September 2019 – How to Fix your Lateral Hip Pain

By Catherine MacRae

I was inspired to write this blog after listening to a recent webinar by Tom Goom (www.running-physio.com) on ‘Lateral Hip Pain – 5 Mistakes that are ruining your results’

Chances are, if you are suffering with lateral hip pain (pain at the side of your hip), you may have Gluteal Tendinopathy. It can manifest as a severe, disabling pain directly over the Greater Trochanter (the bony prominence at the side of your hip), but can be successfully treated with an individualised treatment plan. So what should you expect from physiotherapy intervention with this particular problem?

  • Decreasing ‘Compression’ of the Tendon:

Gluteal Tendinopathy can be provoked by ‘compression’ of the Gluteal tendon insertion point at the bony Greater Trochanter. So our first goal is to decrease time spent in positions that increase this compression. It occurs when the hip is brought into positions of Flexion (Knee towards chest), adduction (Leg across the body), or Hip External Rotation (Outward Hip rotation). Examples of common ‘Compression’ positions are; crossing your legs in sitting, Gluteal stretches, Side sleeping with the affected limb upper most and across the body, and standing ‘hanging’ with hip off to the side.

  • Modifying Activities:

Tendinopathy is often related to an overload episode, where the load that you are applying to the tendon, outweighs its capacity to cope. A reactive response then occurs within the tendon, which leads to pain and inflammation. Activities that involve the tendon going through its’ Stretch shortening cycle (SSC) may need to be modified. This is where the tendon behaves like a spring, stretching then shortening to store and release energy. With the Gluteal Tendons these activities are usually walking & running. In the short term, you may have to modify the intensity and frequency of these activities, to assist in settling pain.

  • Low Level Activation Exercises:

Research has also shown that low level Gluteal activation exercises can assist with pain. With one of the main goals being to improve and maintain Tendon strength, starting to activate the Gluts in a tolerable way, not only starts the rehab pathway, but also can be relieving. Isometric exercise (Holding a static muscle contraction) has been found to reduce pain for up to 45 mins after a single session, and avoid any reduction in muscle strength. (Rio et al 2015)

  • Education:

Managing tendon pain is complex and one of our main goals as physiotherapists is to provide our patients with the confidence and the tools to take control of their rehabilitation. In fact a recent study has highlighted the importance of education as an essential part of Gluteal tendinopathy management.

Visual abstract, showing the study population, design and primary outcomes.

BMJ 2018;361:k1662

LEAP trial: Mellor et al 2018

204 patients with Gluteal tendinopathy were randomly assigned to 3 treatment groups; A program of education on load management, plus exercise (14 sessions over 8 weeks), A Corticosteroid injection, and a ‘wait and see’ group. The results showed that the Education group had better outcomes at 8 weeks and 52 weeks.

BMJ 2018;361:k1662

The Key Education messages that we want to get across to our Tendon pain clients are:

  • Tendons are Strong and Resilient, and will adapt and become even more robust with appropriate loading.
  • Pain is a reaction to increasing Loads and not necessarily Tissue Damage.
  • Our goal is to find the ‘Sweet spot’ with exercise and activity. Too little equals weakness and de-conditioning, and too much aggravates symptoms.

Progressive Rehabilitation Program:

Once we have determined what your individual goals are, a graduated Tendon loading program with be implemented, based on getting you to where you want to be.

As mentioned earlier, this may start with Isometric low level activation exercises, but gradually increase to heavy loading while monitoring for any irritability. Then, progressing to more challenging functional positions (e.g. Single leg squats, Single leg control, Fast movements, impact movements), and finally loading back into ‘compressive’ positions.

Once goals are achieved, a maintenance plan is an important final step. It will allow you to sustain the Tendons capacity to cope with load, and live well and Move well!

References:

  • Tom Goom (running-physio.com): Lateral Hip Pain – 5 Mistakes that are ruining your results.
  • Rio et al 2015: Isometric Exercise induces analgesia and reduces inhibition in Patella Tendinopathy.
  • Mellor et al 2018: Education plus exercise versus corticosteroid injection uses versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial
  • Cook & Docking 2015: “Rehabilitation will increase the ‘capacity’ of your …insert musculoskeletal tissue here….” Defining ‘tissue capacity’: a core concept for clinicians

August 2019 – Load Management for Injury Prevention

Motion Health Exercise Physiology Melbourne

By Catherine Macrae

Whether you are training for a marathon, a hiking holiday, a week at the ski slopes, or even just maintaining the ability to cope with tasks of daily living, managing load is relevant for everyone. Research highlights the need for education on modification of load in addition to strengthening the kinetic chain.

So how do we define load? It’s basically the total volume, type and intensity of activity that an individual undertakes in both training and competition. Measuring and monitoring load is important to the individual and Physiotherapist because we can use the information to our advantage in preventing any Non-contact soft tissue or bony injuries in the future. Your base ‘condition’ or ‘capacity’ will dictate how much load your body may be able to tolerate. If the loads that you apply to your bodies are greater than the tissues capacity to cope, then a reactive response can lead to inflammation, sensitivity and pain.


Courtesy of ‘The Running Physio’- Tom Goom.

The AIS have produced a paper based on best practice guidelines titled ‘Can we think about training loads differently’ – click here to read the paper.

They have set out five key principles of load management to assist in Injury Prevention

1. Establish moderate training loads and ensure these are maintained
Basically, tissues LOVE consistency! If you can apply a consistent level of loading over a period of time, the tissues begin to adapt and when sudden spikes in load do occur, they will be much more likely to cope.

2. Be aware that injuries can be latent following increased training loads
This is why managing and particularly monitoring load is so important. Sudden increases should be avoided, with a general rule of 10% load increases only!

3. Minimise large week to week fluctuations
Consistency is key! Common pitfalls occur when returning from training/loading breaks like holidays or injuries, and individuals resume training at the previous level of load. Illustrated nicely with Dye’s ‘Envelope of Function’ (Courtesy of Tom Goom ‘The Running Physio’)

4. Establish a floor ceiling of safety
Any training program should set out a minimal level of weekly loading, and a maximum level of loading. Ensuring training stays in the ‘Safety sweet spot’

5. Ensure training loads are appropriate for your current situation.
Loads should represent the current tissue capacity. Monitoring how someone is responding to load (i.e Fatigue, sleep, tissue response etc) assists us in graduating a training program appropriately.

The take home message from this, is GET MOVING! Tissues Love and adapt to regular loading. If you have a training aim or competition goal in the future, use the assistance of a Health Professional like a Physiotherapist or Exercise Physiologist, to establish a base training program and assist in monitoring the graduation of your loading to allow you to reach those targets safely, without injury!

March 2019 – Explaining Pain

Explaining Pain
by Catherine Macrae

‘All Pain experiences are a normal response to what your brain thinks is a threat’

The construction of the pain experience in the brain relies on many sensory cues. There are danger sensors throughout the body (Nociceptors), that when excited to a critical level, pass a message on to the spinal cord. Here excitory chemicals are released, which in turn can lead a message to be sent to the brain. The brain relies on credible evidence to process and decide if and what response is required.

Pain is not always produced. Sometimes the brain concludes that other behaviours such as movement are more appropriate to avoid threat or injury.

THE AMOUNT OF PAIN YOU EXPERIENCE DOES NOT ACCURATELY RELATE TO TISSUE HEALTH
Pain is only a protector. The unpleasant feelings produced by the brain are designed to change your behaviour, to allow for your tissues to heal or to avoid perceived threat.

SOMETIMES PAIN IS NOT HELPFUL especially when it persists. All tissues will heal, and the majority of pain will be gone within 3 months. However when Pain becomes persistent, the nociceptors are conditioned to become more sensitive to stimuli.

WE LEARN PAIN and become better at producing it. With Persistent pain thoughts and beliefs become more involved and can contribute to the problem.

RETRAINING THE PAIN SYSTEM:Accept that ‘Retraining the brain is complex’
We cannot easily ‘switch off’ the brain.Using Pain as your guide is also not always helpful. This can lead to drastic limitations of activity and meaning in life.

HOW CAN WE HELP?
Through education and helping you to understand your pain better, the research proves that it can help you cope, and shift unhelpful attitudes and beliefs about your pain.
We can also support you in moving more than you are or believe you are currently capable of through pacing and graded exposure techniques.

Read more about Pain from Lorimer Moseley, one of the world’s leading Pain Scientists at:
https://www.tamethebeast.org/

Our team at Motion Health is available for any further questions