Ep199: 'Understanding Tendinopathies Of The Hip & Pelvis' with special guest Dr Alison Grimaldi

You're listening to the Sports Therapy Association podcast, putting evidence back into soft tissue therapy. Music. Welcome to the Sports Therapy Association podcast, episode 199. My name is Matt Phillips, creativerunchatlife.com. And as always, this episode of the Sports Therapy Association podcast is being recorded live on the Sports Therapy Association YouTube channel. And also for those of you who prefer it on Facebook, it's normally recorded live at eight o'clock.

But because this episode, like last week, is going out at nine o'clock, basically, because my guests, it seems like the experts of tendinopathy all live in Australia for some reason, which we might pick up again tonight. So it's kind of a bit kinder to do this at nine o'clock BST because that's six o'clock over there. So, if you have joined us live, then thank you very much. You're welcome to ask questions as always.

If you're listening to the podcast and you want to join us live, then next week, just put this out there now so you know, those of you who are listening to the first part of the podcast, next week there won't be anything happening. But the week after, part three of this Tendon special with Dr. Ebony Rio will be happening at nine o'clock BST as well. Okay, so do join us then if you fancy being able to ask the guest questions directly and hang out with people in the live lounge.

So yes as i've already said this is part two of a three parts tendon special in part one last week i had the pleasure of spending time with dr a professor sorry doctor hush my mouth professor peter maliaris and let's just bring those of you who listen to podcasts you can't see the screen i'm going to put some nice screenshots up here so yeah it was with professor pete maliaris has been on the show before who like all of my guests is a

hugely prominent and internationally respected tendon researcher and educator co-author of over 100 peer review publications peter is also creator of the internationally acclaimed mastering lower limb tendinopathy online and face-to-face course now in its seventh edition details of which can be heard in episode 198 of the sports therapy association podcast available as always on all popular podcasts players and youtube so a

huge thank you to professor peter maliaris for opening our tendon special last week so tonight in part two, which is entitled Understanding Tendinopathies of the Hip and Pelvis. My guest coming up shortly is the one and only Dr. Alison Brumaldi. And then, like I say, in two weeks' time, on June the 4th, in episode 200. 200. Isn't that fantastic? The topic will be managing tendon pain with special guest Dr. Ebony Rio. Right then, back to my guest tonight. It really doesn't get much bigger than

this, people. I'm so excited and rightfully so. People have been messaging me all day. Dr. Alison Rowdy has got over 30 years of clinical experience with particular expertise in the management of hip, groin and lumbopelvic pain dysfunction.

She's also a fellow of the Australian College of Physiotherapists, Principal Physiotherapist at PhysioTech and an Adjunct senior research fellow at the university of queensland so as always this is a huge opportunity for people who have joined us live and if you listen to the podcast i really do encourage you next in two weeks time to join us live as well because you don't really these opportunities don't come along all the time to ask questions live direct to guests of this

caliber so i do encourage you if you've if you've got um some time free then do join us in a couple of weeks time so anyway i'm babbling on without further ado let's bring up dr allison grimaldi. Music.

Stick to the sports therapy association podcast evidence back soft tissue therapy, how you doing good thanks matt i'm sorry i started babbling then because i'm so keen for people to actually join this i feel quite guilty that i'm not like there's not hundreds of people joining now but it's hey that's education we want to reach people who don't know you don't we Otherwise, it's just an echo chamber. That's right.

So thank you very much. I do appreciate it, especially since it's like six in the morning, isn't it, where you are in not-so-sunny Brisbane, I hear? It's beautiful. Actually, the weather's been lovely. Just a little cool, but only 10 degrees, so it's not sort of like… 10 degrees. Wow, you guys are suffering. Anyway, great to join you today. I really appreciate it. People are joining us now. That's good. People are coming through the door.

Let's just bring some people up. Like I say, if you have joined us live, then do ask questions away. And if you do ask questions, I'll bring your lovely logo or photo up onto the screen. Cecily Hislock says, evening. I have another. No, I'm not having another joke, Cecily Hislock. I'm just going to hide it now. I just listened back to the way I started Peter's podcast last week. No, Cecily, I banned you. Forget it. Let's just move on. Fine. Thanks for joining us, people who are live.

All focus has got to be on Dr. Grimaldi, I'm afraid. So, Dr. Kamaldi, fantastic to have you here. It's a huge topic. We talked about understanding tendinopathies of the hip and pelvis, and we're not going to get through all of that tonight. But I'm wondering, just for listeners who aren't aware, what would the kind of most common tendinopathies of that region be if we were going to dip into

a few of them tonight? Dr. Kamaldi, The most common ones would be gluteal tendinopathy and proximal hamstring tendinopathy. Then we can have some other tendon problems that might occur. Sometimes with adductor-related groin pain, you may get the tendon involved. So we can have adductor tendinopathy. Rectus femoris tendinopathy, we can get sort of at the front of the hip there. And then we can even get other tendons involved, often associated with osteoarthritis.

So, for example, at the back of the hip, the obturator internus tendon that runs right across the back of the hip there can get tendinopathy as well. But the most common ones that we see are going to be gluteal tendinopathy at the lateral hip and proximal hamstring tendinopathy at the ischium. Fantastic. Yeah. So we haven't got time. It would do a massive discredit to you and everything if we tried going into all of those areas.

But I'm wondering as an opening question, in the topic of tendinopathy in general, are there some common themes, do you think, in treating those areas? Although obviously, there's going to be distinctions. Do you think there are some areas which are responsible for mismanagement of tendinopathy of the hip and pelvis, things that aren't quite trickling through to the clinic floor?

I guess one of the common things is that a lot of the tendinopathies around the hip and pelvis are insertional tendinopathies, which just means that the the tendon sort of wraps around a bone for it sort of inserts into that bone. And so there's opportunity for compression of the tendon. And so compression is a really important factor in the development, we think, certainly in the management of tendinopathy. It's something that we tend to reduce to try to reduce pain.

But I guess in terms of mismanagement, I think one of the things that's often prescribed for tendinopathies is stretching. And so particularly with gluteal tendinopathy, which has previously been diagnosed as trochanteric bursitis. And one of the really strong beliefs around trochanteric bursitis was around, it's all about tightness of the ITB.

And so there was lots of, you know, one of the main treatment approaches was stretching of the ITB or trying to mechanically lengthen the ITB and eventually surgically lengthen the ITB. Similar with proximal hamstring tendinopathy that a lot of patients will try to stretch and stretch and stretch. But for both of those situations, stretching isn't terribly helpful and might be provocative because you're actually exposing that insertional tendon to more compressive load.

And with gluteal tendinopathy, particularly tendinopathy, That population is actually really short in their lateral soft tissue structures, even though that's still the common belief, even though now we've sort of moved towards, you know, gluteal tendinopathy is our understanding of the primary condition, but we might also have bursal change there.

But there's still this sort of belief that the ITB must be tight and so there's still some stretching going on out there perhaps but when we actually assess these people in clinic they're actually really tight and they're much more likely to be long in that lateral stability mechanism and that's because that population tends to sit with their knees crossed in adduction, stand and hang on one hip in adduction, walk with excessive adduction, you know, in their normal everyday gait patterns.

And so they spend a lot of time in adduction in a lengthened position. And so they do actually tend to be longer rather than shorter in their ITB and hip abductors. And so stretching is not going to be useful and it's just going to be provocative. We do see a subgroups that are tight, more commonly males that stand with wide legs, sit with wide legs, but they're the much smaller population. But stretching won't help them either because it'll just cause that compression.

Massage can be useful, but the massage is not about lengthening the ITB. What we see in those with gluteal tendinopathy is they often get tender and a bit overactive, if you like, in the vastus lateralis, so in the lateral part of that quads. But that's simply because that muscle is part of the more superficial stability system for the pelvis in the lateral lateralis.

Lateral stability mechanism. And so when the vastus lateralis contracts, it pumps out the ITB and so that helps the ITB in the upper glute max. So if you're weak in the deeper abductors, glute min and glute med, then you need to use more of the superficial abductors and that includes vastus lateralis. So I think, you know, a lot of that tightness and tenderness that we feel down the side of the thigh there is about vastus lateralis trying so hard to, you know, help the lateral hip.

Actually, a couple of weeks ago, I saw a patient who was so weak and she had a large BMI.

So there was a big physical mismatch between her ability to load bear and she would get this massive cramp in her vastus lateralis just trying to weight bear because she had a lot of atrophy and just was not strong enough to weight bear with the weakness that she had and the body weight that she had, but she'd been through all of these investigations trying to, you know, figure out what this problem was in her thigh.

Well, I can explain what the problem is in the thigh. It's a, you know, an enormous overload on your vastus lateralis. So massage can be really useful to help sort of, you know, reduce pain and, but it will only be a very temporary.

You know solution because we have to get to the the root of the cause which is which which is up at the hip there very long answer no that's just i should really just stop the episode there because there's enough there to keep our listeners going on for a good couple of hours i'm like it's just it's everything it's just ticking all my boxes it's fantastic i mean it's recently i gave a webinar for physique management on proximal hamstring tendinopathy

and i i say on that guys i'm just a conduit people maybe like the way i give the information but this information is coming from experts like yourself like peter maliaris in particular the paper he did with tom goom on that and other people as well so to hear you can to hear it from i hate especially from the horse's mouth always seems so disrespectful but hearing it from from you saying things like it's you know it's not always

a stretchy tight issue okay just because it hurts doesn't mean it needs to be stretched and a lot of cases when it comes to insertional tendinopathy the research kind of suggests that maybe that that extra tensile could cause some compression, et cetera, et cetera. So it's really refreshing to hear this message kind of said, because unfortunately, especially with soft tissue therapists, massage therapists, sports massage therapists.

Most of the principles taught are about increasing range of movement, because we know that laying hands and massaging can increase, even though it's kind of not for very long.

It's temporary we can increase visible flexibility and range of movement but because of that all the techniques people use is to kind of stretch and increase but so when it comes to conditions where it's not lack of range of mobility isn't the issue here it's actually the opposite it's actually need to put some stiffness in it sounds like a foreign entity so now it's great thank you so much for mentioning that because it's it really does help therapists think oh god maybe i better

I better crack on with this because if Dr. Alison Grimaldi is saying it's not always a stretching issue, then it must be true. So that's really good. It's really good to hear that.

So, yes, common themes in treating tendinopathies in the hip and pelvis. Yeah, they may well be in insertional and stretching is not always the answer. I wonder whether I'm going to dip into research that you've done. Obviously, it's a long, illustrious career. I don't want to make you feel too old, but I just want to we're going to go back to 2008. Now, I don't like I said off air, I don't need you to recall the afternoon and who you were with and that sort of stuff.

But I think it's just interesting. I just wondered because I looked on ResearchGate. And again, I encourage listeners to go to ResearchGate and look up the names of my guests because you'll get a lovely idea. Obviously, reading just the abstract can be a little bit dangerous. But in most cases, there's links or a lot of cases, there's links to the full text. And in many cases, I hear that if you actually contact the author, they'll be more than happy to give you where they can full text anyway.

But in 2008, your publication, the first one I could find on ResearchGate was MRI Investigations of the Muscles Involved in Lateral Stability of the Hip.

So I was just interested in having you on the show how you came about as that being you know one of the first published papers and at that time did you realize then that this was going to be your future that you're going to become kind of such a respected professional and educator of this area of the body no but it was something that I guess I had a burning desire to try to figure out, you know, some more information about the hip.

And so that paper, well, I think that's actually a link to my PhD thesis. So it was interesting. I did a coursework master's, a sports physio master's in 1997, a while ago now. And that was a very intense year and I absolutely loved it, but it was a lot of work and lots of exams. And, you know, at the end of that That year I went, well, that's it with university. I won't be going to university.

But, you know, as you start sort of, applying that extra knowledge that you get from Masters, which is fantastic. But there were still so many unanswered questions. And back then, there was so little research on the hip. There's been an absolute explosion in the last 10, 15 years, which is fantastic.

But back then, there was very little. And as is very common with people going into particular areas, I'd had a bit of my own hip issue and so and it had been to every course there weren't very many courses either looked up everything the literature and I'm going oh I'm going to have to go and try to answer some questions myself so you know went back to uni to try to answer some questions and I think again with a lot of PhDs that are driven in that way you've sort of got so many questions

and you expect to answer all these things when you go into a PhD. But, you know, and actually I'd intended to do some EMG, but, you know, there was so little information on the hip that we thought, well, let's do some MRI studies first to try to figure out which muscles might be most affected by, you know, joint pathologies. And so then we might be able to, you know, direct the EMG, like figure out what we actually want at EMG. Anyway, the MRI...

Studies ended up so big that my whole PhD ended up a MRI study. And, you know, I initially started, you know, wanting to measure all the muscles around the hip. And then it ended up that, you know, it was such a big project that I ended up focusing on the abductor mechanism, which was the part of the muscular system around the hip that tends to be very regularly affected. It's probably most consistently affected across all different types of pathologies with the hip and hip joint pathologies.

So it ended up sort of focusing more on the hip abductors and looking at people with joint pathologies, so earlier joint pathology and more advanced joint pathology. And then I had an opportunity to also be involved in a bedrest study, which was really interesting. So their PhD ended up being a bit about pathology and then about unloading. And that was actually fascinating. And I think it did start to really change the way I prescribe exercises and the way that I looked at things as well.

Because my, so it was with the Berlin Bedrest Study, which is a study that was run by the European Space Agency. And that's because they were you know looking at trying to keep astronauts up there in space for.

Longer with less you know effect on their musculoskeletal system because it's you know unloading is you know has such dramatic impacts on you know not just bone of course we're aware that it has effects on bone but on the muscular system and it's interesting that all muscles aren't affected equally and so my part of that study was to have a look at what happened to the the abductors after eight weeks of bed rest and so these were normal healthy they were all males but normal

healthy males and a lot of them were PhD students and it was a bit harder than I thought I think they thought it was going to be you know they thought oh I'm just going to lie in bed and you know maybe write up write my papers up and things like that but they weren't allowed to even incline their trunk more than 30 degrees they had to shower and do their daily hygiene you know lying down in bed and so they had force plates in

the end of the bed so they weren't even allowed to you know push into the bed so they wanted them completely unloaded yeah it was crazy so and there was lots of things done to these poor fellows but my part of it was just to look at MRIs sort of over you know every two weeks over that sort of period and it was really interesting because the all muscles aren't affected equally by you know lack of gravitational loading and And like.

So within two weeks, like gluteus minimus, so our deepest hip abductor there had lost on average about 23% of its muscle size, which is quite phenomenal. Whereas muscles like upper glute max and TFL, which both, you know, superficial abductors, the upper fibers of glute max being anything above the center of rotation of the hip joint is more an abductor rather than extensor. So those muscles didn't actually lose any significant size over eight weeks of bed rest.

And piriformis didn't lose size over that time frame either, which is interesting. But lower glute max, which is an extensor, so it gradually lost size over time over that eight weeks. So a bit similar to the quads, other studies done on quads in unloading situations, they gradually sort of reduce, you know, size, but these deeper muscles involved in, you know, joint support seem to be particularly affected by lack of loading. So multifidus is also particularly affected.

Quadratus femoris seems particularly affected as well. And so it really made me start thinking because we see similar sort of patterns happening in joint pathology as well that, you know, we start losing those deeper muscles. We see sort of that more of that fatty atrophy in those deeper muscles in people with joint pathologies as well.

So that link there about loading, I think is so important because when you start getting joint pain, you naturally start offloading that leg and you see people with hip OA standing, they'll be standing on their unaffected side with the other, you know, side bent when they, you know, get up and down out of their chair, they put all their weight through their affected side.

So it's something that I think the lack of loading has a big impact, you know, on muscles and changes in muscle contribution to the synergy. So around the hip, all of our muscles work in synergies, of course, and we see it all the time. And your listeners would be aware of, you know, that that TFL dominance and the TFL hypertrophy that we see.

So that's very common. When we see that, it's usually associated with some deficits in the deep muscles, so particularly gluteus minimus, the deep parts of gluteus medius. And so in terms of then how does that, you know, relate to exercise, then I think getting your foot to the ground is really important to try to stimulate that deeper part of your hip synergies, like particularly your synergies of your buttock. So they're...

Important weight-bearing muscles. So I think having your foot on the ground is really important. So like, I'm not a big fan of what I call leg flapping, which is leg off the ground, you know, type exercises and clams are not my favourite either.

But this is sort of a process. I used to prescribe those exercises, but this paper was part of, you know, my shift, I suppose, in how I prescribe exercise and how I understand muscle function and what drives muscle function and muscle health and weight bearing, I think, for these particular muscles is so incredibly important. So that's one of the main things that I learned, I suppose, out of that study.

That's brilliant. I've been surrounded for years of the importance of loading and how to do it and why to do it but i'd never i've never heard that a lot of it evidently came from yeah a study on forcing phd students to stay in bed supine with force plates under their feet that's incredible, i'm not i'm not sure what that makes you being involved in that i'm not quite sure about the ethics of it but it's no i mean that opened doors i guess in

treatment and and it's so relevant isn't it to tendinopathy because tendons it seems in particular need that loading to regain their stiffness and very interesting very interesting. And actually, something hats off to, who was it here? Carol. Yeah, Carol jumped in very early on at 9-11 saying, should the tendon not be loaded as a continuation to release pain? Yeah, which is interesting as well, because thanks, Carol, because I've got a script here.

I'm just going to ignore it because you guys in the live lounge are going to stimulate my questions for Dr. Alison Grimaldi tonight. So it's interesting.

When it comes to loading, there's this continuum, which a lot of people read about with isometric first and then introduce the isotonics and some people i've heard and seen online which is a terrible place to learn sometimes but that the isometrics are overrated and it's not necessary and take them straight to isotonics but then other people will quote papers which show that isometrics have been linked in with actually reducing pain so what's your take on isometrics as part of let's stick

with gluteal maybe to make it more concrete but yeah isometrics for a rehabilitation of gluteal tendinopathy sure i might just address i think that question might have come in when i was talking about compression and not stretching and i'm not sure if so i'll come back to the isometrics but i guess just addressing that question about should a tendon not be loaded and isn't stretching loading so i guess stretching Stretching is loading, but it's the type of load.

So I guess it's that sort of balance between compressive and tensile loading. So when we're stretching, we're getting a really high amount of compressive loading. And that's one of the things that we... Think is like stimulates a tendon response to create changes in the tendon, but probably not only the tendon, the bursa and at the lateral hip, the iliotibial band as well.

So all of those structures actually end up thickening themselves by, you know, laying down larger proteoglycans, you know, gel sort of molecules in those structures, which are hydrophilic, that suck water into the tendon and the bursa. And the iliotibial band has also been shown to be thickened over the ITB in those with gluteal tendinopathy. And so all of those structures become better at absorbing compressive load.

However, particularly for the tendon, a tendon that is more adapted to compressive load becomes less adapted to its normal tensile load because the collagen fibres get disorganised and they're not all lined up in those nice lines to be able to absorb tensile load.

So I guess I just wanted to address that first in terms of compressive and tensile loads are different things so yes we need to load a tendon but what we're doing in rehab of insertional tendinopathies is particularly in those early phases is trying to reduce exposure to compressive load while we gradually increase exposure to tensile load so then back to exercise mode then how do we do that hold on actually i should therefore say cow sorry

if that's what you were implying and sorry i didn't realize you were going down that path of isn't stretching loading as well i just wanted to say because i've heard that again on social media it's like very polarized and as soon as some people start saying stretching is is excellent for everything other people say we shouldn't be stretching suddenly and then people come back saying ah but stretching is actually a form of load and therefore

we should be stretching but then i think the research shows that yes stretching can cause a load but you'd need to do it something like 12 hours a day for six days a week for it to have the same load as a traditional resistance exercise. So again, it's interpretation of studies, isn't it? You wouldn't be able to give enough load, I think.

The equivalent of going to a gym or something by stretching would you or am i mistaken no no i wouldn't think so particularly with tendons where you know and even the itb like you're going to get more load in the itb when you have muscles contracting it as well but yeah again if if you put someone in stretch position for 12 hours with gluteal tendinopathy i think you'd end up having to yeah put them on a walking aid the next day yeah you'd prove your point and get a bit of low but I

don't think it would yeah be totally anyway so I just thought I'd mention that because I just hear it used as an excuse for people who are trying to defend stretching and we're not saying that stretching is really terrible but I think insertional tendinopathy and I quote it is it's an example of where stretching is not the the fix for all and unfortunately a lot of us and patients believe stretching is the solution for everything we need to educate

a little bit don't we yeah no that's right and I mean again I'm not saying we should never stretch anyone one. But it's just, you have to understand the condition that the patient has when you're providing advice around exercise. And that's, you know, that's not a helpful thing to give to someone with gluteal tendinopathy. It doesn't mean that no one should stretch. But, you know, again, you know, prolonged, sustained stretching just before exercise is also often not a great idea.

You know, a dynamic warm-up is usually better in those situations. But yeah, so it's It's just about the situation when it's appropriate or not to prescribe stretching. But if we go back then to the exercise modes and loading the tendon and how do we do that, I do start with isometrics for gluteal tendinopathy. And I often do it for proximal hamstring tendinopathy as well. And it's something that can help from a pain relief point of view. And if it helps, great. right?

That's, you know, a great little tool that they have that they can actually give themselves some rapid relief actually with proximal hamstring tendinopathy. I had this patient once who was a cabbie, taxi driver. And so obviously he was sitting all the time and he had lots of sitting pain from the proximal hamstring tendinopathy. But so I taught him, you know, an isometric in standing, just, you know, hooking his foot under something and just pulling up.

And so what he'd do is that he'd do a fair and then he'd jump out of his car and he'd stand up next to his sort of door and he'd put his foot you know underneath the door jamb and he'd just pull up you know do that a couple of times and he'd feel so much better so then he was comfortable to sort of do his next his next fair but of course that wasn't going to cure the situation but it was a really good thing for him a tool for

him if you like for getting through his day with more comfort it by having something that he could do to give him some immediate relief. Now, it doesn't work like that for everyone, but for someone who it helps, that's fantastic. Full gluteal tendinopathy. The isometrics that we do, you know, I started doing isometrics for gluteal tenopathy a long time ago, a long time before Ebony's lovely research sort of came out. And initially, it wasn't to do with pain relief.

That wasn't why I was prescribing isometrics. It was actually about retraining that muscle recruitment strategy because we do see such disorder in how that synergy functions.

Contractions so normally when you recruit your abductors you and we use a lot of real-time ultrasound so we can watch it which is lovely so a normal recruitment in the abductors is glute min first so deepest abductor then the deep fibers of glute med then the superficial fibers of glute med and then finally tfl and upper glute max come on just as you're having to you know lift the load of your leg but in the preparation phase we

get this early recruitment of the deep muscles And that's really important because early recruitment of those muscles helps stabilise that hip joint, helps stabilise the centre of rotation. Ready for those big muscles to then do their job and provide some of that power for lifting.

So that's a normal recruitment strategy. But what we often see in people with gluteal tendinopathy, but joint pathologies as well, is that we often see an outside-in recruitment pattern instead of an inside-out recruitment pattern. And so we'll actually see TFL recruit first and sometimes like superficial glute med, you know, recruit with TFL and we'll see this sort of lagging behind in glute med. It's not like that they don't work at all.

But there's just a lag in that sort of recruitment and reduced sort of recruitment in those muscles sometimes. And so what we do is then, you know, try to train them to re-instigate, you know, that early recruitment in that deep muscle system. And so I started doing isometrics, just training the preparation for lift phase, which is where that, you know, that motor control was sort of going wrong. But it was really interesting and it was fantastic when ebony's paper came out because.

Because yeah i'd send someone home and i might have only you know got through that exercise and education and all of that on the first day and then they came back the next session and said oh that exercise you gave me it really helps with my pain and initially i'd go oh okay doesn't really make any sense but when ebony's research came out okay now it really makes sense. So some people get a lot of relief from doing isometrics, not everyone.

And it doesn't necessarily have to be high load isometrics because what we were doing was low load isometrics because we're trying to keep the TFL out of it. So it was more motor control sort of training initially, but we were getting great sort of pain relief from low load isometrics. So even though Ebony's work initially was more high load, like 70 to 80% of an MVC, I'd say ours would be more 20 to 30% of an MVC.

Of a maximum voluntary contraction and so yeah so it's I think it's a nice place to start but there's no way I'd put someone on isometrics and say right you go and do that for six weeks and and then we'll move on to the next phase it's certainly not that and all of my patients usually get isometrics and isotomics on the same day because they are moving and we have this you know it's not like they're in bed they're they're standing they're walking they're going upstairs

stairs, they're getting in and out of chairs, this is our opportunity right now to actually start, movement training with them, which is their early isotonic type exercises. And so I love sort of. Direct transfer into people's everyday life. So, you know, I'd also be starting with, you know, squatting and bridging and lovely closed chain functional exercise, but, you know, teaching them how to do that more comfortably by, you know, positioning their body in a better way.

So with gluteal tendinopathy, it's often about using excessive abduction. And so it's, you know, giving them clues of right, okay, don't shift to the side, you know, keep your knees facing straight ahead. And it's not, again, when we provide education, it's important that we provide it in a way that's not fear-inducing. And so it's not like, you should never walk like that or you're going to damage your tendon.

It's not about that. It's cumulative loading. So I talk a lot about grumpy tendons and I just say to my patients, right, well, educate them around what the problem is and how certain joint positions are going to make your tendons more grumpy. Be. And so this is how that might apply in the things that you're doing in everyday life.

And the big things are sitting positions, standing positions, sleeping positions, you know, walking upstairs, you know, and walking generally, getting in and out of chairs, things like that. And so when you, you know, crystallize that information into a meaningful way for the patient, and these are usually things that are painful for them, then it starts meaning something.

And so exercises, sizes, if we can prescribe them in a way that directly starts targeting the problems that they're having, I think they get there a lot faster. Yes, I am biased, what with Brighton being my hometown, but the Brighton Beard Company really do offer an absolutely amazing selection of luxurious beard balms and impeccably scented oils, all handmade in small batches with 100% natural ingredients.

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And I've heard you talk on other podcasts about how important the subjective assessment is.

I want to talk about objective assessment as well, but I think we would do it injustice by not mentioning how important subjective assessment is as well, because like you say, it can be be different in the case of each patient and also the the rehab you give has to be built around their lives and what they can do and their understanding and they need to understand how important it is so can you give us some kind of ideas of where the subjective

assessment should take us and when we're dealing with a patient in front of us with suspected due to tendinopathy. Yeah great point matt and yeah absolutely the the patient interview is something that it's just a wealth of information. And by the time you get to your objective assessment, you should pretty much have sort of narrowed down your potential diagnoses to usually two or three things.

But so for gluteal tendinopathy, well, anything around the hip, like area of pain, I think is really important. And for tendon pathologies, you do often have a fairly, you know, localized area of pain. And so I do think that's very important for gluteal tendinopathy. Where is the pain and that area of pain should be over the greater trochanter.

They might also get pain down the thigh, whether that's from the tendon themselves itself or whether it's actually related to the changes that I talked about in the iliotibial band. So we might have an ITB fasciopathy, if you like, down the side of the thigh as well. But area of pain I think is a good place to.

Start in terms of you thinking about what might be some local problems sort of going on and so even in my patient interview I'll get the patient to stand up and point with one finger I say can you just stand up and show me exactly where that pain is and because if they can localize it fairly exactly it's probably likely to be something more local rather than oh it's sort of just running across my buttock and down into my thigh so

that might tell me oh okay it might be something a bit bit more referred. So I'm going to be thinking a bit more about the lumbar spine. If it's less local and focal and they can't point to it, they sort of use more a broad hand stroke for where their pain is right across their buttock, down their thigh.

So those things are important. And area of pain, again, when you're asking them about aggravating factors and night pain is very common with this population with gluteal tendinopathy and hip joint pathologies as well. And even with lumbar spine, you can get pain at night. But we want to ask those extra questions. So I think in a patient interview, well, in your objective as well, we become detectives. And I think that's part of the fun part of what we do as well, you know, being a detective.

And so you want to ask more questions about their night pain. So I get pain lying on my side. So don't just go, tick, yep, they've got pain lying on their side. It must be gluteal tenonophily. Actually, a lot of things have pain lying on their side. So when they lie on their side, you know, what is it that hurts? Where does it hurt? And if they say, oh, over that bone on the side of my hip and it's like I roll onto this bone, I get sharp pain over my bone.

If they're talking about the pain directly over the greater trochanter. Then, okay, yeah, that really sounds like gluteal tendinopathy. But if they're saying, oh, yeah, no, it's sort of just a deep ache somewhere, you know, deep around my hip there. And sometimes it's a bit at the front or a bit at the back. I mean, that might be more hip joint. So we might be thinking more OA, femoris tabulae impingement. Dysplasia depends on how old the patient is. If they're post 50,

we might be thinking a bit more about OA. way. If they're sort of younger, we might be thinking FAI or dysplasia. Or it might be, yeah, when I lie on my side and, you know, I'm sort of a bit in a rotated position, then I get this pain that, you know, comes across my buttock, down my legs. Sometimes it hurts in my foot. You know, those are really important pieces of information.

And so I think whenever we ask about aggravating factors, and sometimes early in our career, we're so fixed on the questions and And getting through the questions that we go, right, I've asked that, I've asked that, I've asked that, right, written down the aggravating factors, but we're not thinking about it as we go along sometimes. And that's where you get so much more information when you're thinking about it. And it's a puzzle and you're adding pieces of information to the puzzle.

And the patient offers a piece of information and you go, oh, that's interesting. I want to know a bit more about that because that's going to hit me here or there. So I think area of pain, behavior of pain, you know, those aggravating factors are really important. Past history is so important or the history of, you know, this condition as well. So when did it come on? Oh, well, so this is a, you know, maybe 55-year-old woman.

Well, it's sort of when I went through menopause, I started putting on weight and, you know, my cholesterol was a little high.

And so my GP said look you really need to start losing some weight and you know looking after your heart health and so I started you know walking you know my kids were finally old enough that I didn't have to look after them all the time so I started focusing on myself and I started getting out there and walking and and he said okay and and how were you walking well you know it's really power walking so striding it out and I was trying to do lots of hills so that that's really good

for my heart the GP said and so I started doing all this hill walking and so going from nothing to doing long stride walking which you know puts a lot of sort of impact you know up into the hip when you're taking those really big strides lots of hills which is quite provocative for the hip tendons as well and so there'd sort of been this sudden increase in activity levels.

And then we've also got the demographic of the patient. So, you know, age, you know, menopausal status, you know, a little bit of being a little bit overweight. So we know that that's also linked with, you know, tendinopathies around the hip and lots of tendinopathies as well. And so, again, we've got the demographics, we've got this history, we've got area of pain, we've got behaviour of pain.

Those things are really interesting. And then, you know, give us a lot of information about our diagnosis.

Diagnosis but then as you said before Matt that information about what are the problems that you know how is this impacting your life so what are the functional issues that you have and then you know what do you want to do what do you need to do in your everyday life in your sport in your recreation in your occupation so those are really important things and it was because those are the things we want to focus on it was really interesting in the LEAP trial that we did on gluteal tendinopathy,

that we did a secondary analysis looking at things that might moderate or mediate the effects. So might impact, so baseline factors that might impact your outcomes or the treatment effects of the three different treatment interventions we did, one of those being education and exercise, and then mediators, things that by changing this thing, it was the a change in that thing that might have created the treatment effects.

And it was really interesting in that one of the things that ended up as a significant mediator, something that if we change that, that had a big impact on the overall outcome was patient function, patient specific function that was measured on the patient specific functional scale. So things that patients had identified, this is a problem for me.

And if we change those things, then the patient's overall rating of condition, you know, seem to be, you know, significantly affected by the treatment.

So it was interesting. So the message coming from that is that, you know, to optimize our management outcomes, if we can focus on the things that are important to the patient and they're are affecting their lives, that's likely to give them, you know, the outcome that they want in terms of their global rating of outcome, if you like, and their quality of life.

So that also affected quality of life as well. So yeah, really important points about the things that we want to get out of that patient interview. It's amazing. Again, it's so valuable and you explain it so So, well, a lot of guests on the show have talked about the importance of subjecting. We say it time and time again, and a lot of the issues with our industry are.

Is is jumping to the objective especially if you've just done a cpd course and it's like suddenly you've learned about this and guess what everyone who walks to the clinic the next day has got that thing you found it like why haven't i seen this before so we know we've got our own confirmation biases as soon as we put our hands on i love the way that you say get the patient to point to the area of pain because again if we jump in with our hands and go does this hurt you know guess what

you know it might hurt but it's just because it's coincidence or if you went on the other side they'd probably say it hurt as well so it's really it's so refreshing hearing all of this stuff which we do to get a decent hypothesis and to understand what's going on and look already at ways of rehabbing this person in front of us before we've even touched them and and at the moment there's this again is it getting a bit better i don't know it depends where you look but

this is like hands-on hands-off debate as if it's one or the other which is ridiculous because Because all of the stuff you've talked about means that when we do put our hands on and use the important palpation and all the different stuff we can do to assess, it's more meaningful.

So it's not like one or the other. It's just it needs to be in that order, doesn't it? You've got to give them a good listening to, which I love as a kind of a quote. Some patients just need a good listening to. And they'll give you all the answers. They'll tell you how to fix them. You know, it's amazing. Yeah, absolutely. Absolutely. I think that's incredibly important that you get that information. And the thing is that there are so many tests.

And I know that, again, there's lots of debate about how meaningful are all these tests. But again, they're just clues. We're sort of gathering clues in our objective assessment. But in my HIP Academy, for my video library, I've recorded over 100 different tests around the HIP. There are so many different tests. You cannot possibly do do all the tests to try to screen for everything. So you're always going to do a joint screen, a hip joint screen.

You're always going to do a lumbar spine screen for anything around the hip and pelvis. So, you know, you've got those things that you've got to do. And so then other specific tests, you need to already, before you get to that objective assessment, have a bit of an idea of which things you're going to test.

Otherwise, you're going to spend your whole time assessing and you're not going to get to any treatment and you might even be still assessing in the next treatment session if you want to do all the tests. So I think from a point of efficiency, it's also really important that you've got an idea of what you need to test when you get to that objective assessment.

It's um it's interesting for professionals out there because now we know that subjective is so important and and thanks to educators to yourself hopefully therapists and listeners and people in the live lounge whether you've gone very quiet is it because you're scribbling away notes you can put the pen down we are recording this okay people if you want to ask questions you don't have to write a thing down but now that therapists are appreciating that we need to

listen more and that we're kind of more facilitators rather than operators to quote kind of the diane jacobs and silver and all that but it means the subjective is going to take more time and it's important but.

Unfortunately patients and clients aren't quite on the same page yet and we've got to be careful when they come in we might suddenly think i'm just going to talk to you for an hour and have this that's where the answers are i listen to dr allison groundy i'm going to touch you and yet again with classic mistake is that at that moment in time the patient just wanted to come in and feel good from a massage and they're not happy they

don't come back and see you so again it's checking the expectations of the patient isn't it before you jump in with any protocol.

Yeah yeah absolutely and hands-on is just so powerful and yes you definitely need to do a physical assessment but even in that first session if you can get your hands on a patient and i often do a little bit of massage in that first session for example with gluteal tendinopathy As I said, they're often, you know, tender up that lateral thigh and their TFL and the upper glute max, you know, is often quite, you know, tender and stiff, if you like.

So I'll get them in a nice, comfortable position and I'll give them some massage while I'm educating them. And it's really great because they get their hands-on treatment that, you know, will give them some, you know, very short-term relief, but it'll give them some relief. But you're getting your hands on. And I think there's something about that in terms of that sort of therapeutic alliance. But you're telling them that I understand that you're in pain and that you need some relief right now.

But while we're doing that for you, we're going to educate you about what the longer term, you know, treatment or longer term management is going to involve. And so, you know, I'll talk to them about, you know. The role that massage plays while I'm doing that massage, that massage can help ease some of your symptoms, but it's not going to be something that's going to solve the situation for the longer term.

So while we're sort of giving you some relief here, I'm going to talk you through some things that you can do in everyday life to try to reduce that grumpiness in your tendon. And then exercise is going to be the other thing that's going to be so important in your long-term outcome and management of this condition.

So I do believe hands-on treatments are useful, but not in, like, if we were just massaging and then they think that that is the treatment and then we keep just providing massage for months and months and months, you know, that's not going to ever get an adequate solution.

It'll give them some short-term relief and that can be very useful as an adjunct but i think it's just important that we put that together with you know our education and our and exercise approaches as well it's fantastic man so that's really hopefully it's really empowering for listeners to understand that because again in this era we live in where it's kind of like hands on our hands off people don't understand it's not a case of that it's just you're going

to do different things with your hands you know not everybody likes being touched That's what you could call it, like, again, Diane J, because it's all about this primal grooming. It's social grooming. It's like humans like touch. When we're educating kids, normally the best education is done with an arm around them. It's that contact which starts off, which opens up that alliance, if you like, that third particular alliance.

So it's not a case of hands on, hands off, is it? It's just explaining to the client, this isn't fixing you. I'm not going to bend you back in position again. But this is what we're going to do as you're doing that. And it can be really useful. Yeah, that's right. Right. And even when we're doing things like movement education and like providing exercise therapy, and if we're doing functional things, you know, it's like movement training as well.

We're going to put our hands on like, because tactile facilitation is really useful in terms of helping them find that, you know, that better position, that position that's going to be less provocative for them. So hands-on can be very useful, you know, not just in hands-on manual your therapy techniques but but also in the way we you know train our patients and provide them cues and feedback for what they're doing in movement training or exercise therapy.

Amazing um i'm just looking at the clock and thinking great six minutes left i wish it was only we just started six minutes but there's you've already given such amazing information of allison it's incredible but i want to no i can't i can't go into anything else i was oh just quickly because i know it's topical as well and i've heard you talk about it before and i think you put it really nicely.

Corticosteroid injections is something which a lot of listeners will probably either have clients coming saying, I think I need an injection, I need this. And unfortunately, sometimes they're told by other therapists. As they're moving around trying to find an answer they want.

But what is the lowdown, according to you and your research on corticosteroid injections with either tendinopathies of the region in general or gluteal tendinopathies? Where is their place? Okay. So the evidence that we have for gluteal tendinopathy suggests that cortisone can definitely provide some short-term relief, but longer term that tends to be poorer outcomes, And the outcomes are often not better than wait and see or doing nothing in the longer term.

So we did a randomized controlled trial comparing education, exercise, a corticosteroid approach, and a wait and see approach. And we looked at their global rating of change, so their global improvement, and we looked at pain intensity. So they were our primary outcomes at eight weeks and 52 weeks. And so at eight weeks, and I think someone in the chat there has asked about timeframe as well. So this might answer that question. So at eight weeks, education and exercise was superior.

And so it had significantly better outcomes in terms of overall change that the patient had rated their overall condition, but also in terms of pain intensity. So education exercise had reduced pain intensity at eight weeks more than corticosteroid injection and the wait and see, of course. And then at 12 months, again, the education exercise group was again significantly better in terms of their global rating of change.

So their overall outcome and their quality of life was significantly better.

The pain intensity was similar so it was not significantly different between cortisone and education exercise at that 12-month period because pain had sort of generally you know reduced in all groups but the corticosteroid group and the education exercise group still had less pain than the wait and see group so there was still some effect on pain levels at that 12-month point So it's interesting looking at, right, well, why were they rating themselves as, you know, not as good compared to

the education exercise group? And part of that is, you know, and that's why we did sort of the moderator and mediators things as well to sort of see what factors might have been affected. But so things like, you know, quality of life was certainly higher in the education and exercise group. So there's something that was changing in that group that was more than just pain intensity. One of the things we found that was interesting was pain constancy.

And so we asked patients, so over the last week, as a percentage of time, what percent of time have you had pain? Where 0% is you haven't had any pain and 100% is you've had constant pain.

And interestingly the education and exercise group had significantly lower pain constancy both in the short term and in the long term as well which is something to be really aware of for clinicians as well because patients will often come back and say the pain's the same but they might be talking about pain intensity and so you might get similar pain intensity but actually pain constancy is much less so if you've got a patient who has come in initially with I've got pain

constantly or 80% of the time I have pain, but now you've got the same pain intensity, but the pain constancy is only 20% of the time. That's a really big improvement. And that's, you know, that really has a good impact on your quality of life because you're not having to think about this pain all the time. So that's, that's something that probably, you know, influenced that outcome as well.

But I think the other thing about cortisone is that like within that very early period, like they do get some immediate pain relief. And we can get some change in education and exercise even within a few weeks. So we usually talk about tendinopathy management as it's a longer term thing because you need to do exercise for the longer term and to address any deconditioning and tendon health, that's a a longer term game.

So we're sort of talking six to 12 months with that, but we can change pain relatively quickly, but not as quickly as cortisone. In that cortisone, you'll get an immediate response from having that cortisone injection. And the interesting thing that I see in clinic and actually looking at the results of the trial as well, we tracked activity levels as well for these three different groups.

Now, it wasn't significantly different, but I'm mentioning it because it's something that I see in the clinic all the time in terms of behavioural response to different interventions. And so the education exercise group got obviously detailed, you know, education and advice, and they were told to reduce your activity for the moment, for the first few weeks.

We're going to, you know, help you, you know, learn to walk in ways that are less, you know, aggravating and, you know, we're going to get your exercises going and then we'll gradually increase your activity levels again, usually after that four-week mark. And. The other two groups, the cortisone group and the wait and see group, they both did get a basic pamphlet. And that pamphlet did give them some information about what the condition was.

And it basically said something like, you know, if you're getting pain with activity, reduce your activity initially and then gradually increase it, avoiding rapid spikes in activity levels. So just that basic piece of information.

And it's really interesting to look at the traces of what happened so the education exercise group and the wait and see group their activity levels both came down for the first four weeks and then gradually increased over time the corticosteroid group who'd got the same information as the wait and see group their activity levels from baseline went up for four weeks and then it came down and stayed down lower over time yeah and as i said it wasn't statistically significant,

but it's what I see in clinic. If you take pain away really immediately, I see it as robbing the patient of the opportunity to learn how to effectively load manage themselves. Because if the pain's not there the next time they go upstairs, they forget that actually my therapist told me to walk with my feet a little bit wider, to not shift my hips to the side, you know, the tips that we give people, you know, I started getting pain in sitting.

Oh, I've been sitting with my knees crossed the whole time. You know, these things that pain is a really important teacher. If we take that away completely, really rapidly, then patients don't attend to that load management advice, not because they're naughty people, but just it's not there. The stimulus is not there to learn. And again, with exercise, are they as compliant with exercise? No. Again, not because they're naughty people, but because, you know, we all have busy lives.

We've got other, you know, demands on us. We've got children and work and everything going on. If you don't have pain there saying, you need to do something about me, then they're going to go, well, actually, you know, my son needs me to do this. My work needs me to do that. I'll get to the exercise later, you know, and so we see less exercise compliance, less exercise volume, less attendance to load management.

So a lot of the time, you know, our medical colleagues, you know, who are trying to do the right thing by their patient, but they're trying to give them that quick pain relief. But it's often given in the context of we'll reduce your pain quickly so that you can attend to your exercise. Actually, that doesn't happen in the real world. If you reduce the pain, they're not going to attend to their exercise. Not that I'm an awful person saying we need to keep them in pain.

No, it's not that. We want to reduce their pain rapidly. But you want to have a little inkling there so that they get that little reminder and then immediately they start learning. They start learning. And these are the things that are going to change them for the longer term and help them them effectively load manage for the longer term.

If we rob them of that opportunity, actually, when the pain comes back, interestingly, patients don't think from my conversations with them, they don't think, well, that didn't work. I'm not going to have another injection. They think, well, that worked. I need to go and have another injection. Even if the pain relief was only for two days, I'll go, well, that worked.

I'm going to need to have another injection. And so it seems to set up this cycle of, you know, passive treatment, you know, seeking passive treatments and quick fixes. And so I think from a lot of behavioral effects that it has, and then of course, it's the biological effects it has on the tissue. So cortisone is toxic. It's a very powerful pain reliever, but it's toxic to tendon tissues. It's toxic to all our musculoskeletal tissues. So, and how much is safe?

We actually don't have information for that, but we know that the more cortisone injections people have had around their gluteal tendons, the more unhealthy those tendons are, the more likely they are to progress to surgery. You know, the worse they're often going to do post-surgery. So, you know, more cortisone is not going to be a good thing for them.

So, So it's important that, you know, and we don't want to make, if someone, a patient comes to you and they've already had a cortisone injection, of course, we're not going to say, oh dear, that's terrible. We can't help you now. But it's just, I suppose, being mindful that if they have already had cortisone injection, often our outcomes are actually slower and they might be reduced, particularly with multiple injections.

You might have to lower your expectations about how fast they might progress and where you might get them to, because I think it does change the responsiveness of the tendons and the health of those tendons. But, you know, this is just, a lot of that is my. Clinical extrapolation of the research and what I've seen from 30 years of clinical practice. And so I would much rather treat a patient who's never had a cortisone injection.

And so it's educating, you know, our doctors as well and say, don't try to help me. Like they're trying to be really helpful. I mean, they're trying to help the patient, of course, but often it ends up not being that helpful.

And so I educate my referrers about, yeah, just, you know, can you just not help me don't don't give that cortisone injection and so but you know it's hard because the patient you know is pushing the doctor for you know you know a pain response but I'd rather them actually have some oral pain medication for a period of time um rather than that sort of local injection at the at the hip and then if you know so often patients will come to me for my referrals and And they might have a,

like a referral for a cortisone injection, although I haven't had that recently, but, you know, probably earlier in my education process before the doctors could see, I suppose that actually, you know, we can have the effect without the cortisone, the patient would turn up with the referral and they'd say, the doctor told me to ask you about whether I should have this. And then I'd go, all right, it's good that you've got that up your sleeve.

So we've got that up, you know, as a backstop, but let's try these things first. And then if you need it, we've got that, you know, we can fall back on. But, you know, let's try this first. And generally, I'd prefer people to, you know, if they're really severe, I'd prefer them to use a walking aid and use some oral analgesics initially and just see if we can get them calmed down. Of course, if they need it, they need it. If their pain is severe, they're not sleeping and things like that.

But you'd be surprised how much impact we can have in a couple of weeks with some good good education and you know a walking aid if necessary if it's really severe limping so walking stick crutch or something yeah and that's not that like that we're saying you need to be on a stick forever now no this is a temporary thing and so often i use a crutch rather than a stick because a crutch seems like a an injury that you'll progress past rather than a stick

seems like a disability it's interesting yeah good good points you know that's so a lot of patients will be happier to use a crutch than a stick. Very cool. And it is all about behavior. And I think that that conversation really can test the relationship you've got with the patient. It tests all your skills of active listening and letting them speak and then educate. Education is not something we're taught as clinicians, isn't it?

We're typically taught, whatever we are, to do things with our hands. And we're not taught how to educate or to get on with people and help behavior change.

It's missing from our toolbox. box so yeah it's fascinating to hear that but putting it into effect is yeah it's a little change of conditions look i'm keeping you past your time i know i mean i've got nothing to do now i've got somebody watching tv eat up my dinner go to bed but it's different for you you've probably got a whole day ahead for you so i'm conscious of that i do want to just quickly mention thank you for the questions in there sorry i didn't get to them but

you can understand why i didn't want to interrupt that car gregory says just joined and already love what i hear re-watching tomorrow cloud car you will love this i know you and you will really enjoy the full hour and maria maxieri thanks for joining us and maria from the st school says absolutely touches context for health literacy yep lovely and maria is one of our national champions for modern approach to your hands on

and massage and everything time frame we had gary benson here says was there and increased confidence and movement in the education and exercise group?

Good question, Gary. Yeah, good question, Gary. And yes, there was. And that's really important. Well, what we measured was pain self-efficacy. Okay. So, and part of the questions in there are around, you know, doing your physical activity and despite the pain.

And I do think that change in confidence is something that does underpin them, you know, feeling more like supervised training that we do feeling more confident in the way that they move I think that does really impact on their quality of life because they start doing more things and getting back to the things that they want to do and need to do and so yes confidence is something that I think is really important and education and reassurance and showing them

how to move and sometimes I think education gets a bad rap because it's sort of like like, you know, you're making them fearful. Actually, no, we shouldn't be making them fearful. It's how you do it. And it's actually about empowering them. So if they can't walk upstairs because they feel like someone's ice-picking them in the greater Trichana, but you can show them how to do that without an ice-picking the greater Trichana, that's not fear-inducing, it's empowering and it's relieving.

And they finally understand why they have this problem and what they can do about it. And it's, you know, the impact on their confidence, I think, is incredible. And that's what we showed in that first sort of eight weeks there, pain, self-efficacy, that confidence dramatically increased, which is great. Fantastic. Right. I love the way you provided a fantastic segue for Ebony, Dr. Ebony Rio, for next week. We'll be talking about pain and pain management.

And you mentioned her paper as well with the isometrics. And yeah, so that's a lovely segue. Like I say, in two weeks' time, people, not next week. We're having a bit of a break. But the week after, Ebony Rio's not. She's flying somewhere and coming back somewhere. So that's why we're moving it forwards. But we will have the pleasure of an hour with Dr.

Ebony Rio in two weeks' time, still at 9 o'clock BST. but i just want to make sure if people are interested in further education obviously there's so much great work you do for education as well as in clinics i'm just going to bring this up for people in the live lounge let's put it on here the website if you're interested people so drallisongramaldi.com and across social media thank you allison for just having dr allison gramaldi anywhere

with a lot of people it changes it depends whether you're on twitter or Instagram or that it's just so simple Dr Alison Grimaldi is where you will find Dr Alison Grimaldi so well done on that I'm getting your name in there but yeah the website is a wealth of knowledge just talk us briefly if you're okay for a couple of minutes because I'm conscious it is. 12 past where I am and where you are. You mentioned the Hip Academy.

Let us know a little bit quickly, briefly about that. Sure. So, excuse me, Hip Academy is a group of health professionals from all over the world. So health and exercise professionals. And it's a lovely community that we get together, you know, every couple of months or so and do an extra lecture and a live lecture and questions and we do case presentations as well. And those are all recorded and part of our library of resources, but Hip Academy members also get access to all the hip courses.

So there's four different hip courses, there's four eBooks as well. And then there's that large video library that I mentioned before that contains little short videos of all the different assessment techniques. And so that's not only diagnostic techniques, but muscle assessment techniques as as well, and exercises. And so that goes through how we'd, you know, prescribe the exercise to a patient. So it's got voice over there of the cues that we use for patients.

Yeah, so there's lots of information there and information on reading x-rays and MRIs and things like that. So yeah, so it's a great community. And the bit I love best is the live meetings because we do have people sort of logging in from lots of different professions and different places all over the world. So it's great to get discussion from different perspectives as well about different conditions. So yeah, you're very welcome if you'd like to join us at Hip Academy.

If you have a specific interest in gluteal tendinopathy and you don't want to do the whole Academy thing, there's a course on lateral hip and buttock pain. There's an e-book on gluteal tendinopathy and there's one on proximal hamstring tendinopathy as well, or you can get the whole e-book series as well. So depending on how deep you want to go into it, there are different resources for your needs.

Fantastic. And hopefully, listeners, you can hear from the hour we've spent with Dr. Alison Grimaldi tonight. You can imagine how it's going to be presented in, if I can say, a wonderfully infectious, passionate way. It's just amazing. And that's important as well. There's so many courses out there. And one of the things is, is the person giving the course presenting it in a way that you can take in and enjoy it.

So yeah, do check that out. And there's also on On the website, dralisongabaldi.com, there's also a blog. There is loads of information. Oh, I've just taken it off. There's loads of information for you to check out. So I do recommend you go there. It will be in the show notes, people, if you want to go and have a look. So yeah, do check it out. And there's some wonderful blogs there. And also, like Alison has said, links to the books and the video library.

So yeah, a wealth of information, fantastic stuff. So we appreciate that, Alison. Thank you. And also, ironically, you're over in the UK in a week or so, aren't you? It's too late to book you people. Don't get excited. But you're coming over here.

Yeah yep so i'll be over i think there might be there might be a couple of places left on a couple london courses i'm not sure but a lot of them are booked out but there might be a couple of places in london so vital pm is who's hosting it so that's available there and matt the other thing i just wanted to mention to your listeners is that course on my other website if they're interested in that.

So there's another website that I have that is patient-facing, so hippainhelp.com. And if you're interested, or you might have patients that are interested as well, but there is a course that I've done there for patients on gluteal tendinopathy. And so that sort of goes through a number of educational videos. And so from your therapist perspective, that might be nice at least to sort of see what sort of education that I'm usually providing to my patients.

And then there's also exercises there as well. And so there's videos of the exercises and cues about what things that we focus on in the exercises and information about how to progress or how to regress if you have a flare up or things like that. So that's another resource that might be helpful as well. And that's, what was it, hip health? Hippainhelp.com. Hippainhelp.com. We'll make sure that goes in the notes.

Yeah, that's brilliant like we're saying off air seeing how you can educate a patient and using the terminology of patient we get on with that that's going to be a wealth of information as well so thank you for that yes all of that will be in the in the notes people so there we go it's 17 minutes past dr arson round i hope i haven't caused you to miss anything coming up no that's okay so and thank you so much everyone who's joined us live as well some amazing questions in

there thank you for people listening to the podcast if you are listening then check out all of the links which will be in the show notes and do please leave a rating as well on particularly google podcasts apple podcasts because it just helps the information shared by our wonderful guests just appear more in google which is all about what's all about it's all about education like i say next week in two weeks time sorry dr ebony rio will be with us um

to focus on managing tendon and pain which will be a lovely continuation of some of tonight's themes so if you listen to the podcast you want to join us for that then that will be june the 4th at nine o'clock bst british standard time so there we go right thank you once again dr alice good mouthy for your time it's been absolutely amazing really really appreciate it no worries thanks so much for having me and thanks

all the listeners to um listening thanks people take care of each other we'll see you soon. Music.