produce pain and you're only doing the back. And that produces pain in the hamstring that might increase the, your confidence in being those only just referred from the back. And sometimes I ask clients, it's not very accurate, but sometimes I ask clients like on a day when your back pain is quite bad, is the hamstring pain also quite bad and if there's a relationship between the two and if they say, yeah, it's, it's only my hamstrings only coming on when I have bad back days, um, it might increase your, um, likelihood of it being referred from the back. Uh, I wouldn't necessarily totally rule it in, but it's still slowly increasing your confidence, whether it's one or the other. Yeah, that's a good point. I think, uh, exploring the relationship between the two symptoms is a very, very important part of the workout. Cool. Glad we agree on that one. The last one was, I guess, hip joint pathology. Like there might be something totally, something going on within the joint itself that masquerades as PhD. Do you want to talk about that a little bit? Yeah, again, relatively unusual for the hip joint to give buttock pain, but it can normally with hip joint problems. So we're talking about hip joint osteoarthritis or a labral tear in the hip or... even ephemeral acetabular impingement or FAI that we spoke very briefly about before, but they normally cause groin pain or they describe it as grass pains, or kind of the front or the outside of the hip rather than deep buttock pain. But there's a few studies showing that when you inject people's hip joint with a noxious stimulus, so something to make them sore, sometimes they'll point to their buttock and they'll point to their deep buttock as the location of pain after you've irritated their hip joint. They're going to a small percentage of population, but if someone's got buttock pain, you need to consider hip joint, particularly if their symptoms are aggravated by things that put load of the hip joint. So twisting movements, like getting in and out of the car or rolling over in bed or those kinds of things. Yeah. Okay. That makes total sense. So we're talking about the SIJ, we're talking about the lower back, we're talking about the hip. There could be pathologies within that can refer into that, the buttock region or around the sitting bones. So Good to know. It seems like there's just some quite simple tests. If once you go to a physio, go to a health professional, they can, um, do some, and it could be like increase their confidence 100%. That could be something else and it's not really PhD, but then sometimes, like we know it's not a perfect world. It can sometimes blur between the two. And like you said, then we treat something and if you respond to it and you respond better to it, then it increases our likelihood. It's actually that diagnosis. Whereas if it's not responding or if it's getting worse, um, when we would expect it to get better, that's when we need to broaden our horizons, potentially look at another diagnosis. Would you agree with that? Yeah, I agree completely. This podcast is also sponsored by the Breakthrough Running Clinic, which is my own online physiotherapy business where I treat clients all over the world. I always recommended that my clients build on their own knowledge and try to manage their symptoms on their own to build self-confidence. However, if you still require a tailored approach and one-on-one guidance, whether you are a runner or not, I'm more than happy to be on your team. You can sign up for one week or one month packages and have me by your side every step of the way through the duration of your package. So head to the Breakthrough Running Clinic link in the show notes to learn more. The other thing that you wanted to talk about was like the false positive rate on imaging. Do you wanna just... dive into that. Oh there's only one study on this but I'm aware it's out of the UK I think and Sydney but basically what they did is they got a large group of people with no buttock pain, no symptoms at all and they did some MRI scans of their hamstring region or their buttock region and they wanted to see how many people in this group have changes in their hamstring tendon and a lot was about 60 or 65 percent and the age range was quite wide here, anywhere between 13 and 88 years old, every day it was 51, but quite a lot of people had thickening of the hamstring tendon. So it just makes a little bit more muddy doesn't it, you think someone's got proximal hamstring tendinopathy, you do a scan the tendon will look different bang there's your diagnosis but what can happen is the tendon can look on health MRI, but can not be causing pain, which is again, something a bit of a funny concept. You think of it stick on, if it's thickened on MRI, you think, gee, it must be causing the symptoms. It's not always causing the symptoms. It's the tricky thing with PHT, there's no guaranteed or gold standard, I guess, of diagnosis. It's a tricky one that a lot of people, they want to, they want to. rely on the images, they want to fixate on the, what the images are found. And it could be really tough once they believe their scans to convince them otherwise. And like you said, so if you scan a whole bunch of healthy people and they're shown to have some sort of tendon thickening, what's the odds of someone actually having proximal hamstring tendinopathy or having something else, say if it's referred to the lower back. And then they scan them and say, Hey, there's pathology going on in this hamstring tendon that could increase your likelihood of it being that. And someone might be convinced otherwise, but like you said, it's a false positive there it's showing that it might be proximal hamstring tendinopathy. When in fact, the pain is not even coming from there. So it's very important that we don't just rely on scans and we actually use it as a bit of evidence, but piece that with all the other bits of evidence, that being like your history, the location, nature of the pain and all the tests that are done by the health professional. Yeah, it's kind of one of the follies of what you've got, these great technologies now with really high quality MRI scans that can show lots and lots of these, have lots and lots of things, but sometimes it can actually muddy the waters and we see it with shoulder problems or knee problems, you might say five or six different things on the MRI report for a shoulder, but teasing at what's causing the symptoms that can be challenging and some similar things around the hip as well. Yeah, and that's where the, health professional actually has to be very mindful of how they communicate the results to a patient as well. And we know, say for lower back pain, we know we have to be very careful of how we interpret symptoms or how we read the scans in front of the patient because it could show degeneration. It could show like the disc degeneration and disc damage and things when we know that's completely normal in most of the population above say the age of 45. And the same could be said for these tendons when we start scanning them. Some people can be very worried, very fearful, very apprehensive once they get the scan, oh, it's gonna show all this damage, it's gonna show these tendon issues. And then it comes back and it actually shows that to be true. It just confirms their beliefs and actually sparks more anxiety when in fact it might be completely unnecessary. Yes, yeah. And at the same time at the opposite end of the spectrum, I guess you don't want to be dismissive of real pathology. If someone comes in with, you know, something that fits with their clinical symptoms, you don't want to say, oh no, don't, some people have this anyway, don't, don't worry too much about it. Cause often it's completely relevant, but yeah, it can be challenging to find the right balance. I agree. Yeah. It's, it's a piece of the evidence. It's not the answer. It's a piece of the evidence that we need to consider and we need to, you know, tiptoe around delicately and not just. Be like, oh, the tests show this, but the scans show this. I'm going to go with what the scan shows. It's, it's just another piece of evidence that goes in with everything else. Let's talk about a couple of the studies you're currently involved in. I think you said there was about two that you're currently doing. Do you wanna talk about those? Yeah, sure. So I'm enrolled in a master's of research at La Trobe University. So my background project is in sports physiotherapy. I did a sports physiotherapy master's at La Trobe in 2009 and 2010. I've done a lot variety of sports work. So athletics, basketball, football, and a few different things. But... gone back to do some research. I started that a couple of years ago, got a really good research team, including Jill Cook, who you mentioned before, who's a professor, Jill Cook, who's published a lot on tendon for over 20 years. So the first study we're doing is, we're looking for people now, we're recruiting now. It's a study comparing the effect of two different types of exercise. So isotonic exercise, which is like your typical strength exercise at the gym, compared to isometric exercise, which we just hold a heavy weight and then your muscle doesn't shorten or lengthen. So we're comparing. those two exercises in people with PHT to see, does it change their pain? Does it change their strength? Does it change their sitting symptoms? So if anyone's in Melbourne, Victoria, Australia, and you're interested in being involved in that trial, we're recruiting now, you can contact me. The second trial is a slightly bigger one and very exciting trial. So hopefully enrolling in the next three to six months once we get through ethics, but. looking for 50 people and they get either treatment of physiotherapy. So physiotherapy is one of the things we've talked about today. So education, advice, a heavy strength program or a progressive strength program. And the other group get shockwave therapy or extracorporeal shockwave therapy, which is there's one study from Italy by Dr. Caccio for about 10 years ago now, that showed excellent results with shockwave therapy in people with PH. They're actually professional athletes with PHT. So we're comparing our physiotherapy protocol to something quite similar to his shockwave protocol with the addition of education. So we know education advice is very helpful in a lot of conditions, including PHT. Okay, and so you'll most likely be recruiting in about three to six months. If all goes well. Three to six months. Yeah, three to six months for the second trial all going well. And the treatments across metropolitan Melbourne and also in Ballarat in Victoria, the treatment is at no cost to participants. And yeah, but we think both treatments are equally likely to help. So we can treat both with an equal mindset, I guess. Yeah. I do have the ability to put some links or information in the show notes. If someone wants to reach out to you to participating in these studies. Should I just put your email or something on the show notes? Yeah, email's great. I'll send you through some details, email, and happy to have my phone number listed there, that's fine. Cool. And I'll probably put a post out to see if anyone else wants to participate in the studies. Is there any particular inclusion criteria apart from having PhD, like duration of symptoms or severity, or do they need to be seeing a current physio or something? Yep. So duration is at least three months. And the symptoms have to be of gradual onset. So if you had that kind of water skiing injury that we spoke about before, where you felt something go, that would probably make you an eligible for this trial. So gradual onset of symptoms, age is 18 to 60 for the first trial and 18 to 65 for the second trial. And, um, they're the main inclusion criteria. There's a variety of tests that we go through at the start to make sure you're eligible for the trial. But if you've, if you've got PhD, we think you've got PhD, it's been there at least three months. You may well be eligible. Cool. And the, um, especially for the first one, you said you need them in Melbourne. Is that because you're doing a lot of the tests, like I have to be in person like at La Trobe or is it via like, um, we're using a lab. Yeah. We're using a lab for the first trial, just to get some really accurate strength measurements. So they have to meet with me once that can be anywhere over Melbourne really. And then the same three sessions at La Trobe university. The first session is quite short, about 30 minutes. we just familiarise them with the equipment. And then the second two sessions are about an hour or 80 minutes where we do some different strength exercises and see what the response is to those. And then, so they have to be able to attend Latrobe and Bandura on three occasions. And then the second trial, there's a variety of sites we've got who are providing treatment across Melbourne. So basically most parts of Melbourne are covered from the West to the Mornington Peninsula and everywhere in between. And also Ballarat as well. Yeah. Well, the beauty of this podcast is like almost everyone that's listening has proximal hamstring tendinopathy and, uh, whether they're in the Melbourne region. We'll wait and see, but I reckon we can get a couple of people on board and I'm excited to hear what the results are and how the tests actually go. So I look forward to, um, bringing people updates in say three to six months time, once things start, once that second study starts recruiting people, um, have a reach out because I'll pitch it into like. the intro of another podcast episode that I bring out that week and a couple of posts out and we'll see if people are interested in that one too. That would be great. Thanks. Is there any other like links or social media or something that you want me to include in the show notes? Look, I've got a physiotherapy page on Facebook that doesn't actually that much use, but I probably should use a bit more now with this PhD study. So if you just drop in the aid and rich physiotherapist, you'll find me on Facebook. That's probably the... best way of getting in touch. Yeah. Can do I'll do that. And I'll include your email as well. Aidan, rich, thank you for coming on and, um, bringing light to what can be quite confusing when it comes to different diagnosis, but, um, I think we've simplified it really well. And I think the overall message would be to, if someone's not really responding to treatment and they haven't really sussed out a professional help, definitely. Um, just get a professional who's seen this a lot before to do some tests to help. Maybe with your confidence that it is, it might be PhD. It might be reassuring to know that it's PhD, but if something's a ride and something's really not fitting the piece of the puzzle, then perhaps we get it medically assessed and yeah, cause it could potentially be something else. Thanks once again for listening and taking control of your rehab. If you are a runner and love learning through the podcast format, then go ahead and check out the Run Smarter podcast, hosted by me. I'll include the link along with all the other links mentioned today in the show notes. So open up your device, click on the show description, and all the links will be there waiting for you. Congratulations on paving your way forward towards an empowering, pain-free future, and remember, Knowledge is Power.