Nonarthritic Hip Pain with Keelan Enseki - Episode 42

Hip pain is common in athletes, especially in sports like ice hockey.

Nonarthritic hip pain encompasses a variety of intra-articular diagnoses that are often seen in these athletes that are not related directly to osteoarthritis. These include dysplasia, bony changes, femoroacetabular impingement, labral tears, and more.

A recent clinical practice guideline on this topic was published in JOSPT to help guide us. In this episode, I talk to the lead author, Keelan Enseki, about the findings of the CPG.

Full show notes: https://mikereinold.com/nonarthritic-hip-pain-with-keelan-enseki

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Transcript

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On this episode of the sports physical therapy podcast, I'm joined by Keelan and Secchi. Keelan works at the university of Pittsburgh medical center is currently the director of clinical practice innovation and the administrative director of physical therapy, residency programs. He's also an adjunct professor at the university of Pittsburgh. We're going to talk about his recent publication in JSP. S P T a clinical practice guideline on non arthritic hip pain. Welcome to the Sports Physical Therapy Podcast. I'm your host, Mike Reinald from Mike Reinald. com. how's it going? Thanks so much for joining us on the podcast today. Hey, I appreciate it. Thanks for having me. This is great. Yeah, no, it's good to connect. We, um, you know, we spent some time up in Boston at the Orthopedic Summit and I really loved your talks. I really loved learning from you. I mean, a bunch of great insight. You're doing a bunch of great stuff, um, that I'm really excited to talk about today. We got some big topics because you've got some really big publications out there, but, uh, this is pretty exciting. I've been looking forward to talking to you for a bit. Great. Thanks for having me. I think it's, uh, this is a great, uh, a great, a great medium to talk about this, these topics. And I hope I can, uh, provide the audience with a little bit of, if not clarification, a little bit of structure and how you can use them in clinical practice. I think that's great, right. So Keelan just recently published a clinical practice guideline in JOSPT on essentially non arthritic hip pain, and I guess, I think for a lot of my listeners, I'd like to go, before we get like too deep into the paper, um, which I'm excited about, um, there's so much work that goes into a CPG, and I'm not sure people realize that, right? So I feel like, like, to give a little clarity in terms of like, what it takes to make a CPG and how in depth and valuable these things are. Why don't we start off, before we get into the actual meat of the, of the paper and what we actually do with non arthritic hip pain, why don't you tell us a little bit about the process behind creating a clinical practice guideline and what goes into that? Yeah, absolutely. And you're right. It's a, it's, it's a labor of love. And sometimes, you know, by the time we finish one, I always say, I'm not going to do another one, but you know, here I am again. So, you know, I guess I, I, I'm not always truthful with myself. You know, we started, not we, but the, um, the APTA. And at the time it would have been the section. Now the academy, orthopedics, along with at times, uh, the sports academy, uh, was the section at the time. Sort of these CPGs relevant to musculoskeletal conditions in 2006 with the idea that, and I became in 2007 with an arthritic one, uh, arthritic, uh, hip pain CPG, um, that has been published twice and we're in the, we're in the third revision stage now. But, uh, the idea was to, uh, um, provide evidence based guidelines for clinicians to know with common musculoskeletal conditions, just where we're at with the literature. And then over time it's evolved to make. Recommendations to and strength of recommendations, meaning that, you know, based on the amount of literature, it's available. What are the things that you should be, uh, in most cases, definitely be doing. And what are the things that maybe don't have as much evidence doesn't mean you shouldn't do them. It just means that maybe at this point, we just don't have, you know, much to say about it. And it's quite an involved process because for each 1 of these, there's a systematic review, um, uh, looking at, Diagnosis, intervention, prognosis, um, and outcomes. And then we even have more scoping reviews and often, uh, statements that are not, maybe not as heavily researched, but related to that. And, uh, it involves, you know, a heavy literature review amongst a team of authors. There's. We have three, you know, editors, I believe, um, we have external reviewers that aren't all physical therapists. This includes our surgical and physician colleagues, even, uh, other individuals and health care providers and people within the health care system. So, they undergo this comprehensive review, numerous rounds of that, and then eventually what we want to do is produce a product, if you will, that is a snapshot of where the literature lies and given in the idea, you know, in general, again, is to give our clinicians. Uh, an idea of, you know, what is out there, because many of us, I'll include myself, just don't have the time to go parsing through the literature to look for all of this. Right. And you know, I think the comment that you said that I really liked here was that this is a summary of what we currently know. And sometimes we know things work. Sometimes we know things don't work. Sometimes there's a lot of gray, right? We kind of, you know, we teach this to our students, uh, um, and our, our, our people online is kind of like our light system, right? The red light, green light, yellow light, right? If we have firm evidence that something doesn't work, obviously that's a red light. If we have firm evidence that something does work, that's a green light. But the majority of what we do is yellow, right? The more we, we don't have enough overwhelming evidence on, on much to do it. So to, to put together a summary of, of everything we know, not only is a huge task, but such an amazing thing for clinicians to learn from, because you have to be sure that you understand those red and those greens, but then more importantly, that you understand some of the context of the yellows. And I think when you put that all together, that's when you start making some really good decisions as a clinician. Yeah. And I think that's, that's a very good analogy and really to me, often with these guidelines, the yellow is the most important part because reds, I mean, if you're doing something that's red based, you probably better second, there's a lot of second thoughts. There's not a lot of reds out there though. I mean, other than things that are probably contraindicated. Uh, that you probably already knew, right? You probably learned that in PT school, the greens, many of us know that because we get so much of that, but the yellows where a lot of your practice lies in non arthritic hip pain specifically is an example. That's where we have a ton of yellows that you would see. It's better than we had before. And I think that in one way we should say, you know, that shouldn't scare you away from using that. That's all we have. So use good clinical rationale. No, it's not a red. Um, on the other hand, if there's a green in there and At times, there's not a lot of those, and you should really question yourself at times whether, hey, at least I should be doing the greens, right? And then, you know, and then the yellows, you have to use your clinical decision making, which is, that's what we do, you know? Right, exactly, right. And, you know, there's, I get it, like, if you're an early career professional, there's a lot of paralysis by analysis, right? There's so much information out there, it's daunting. Right. And you know, some people, um, you know, some people, you know, the social media, uh, crowd, there's certain people that like to focus on the red lights. There's certain people that like to talk about like what doesn't work or what we shouldn't do. Right. And I think sometimes that just leaves more doubt in people's mind that they don't know what to do. So this is such a valuable resource to try to, I think actually shed some light that none of us know exactly what to do. We're just trying our hardest within the available evidence. Exactly. Yeah. Yeah. So what do you think here? So clinicians have seen CPGs for a long time. There's, we've been, like you said, we've been publishing, uh, as you know, our academies in the APTA, we've kind of had an initiative towards this for the last couple of decades or so. Um, there's a lot of information in a CPG. We've kind of hit on this a little bit, but are there any other tips you think clinicians should know about how to best use the CPG to, to guide what they do in their practice other than what we've already talked about? Because I do think sometimes people see these, these. beast of a documents in JOSPT like I think the one we're about to talk about was like 70 something pages with all the, with all the references and stuff in it is, you know, what would you recommend to some of your students or early career professionals that are just getting started? How do you use the CPG to get the most out of it for your clinical practice? Yeah, that's a very good question. I think you can look at using the CPG on multiple levels and depending what your intended purpose is, uh, you can give it a more Kind of, I don't want to call it a glancing look. You know, I never want to tell anyone to just go to the summaries, but at times you're in the clinic, grab it, go to the summaries. If you just want to check yourself or get a, just a general direction, right? And that's the term I would typically use. If you're a researcher or you're a paper, or you just want more information, go a little deeper into it. Then, you know, we have that information there. So you can kind of adjust the way into the extent that you use these in clinical practice. And that's, there's, there's nothing wrong with that. Right. When we, we published these, we didn't, we knew not everybody's going to go through and check our literature review, which is clearly spiraled out. You have to do that in a good CPG, but you know, I don't do that with every CPG that I use. So I would say, I would recommend that clinicians use these in the manner that best fits them. They were kind of designed that way. I would also caution people, uh, against, uh, thinking they're going to open this and get a cookbook, right? This is not the same as getting just your, not just, but your post operative protocol that you may, You know, get with a patient or a non operative protocol where everything is very specifically spelled out. We don't call out many various, very many specific exercises or, or very specific timelines. There's not a lot of evidence of most of that, for one thing. It's not intended to do that. It's guidance. It's a lot, it's a, a kind of a guardrail to check yourself if you're way off course. Maybe you're on course and this just reaffirms what you already know and what you're already doing. So I would say adjust your usage of these to your intention. Um, you know, that's how they are designed to be utilized. And they're not designed to replace solid clinical decision making. We always make that, maybe that's a liability thing, but we always make that disclaimer because really, it's there to help make those decisions. But the document never makes the decisions for you. That's the way you, I, and all our therapist colleagues are trained. That's, that's great. And I think for middle and even late career professionals like myself, sometimes I use CPGs to almost like check my biases, right? Just to make sure that the things that I've been doing for a particular topic, maybe are still using best practices. Uh, evidence and maybe there's something new that came up. Maybe there's, there's new information, you know, good or bad about some of the things I've done. So I've also used it, you know, as I evolve with my career to make sure that I'm staying on pace with, with as much current evidence as I can. Yeah, I know. But, you know, I I've seen, you know, probably 80 90 percent knee or hip patients, but I will see knees and shoulders. Everyone's on despite what people might think. And often I that's where I'm going to the CPGs for the knees and shoulders because I know, you know, I'm just not up to date on some of that evidence or I may or may not be. But I want to know and this is a good way for me to go. Okay, I'm doing this now and I've been doing this for 5 years, but maybe that's not what I should be doing now. And maybe there's something that's, you know, a better fit in regard to evidence. So I'll often use it to check my practice just as you described. Thank you. Yeah, it makes sense. Especially when you don't, like you said, you're, you're, you do a lot of hip when you're, you have something new in front of you that you haven't seen in a while, that's a good way to kind of just check and say, wow, you know, let me make sure I'm on pace. And, you know, to me, to me, that's what makes you an expert clinician. It's not that you know everything. It's just that you know how to find the answers. Right. You know, and what you don't know. Right. That's a big, that's a big part of it. So, yeah, absolutely. You've actually alluded to this, but the current CPG that you published is actually an update to one you did in 2014 and you've actually already out alluded to the fact that you're already working on the next revision, even though this one just got published. Tell me a little bit about your thoughts on that. Like, like what, what's your, what's your cadence for that? Like, is there a specific cadence that you'd like to do? And, and, and tell me a little bit about the rationale behind that. Yeah. So, you know, when we, when these, these. When the, when this, uh, the CPGs were in development, it's much, and you're always very, as a group, you know, you're pretty, uh, um, you know, you think big, right? So the thought process, and there's some organizations that can do this, you know, these every five years. That's really a challenge, a big challenge, they take several years to do, and especially if you're authoring more than one, and many of us are to some extent, and of course, you know, these, the authors, uh, you know, for most, it's volunteer, right? You do this in, uh, It's so it is for historical context when we did in our non arthritic pain. Uh, in 2000, it's published in 2014. 2013 was the literature. We stopped the literature review. Uh, you can look at that document. Uh, I said, look at it now. I'm like, wow, we really not we've just collectively. There wasn't much out there. We have all these F level recommendations. So that was kind of one. You know, it, it's, it's a good way to, to, to uh, uh, uh, keep yourself honest in how much you do or don't know and how much we do or do not know. And then, you know, you fast forward to 2023, which isn't five years later, right? It's nine years later. Right. And we have some better recommend, better in terms of stronger recommendations, say better. Some of'em are the same just with higher grades. There's a little historical context there. When it came to 2018, uh, I felt a number of us fell a little bit behind Covid hit. Where we thought we'd be less busy. It was actually more busy just from having to integrate a telehealth system together. Um, and so by circumstances we got delayed, I would say in this case, and not that I want to do this all the time, we might've been fortunate a bit because it passed the 2018 mark when we updated our literature view, which we had to do going into this year before we published them, there's been some pretty big studies, some SRs, a number of SRs came out, but also some clinical trials. Some of them are. Even comparing surgery against P. T. But you can glean P. T. Information from that. I think in this case, it just worked out that that, you know, publishing it this year and a little bit of a delay allowed us to capture, uh, this this kind of large body of information that that allowed us to make stronger recommendations. It won't be our goal to always do that. I think it's just by chance worked out that way. Um, But I do think it's a, if you ever want to see a CPG where things have changed a lot, this is one of those where you can see the amount of evidence which has grown substantially since we published in 2014. Yeah, I mean, you could argue in 2014 what your CPG showed was that we have a lot more to learn still, right? Yes. That's a big deal. With non R30k, you know, I'd hate to say that. You know, we're, we're not behind with the hip, right. But like a joint like the shoulder with arthroscopy starting, you know, decades earlier than the hip. I just feel like we learned more faster about some joints. And you know, the hip is something that we're starting to, to learn more and more about. So, uh, definitely timely to get this out. And I'm already excited for your next revision. And the goal is like to have a revision and say like, you know, we've, we've, like you said, we've fine tuned some of our thoughts, but. It's not like we were far off. We just fine tuned our thoughts. Um, you usually see there's the very few instances in a revision for those that were revisions exist. You're not usually taking one eighties, right? You're kind of doing this a bit. Very rarely you're going the other way and say, no, I was completely wrong before, which I guess is good, but it's subtleties and strength of recommendations that sometimes you know what I was doing that I was right. Because now there's more literature to support it. Love it. Love it. Well, the topic of the paper is non arthritic hip. I want to start with that because I think we all deal with a lot of non arthritic hip pain. Hip pain's huge, right? We're seeing this a lot as people become more athletic in the sports world and not even just like professional collegiate athletes, but just like our everyday athletes playing pickleball and golf and everything else that they're doing now. We're seeing so much more hip pain 20 years ago, just for me personally. But, um, to me, non arthritic hip pain, that's a, that's pretty big. Like what, what exactly does that? statement mean to you? What are the diagnoses that you would include in a non arthritic hip pain? Yeah, that's a very good question. And it's a question we get all the time. And again, some context there, just using that term has been a source of, uh, not controversy, but within group, uh, let's just call it discussion and debate. You know, you'll see in the literature, some people call it pre arthritic hip pain. Other people will say, well, that we don't have enough evidence to say it's all pre arthritic. Displasia, probably we have a pretty good idea there becoming more accepted, but so the term itself has been somewhat debated at times when we use that term and in particular, this guideline, but I think in general, in the literature, it is pretty encompassing, you know, sometimes I'll tell my residents and students, you know, I think of anything that's in that joint, you know, that isn't losing joint space and the cartilage is intact or you know, Majority of the majority of its attack. That's your non arthritic hip pain. But to be more specific, you know, we define it as an intraarticular condition. So that's the main thing. It's, you know, all our extra articular issues are not counted here, though they may exist along with it. Um, and it includes now I will note, I should note this too. If you look at our guideline, we are talking about for the most part, the skeletally mature population. So we're not going into the very young Children, infants and such for displays is an issue. But I only say that because we do mention dysplasia developmental dysplasia is part of our non arthritic You know, kind of umbrella under the umbrella, if you will. The big one is F A I S. That's where most of the literature is. Femoral acetabular impingement. We use the term syndrome to say those individuals that are symptomatic. Um, acetabular dysplasia, instability of the hip that is not even related to bony issues, micro instability, which is an emerging and debatable term. The labral tears, which usually come along with all these other issues. You can have them isolated, but usually there's an underlying cause. Uh, osteochondral lesions, loose bodies, ligament tears, or your, or your kind of, uh, the, the, the, the, what's in that bucket when we use that term. Thank you. Right. And I, I, I kind of like what we're doing with the hip here. So, especially because, you know, I consider myself more of a shoulder specialist to myself. Um, I don't want to say we made mistakes with the shoulder, but because I don't think we really did. I think the shoulder experts kind of had had a thought in their mind, but we tried to get like very specific with our pathology, our diagnoses, right? You know, the whole concept of impingement, what does that mean? You know, slap tears, like labral tears, same kind of concept. And I, when I teach people what we do for the shoulder, again, we take a huge step back and say like, I'm not sure it matters, right? If you have a slap tear versus a capsular tear versus this, you know, it's almost the same thing where we have shoulder pain. And we're going to have the same concepts of how we help people kind of get back from that as long as like you said, it's not arthritic. It's not something that needs surgery tomorrow, that type of thing. It's, it's, it's, it's kind of going together. So I feel like you guys are doing a better job at the hip than we did initially with the shoulders. We tried super hard to have like. Specific distinct diagnoses and say with shoulder impingement, you do this with instability, you do this. And realistically, there's probably a lot of overlap between all those different diagnoses. And I really like the way you guys are laying it out with the hip because I think it makes more sense that way. And we were fortunate. Part of it's because it's just a, if you want to call it a younger diagnosis, that, you know, we, we, surgery usually is ahead of us in terms of putting out anatomical terms, and it's very important than what they're addressing. But they gave us, for lack of a better term, kind of a, us just being collectively, you know, rehabilitation clinicians, a seat at the table to kind of say, okay, how are we going to define this? Like, femorocetabular impingement is anatomical, morphological. syndrome qualifies it as being an issue. And so, so some of that terminology, we've luckily been able to, to get a kind of a, uh, an agreement upon, not always agreement, but, uh, we, we've kind of been able to interact at a level that has allowed us to come up with terminology, which I think is, is friendly to everyone involved. And we have arguments, not everyone, even our PTs on this. CPG. Some are much more anatomical, biomechanical based. Others are more, you know, it's movement dysfunction. That's not as important. Uh, so we had to go through several rounds of voting and discussion to come up with some of these terms, but I think at least, you know, we, we, we try to make it clinician friendly and clinician useful. Right. Yeah. I mean, if I use the word shoulder impingement on Twitter right now, just, just, you know, go, go hide. Right. You can't, you can't, use that thing. And, you know, you try to tell, you try to tell the younger generation, you're like, ah, no, no. I mean, we all know that you, you impinge. I mean, you have, you have contact every time you move your arm. It's when that becomes symptomatic that. You know, that's what we're talking about, but you know, it's, it's a nuance type thing. So again, like kudos to you guys. I think you're doing, you're, you're, you're learning from the mistakes of the shoulder. I think, you know, better ways that we can articulate this and, and diagnose it and label it so that way we can get better outcomes. I think that's the intent. So, you know, again, kudos to you guys for doing that. You know, being late to the game has, at times, has advantages. Well, we can see what everyone else has been doing. You get yelled at on Twitter less than I do. That's perfect. Yeah, well, yeah, we see it. We're like, oh, yeah, I don't want that to happen. You know, that's awesome. So I love asking this question because whenever I talk to hip people, because I, I personally don't see a ton of hips. I do see some hips every now and then. I don't see a ton of hips. Uh, but you know, for myself, when I talk to my friends, especially my friends in the NHL and the hockey world, stuff like that, they say, if. The majority, if not all of their athletes have. changes. They have changes in their hip, especially if you do imaging on everybody. They all have changes. Uh, they're not always symptomatic. Sometimes they are, maybe they're about to be, who knows? My question I always ask people like yourself here is that, are any of these changes normal, accepted? You know, how often do they progress to symptoms? Those types of things. Are we over diagnosing, which then leads to over treatment and over surgeries, that type of thing? Like, like where are we with, with what we understand about these? bony changes, the labral changes, the FAI type things, like how much of this is normal within our society and how much of this is going to lead to future pathology. Yeah, it's a great, very good question. It could be a charge question at times. Um, and hockey is the perfect sport to bring up for this because that's where we have a lot. We do have a lot of data on that. Um, you know, and it is a, if not the prime example of this discussion. And, you know, it's interesting, you know, if you compare it to like displays or where you were often we talk about display that there are various reasons, but often that's that's determined very early development that has nothing to do with athletics that you're in. It may later on affect that. But we do know with these impingement, impingement presentation, right? And when I say that, I should say, not the clinical presentation, impingement changes, um, these can happen. There's plenty of evidence to say that, and Hawk is the perfect example, that, you know, it's a response to loading. And, you know, we, I think the general consensus is now we should be very cautious about. Tagging a pathological term onto that just because you see it, right? You have an image. I've got, um, Freddie food passed away a number of years ago. I don't think anyone would say surprise if we were doing a case in rounds of someone was and they said, I think I was tagged on and it wasn't what they were there for. He said, now you're kind of, you know, you're biasing them with a term that. You know, is it's going to be, you know, maybe negatively looked at and such. So I think you have to, you want to know these things because they are relevant, but I think we have to look at it as a morphological and this way of describing our guidelines. There are morphological variations that have been described and some of them should be looked at often think of hockey. It's a response to loading. You're not going to avoid it if you play enough hockey. And at the same time, no one's saying don't play hockey because you see these changes. I think, uh, when we look at those people that have become symptomatic, For as much as we know, and some of this we don't know, because you can see the same radiograph of someone who does the same thing, and they're not, uh, so not saying that we have this down perfectly, but I think there's kind of a balance there, and it's a balance between those changes that have occurred. Do they get to a certain extent? So there is some literature out there on, think of a CAM impingement, the degree and how much excessive bone is there, and the prognosis related to that, and not that this is radiology, but again, alpha angles that are very big. But 60 degrees, they're more likely not to do well and made it may be an issue where they're more likely to go to surgery. And then you have to look at the factors intrinsic to that individual. So, you know, one of the statements we make is Yes, we know we talked about the morphological component. If someone presents to you with symptoms, when you evaluate that individual, thus the importance of a thorough examination, are they shown impairments? Do they have strength, range of motion, movement, quality impairments? If they do, That's low hanging fruit. You should at least address that before you make a clinical decision. And, you know, as a team, is this person, you know, a surgical candidate? And then, of course, there's many other factors that go into play to the level of the athlete. Um, in the example, I will give if you have a pristine athlete in front of you, in terms of no physical impairments that are in a They played a high level. Think of your division one professional level athletes, um, you know, no physical impairments, uh, they're showing definitive hip pain, everything, you know, fits the picture. Um, and then the radiographs and imaging shows giant cam lesion, you know, tears limb that individual, there's probably gonna be a lower threshold of them going to surgery for all those different reasons. And probably some, I didn't even mention, we get our other individuals who may have some of those features, but they are a motor mess, so to speak, terrible movement quality. Maybe they're just. They're, they're general work. And if you think of your high school kid, it may not be, you know, an elite level. I think, but he plays and wants to keep playing terrible motor quality, terrible relative strength. Um, you know, uh, terrible just doesn't work out right to begin with, you know, saw something on, uh, you know, uh, uh, incredible Instagram account, where they should exercise. You know, there's a lot of things there we can change. We can get them out. We might be able to get them out of this. They would probably be the services that go to surgery right now, when there's a lot of things that we can actually change with those individuals. You know, it's funny you say that too, because we, we, there's a lot of things on social media that I see that I'm like, Ooh, they're, they're going to regret that hip mobility drill one day, right? We have a, we have a lot of people forcing hip mobility online right now, and you're like, wow, that's, yeah. I mean, just because oftentimes you don't have mobility in your hip for an anatomical reason. So if you just push it, that's going to be a problem, right? But yeah, that's how they learn. And that's where Wes, you know, is, is the. You know, uh, you know, physical therapists and certified like trainers and licensed. We have a little more knowledge that we we should we can help them make those decisions. Yeah, it's hip mobility something you need and can get safely or do we maybe have to make some concessions here at least, you know, uh, not withstanding surgery that that, you know, we're gonna have to look at other ways of getting to where you need to be because you're never going to get through that bone to get that extra hip mobility or you're going to cause issues in doing so. There's a finite end to it, right? You can't push bone. So, you know, it is what it is, but, um, what would you say to the clinician that would bring up the argument that, well, if I did an x ray on, you know, a whole team, half the teams, let's say they all have the same lesions, they all have the same bony, you know, chem, you know, pin services, they all have the same thing. Half of them are symptomatic. Half of them aren't, you know, what would you say to the person that says, well, well, you can't blame it on that. Then if, if, if not everybody's symptomatic, then it can't be from that. Like, what do you, what do you say in that search circumstance? Transcribed It's a, it's a valid argument, right? Why would I, you know, if the baseline is everyone has it, um, and then, you know, why should I be paying attention to it? And to some degree, when you look at it from a rehabilitation perspective, there's some validity to that argument. It probably won't, knowing that someone has, uh, a radiographic Evidence of, you know, impingement probably won't change directly the things you would do, you know, in a solid rehabilitation program. What I would tell those individuals is just think about it as a, uh, at the time of footnote, right? But look for the impairments, look for anything that is treatable that we can address in these athletes. Once you have done that, and, and so I always, this is what we tell our patients, right? I've identified impairments here that I think are related to, you know, whether it's movement, strength, what have you, related to your current condition. If we make improvement of all these impairments, but your condition is the same or worse, I know there's an anatomical underpinning there that could be responsible for it. And that would be our next level we drop down. It's, you know what, maybe this is the time to refer further, refer back. You know, now we start considering the anatomical issue. Um, so that's the way I would look at it. You don't have to put it. at the forefront, and maybe you don't even want to present it to the athlete that way, but you should take note. There may be a reason why they're not improving despite everything you do, especially if your reevaluation shows they're improving and all those other measurements that were deficient before. That makes sense, and you said it earlier, but tell me again, so what's the percentage that progress on to further either symptoms or worsening of the pathology? You said it, I think, earlier. Yeah, you know, it's not really known, and the reason I say that is because I don't even, I may be off a little, a little bit on the literature here because some of our colleagues, you know, in Europe, I think have a little better idea of this, or could probably state it more granularly, but, um, we don't really know for sure. Uh, what we do know is that we see trends. So in certain sports, the individuals that show these are probably more likely to go on. And I think a lot of it is just the demand of the sport, to be honest with you. It may not be the pathology at all. Um, the other thing we don't know, but we are seeing, and I think this is what you're asking about. You know, when you have these larger, more prominent, uh, alpha angles, cam, cam, uh, impingements where it's been most, uh, we'll see the most evidence. There is data that is emerging to show that beyond a certain point, some individuals are more likely to develop chondrolesions. And that, that may not even be symptomatic, just that, that their joint health may be at a higher risk. So there is, you know, I think there's probably an anatomical, I, I think, I feel pretty confident saying there's an anatomical threshold. We don't exactly know what it is yet, but. We're getting closer to it, probably defining that that helps drive, not only, you know, uh, physical therapy intervention and thresholds or referral, but obviously our surgical colleagues are looking at that as well. Yeah. So maybe a sneak peek at the third edition of the CPG we'll learn more over time. Right. Yeah. I'm hoping we have more to say, right. And I feel like in this particular topic, we, we probably will, you know, just because people are really focusing on, this is big in sports right now, among other topics, this is a big one. Yeah, I mean, we deal with it too. I mean, you know, relating back to the shoulder again, you have a lot of people like in their 40s that are super active doing like aggressive stuff in the gym, stuff like that. And yeah, they have a small rotator cuff tear. And they're like, well, I mean, you know, tons of people have rotator cuff tears. That's not a big deal. I'm like, yeah, sure. But like, you don't want them to get bigger. Like, I don't know, I wouldn't just like ignore that if I were you, but you know, I think at least if anything, it can be used to educate patients. Where, you know, and again, some don't listen to us, but you know, like, okay, yeah, we're not telling you not to do things, but you might want to at least, uh, you know, take this as a precautionary, uh, you know, warning that there's some things maybe you don't want to do adult don't tempt fate. Right. For sure. For sure. All right, let's, let's get into the meat of the paper, obviously. And, um, I thought for the listeners, cause there's even more than what we're about to talk about in the paper. So you should check it out. Uh, I'll put a link in the show notes, but, um, uh, let's break it into three buckets. Like, so what are the CPG recommendations for let's say Diagnosis diagnosis, and then examination, and then treatment right that's that's what clinicians deal with every day like what are the recommendations let's start with diagnosis but like what's the summary what you guys come up with and how you would recommend we diagnose this non arthritic hip pain. So diagnosis and this is probably the trickiest part and it seems so simple because you almost you know you kind of call it out in the In the title, but we looked at the diagnostic criteria as in terms of so the one thing we don't put away. We don't do formal reviews on imaging for these because we don't typically make imaging decisions. So, again, that's another topic and physical therapy, but we're usually not we, we, we go in with the assumption that. That imaging is not part of review. We do speak to it. We have a, we have the imaging section, uh, check what, what is written with our physicians. But the reason I say that is we, we, we, we speak to it, but we don't add it into the literature review. So if you look at our diagnostic criteria, we give these C level recommendations. That's basically saying that. Uh, it's it's it is weak evidence, and I don't want to put that in a negative light because weak is better than none. You know, we had before. Um, but when you look at this, we have, uh, the clinical presentation, typically groin pain, though it can be others, but groin pain is kind of telltale. We have the idea of this anatomy underpinning, which we've just discussed. And then when you look at most of the special tests for, FAI or FAIS, particularly, they're not as special as we might think. They are much better suited to rule it out, right? Because they're positive on a lot of other conditions. I just saw a stress fracture the other day, which was a positive. So when we look at this, that's the reason we give this kind of C level recommendation. It basically says we have to go on a constellation of symptoms and signs, but we're much better telling when it's not there and when it is there. Luckily, I would say, in, in, in cases, this is not a, this, these diagnoses, and I'm using FIS as the example because it has by far the most literature, dysplasia is, you know, a far second, um, you know, we can get an idea, and then, which I think we'll probably discuss momentarily, you know, the impairment component, where we assign, let's just call it the physical therapy, or the movement assistant diagnosis, as we'll discuss in a minute, I believe, we have much more, um, The literature is stronger for that. We have some B's, even A level recommendation. It's kind of a funnel. We get this idea of what is there. We rule out more serious things. We speak to that in the CPG, um, you know, or other, other issues that may not be HIP related. And then, uh, and then we move towards kind of verifying the impairments, which we make part of the diagnosis or movement diagnosis as we move along the examination. Yeah. Great. I mean, great, great way of saying it there too. And, and, you know, we're, you know, going into the special tests and the concept of that, like we're, we're never going to be perfect. Right. But I really like how you recommended it. It's sometimes special tests are helpful to rule out as much as they are. That was, that was a really neat, um, you know, summary of that. I like that. Well, we tell our residents and students you get that positive impingement test. Uh, don't, don't, don't fully invest in the diagnosis of femorostatic impingement syndrome, but if you don't get it. You might wanna be suspicious. Are you looking at something else there? Because it's pretty rare. That's right. You know, the literature says that, that you're not gonna get somebody symptomatic without it. So it truly does help rule out, you know, more than, than rule in That makes perfect sense actually. You know, and when, when you look into it, and again, what are you gonna do for non-art, hip pain? You're, you're gonna take a step back and you're gonna treat the impairments that you found, right? Which we're about to talk about, right? Yeah. You're gonna do that anyway and then, you know, if it succeeds, it succeeds. If it doesn't, you, you know, maybe the pathology is, is too far down the road, right? And you gotta tackle that, but, In most cases, they weren't jumping to another form of treatment. Anyway, they were probably going to be in a conservative bucket with you, uh, in rehabilitation. So you, if you missed. Or, you know, radiographs later on, they get radiographs and you're off with another diagnosis other than take a stress fracture or something like that, you, low risk, right? You would have been treated conservatively anyway. Exactly. Right. We say that all the time. You know, we always, people ask about imaging all the time. Should I get an imaging? And I'm always pro imaging. I mean, why not? I mean, the more information, the better in my mind. Um, you know, we always tell them we're not going to treat the image. A big part of it, we're gonna treat them. But, you know, but for me, I just, uh, you know, I, I wanna understand, but if it, if it's not gonna change what I do, I tell'em that. I'm like, look, exactly. Yeah. I don't really, it doesn't really matter if this shows your ligaments torn or not. I'm gonna, I'm treating under the assumption that it, it's at least damaged and we're gonna work around those parameters anyway, for example. So. Exactly. You know, it is what it is. So that's how I discuss it with patients too, because they always ask you about imaging. Oh, yeah, always. I mean, it's just what what they do. Everybody, everybody's their own advocate now in such an amazing way. I actually love it. But you know, we're just there to guide them. And I think that's what we do with our with our experience. But exactly. All right, well, let's get in the big one. Talk about treatment, right? Yeah. So okay, what do we do with these people? Right? So what do we know works? What do we know doesn't work? What you know, where are we at with the with treatment recommendations based on the CPG? Yeah, this is where we had the most notable change in terms of the amount of literature that came out there. I mean, you can look at our intervention from 2014 and it was a report cards all out. So it's basically I was saying, this is what we do. You know, it is absolutely expert opinion. And I don't, I use the term expert again, very loosely in 2014. Probably still today, but this is where we've had some solid evidence to show, uh, you know, what we do. And it is interesting if you look at this in kind of a hierarchy, and this won't be a surprise. I think this is great. I'm glad I can explain this here because I think people get confused. Um, you look at our, our, our evidence recommendations. We have everything from a We don't have any A's, but we have B level down to F's, which some of those refs, and they were asked before, and you may get a little bit surprised when you see some of those F's because you're like, that's what I do, but people shouldn't misinterpret this finding. The multi modal intervention, which is a term I should probably explain in this case, has the highest rating. It's a B. The reason it has that Is that most studies that looked at conserve the physical therapy intervention or management for most of this F. A. I. S. or other conditions, you know, in there. But, but F. A. S. by far is the private where the focus point is lies the most, um, most of those protocols were multimodal. So they involve strength. It's what we do in the clinic. Most of the time strengthening. Often some component, manual therapy, education, um, uh, you know, in a, in therapeutic exercise, of course, you know, other therapeutic exercise, neuromuscular control and movement. Pattern training is a specific term. Mona, many of our studies, most of our studies just use it all combined. So we are basing our, our, uh, recommendations based on the, the, the, the. The strength of evidence from those studies, when we look at studies that specifically try to pull out very specific, the effects of very specific interventions while controlling, you know, not having no other influences, there's not many, right? And then what you see is you see these C level recommendations where we, I would say that's, that's a success for us. There's nothing like that. So you will see education, movement, pattern training, which. Some people's confusing, but that is a term of the wash you group. Uh, I don't want to say they coined it, but that's really where it comes from a very specific, uh, you know, uh, training with with queuing on daily and other activities. Um, and then, um, you know, uh, then as we go down the line, you see manual therapy, you see, uh, therapeutic exercise. You see some F levels there. People shouldn't be. I don't want people to look at it and say, don't do these things. It just says we don't have evidence right now that it specifically tried to pull out that intervention. But that makes sense too, because I don't remember the last time I had someone come in with an FAIS or non arthritic hip pain diagnosis and the only thing I did with them was manual therapy. So it's hard to pull that out. Studies just aren't there. Right. Right. And you know what I, I, I have a suggestion to the world, right? I'll leave it at this. This is, this is a big one, right? But I, I wanna switch E and F right? When,'cause when we talk about f, F sounds bad, right? F sounds bad. Yeah, it does. F stands for, for, for expert opinion, right? So that's why I think it's a better E right? Because expert e you know, I mean that type of thing. Yeah. But, um, I, I switch e f in there. Um, I'm gonna bring that up in the next meeting. All right, but you know what, let's, let's change the system together. Uh, you know, I, I hate to, I hate to have pessimism with this here, but like, we're, we're not going to get anywhere as a profession if we do studies that say that, and we're starting to see these, like does manual therapy work for non arthritic hip pain? You're like, wow, that is, you can't make a study that shows that, right? And then you look at the methodology. You have 10 different diagnoses. You have subjects from age 18 to 65, right? And, and no definition of manual therapy, right? So of course, you're not going to find that anything. that, that anything works. You're just going to keep finding vague that there's no evidence that it does or doesn't work if we keep doing that. So, I don't know how we control those studies better, right? If that's even possible, but that's the reason why there's so much, you know, vagueness to it. So, people just have to realize like we're, we're humans here, right? We can't, you don't want to sacrifice the quality of the care that you're giving your person here to, to produce a well designed prospective study. So, you know, we have to take that with a grain saw and just realize that. We're not going to always have these huge green lights, right? Most of what we do is yellow, and we have to be able to accept that, right? And there's been some separate, uh, in almost in parallel to our publication, uh, and, and some of we couldn't include, so we couldn't just because of the time frame. This is some, but a number of, uh, publications that came out from various groups as international groups that have noted just what you said there, that when we look at the quality of how these studies are even often describing what they're doing, manual therapy is a good example. Even our exercise. interventions as they're discussed. It's hard to sometimes, it's hard to interpret these because you couldn't reproduce what they said. It's just not there. So what type of exercise were they doing? They'll call it optimal exercise, but it's not listed, you know, and in the same amount of therapy techniques that can encompass. It's a million different things. For sure. For sure. And I think you're almost, you're almost looking for green lights, you know, to keep going with our analogy on this episode, but like, you're almost looking for green lights in those studies because it's going to be really hard to say that it didn't work because man, that was, you know, you're throwing darts at the wall almost. Right. And that's, right. That's the hard part. So for me, I, if we're pleasantly surprised that a study like that shows. Uh, a positive effect, that's a win, but if it doesn't show an interactive event, like then, okay, I'm, I'm not, I'm just saying, okay. All right. Well, that didn't work, but that hasn't ruled it out yet. In my mind, at least it's interesting. There's a study. I always say where I. Uh, I use it to justify and there's others out there, but why we utilize movement quality training. So it involves a step down and single leg, um, squad. And if you prove those, you improve individual heroes, including sports specific heroes for impeachment. I think this is a great study. One of my co authors on the Martin on the, um. TBG wrote it, and I said, this is going to really drive her. It does drive my decision making. However, just because due to the, you know, the way that we, you know, grade these, if you look at it, it helped drive that recommendation to a C, right? In my mind, I'm like, this is, you know, it's me. It still is. It's a huge thing, but that's where you have to think that that's where sometimes diving a little deeper saying, I see the studies listed there. I'm going to go look at it. It could still help drive your clinical practice. Don't think a C or even an F, you know, should scare you away. It just may tell you that we have more to learn on it, you know, but, but it doesn't mean that you shouldn't do it. I love it. All right. So quick summary then based on the CPG, um, what, what do we, what do we know based on treatments? What, what should people incorporate into the treatments for non arthritic hip pain? So luckily a lot of people are gonna look at this and say, you know what? I've been doing that. You know, I've been doing right. I've been I've been measuring impairments and I've been treating them appropriately. And this just makes sense. So I think you're gonna get a lot of people in a great way, you know, let's say I've been doing that. I think the way you look at it is where we are now with the evidence. there is, um, it still supports an impairment based approach, right? So what we know is that, you know, some form of the treatment will usually involve some form of strengthening. Now we do have the, we do know what the strength patterns Most often look like an individual. So you might want to check it and see are the weaknesses I'm finding for this individual. What we know about the population. They probably will be most of the time, but it's always good to check against. We know activity modification. There's probably a role in that. Probably been doing that all along. I hope we have been, you know, um, you know, but, but there's a, you know, that's an education component. Movement quality is probably, it's really come to the forefront in that, I don't think of what we all, many of us, right, have been looking at. But if you weren't, if you weren't looking at the quality of movement, not just the strength, not just, you know, mobility, but what do they look like when they move? And now we even have some validated tests to assess that that are common in other conditions, but single leg step down. Single leg squat star excursion balance test. There's some literature to support that in this group. It's a correlation with strength deficit such. So, um, again, many of us have been doing those things, but we should take that kind of true multi modal approach to treatment impairment based. And then I think the other thing is we were discussing, you know, a number of minutes ago when someone doesn't improve and we're doing the things we should be doing, right? anatomical underpinning. There may be a discussion there, right? There may be a threshold and that threshold can vary. We hit where, where we may want to get further consultation. Um, and the other treatment neuromuscular education, manual therapy, of course, if it's indicated, go ahead and utilize it. They're low risk too. I mean, there may be some cautions and someone displays you, but. Your clinical reasoning would tell you not to do that with someone dysplasia anyway, you know, so, uh, you know, joint mobilization, someone who's hyper mobile. So again, I think, you know, this multimodal strongest recommendation we make probably falls in line with the impairment based approach that most of us that I would just say that we now have more evidence to show how we can assess and treat movement quality, uh, for individuals, you know, who have those deficits. Amazing stuff. So, uh, check out Keelan's CPG. You have to check it out. It's, it's pretty impressive. And if you aren't treating a ton of hips yet, you should check it out even more, right? So that way you're prepared for when, when, when they do come to your clinic the next time. But, um, we're going to see this more and more in sports. So, so it, for me, I thought this was a very helpful thing to do. And like Keelan said, I, you know, I, um, I would. Consider myself an experience just for tenure, like an experienced clinician and reading it. It actually actually made me feel better about myself that you know what there wasn't something magical. I was unaware of this. This it's just the basics. It's you know, the multimodal basics and I think you said that really well. So check out the link to the CPG in the show notes and then Keelan before I let you go. Got to go with a high five, five quick questions, five quick answers. Some learn a little bit about yourself. Um, I like these because you know, it's, it's, you get, you go into, into people's minds a little bit. So it's always fun. But first question, what are you currently doing for your own professional development? What are you doing for yourself? So I'm trying to take a deeper dive and it's not even to the hip right now because there's nothing out there on it, but I'm hoping to pull it over that on this, the whole neurocognitive aspect of orthopedic musculoskeletal injuries in athletes. You always talked about it before, right? But I think of the work that grooms and others have been doing, seen in the ACL population, and it just piqued my interest. I wonder if I can pull it over into what I do. You know, and there's nothing out there on it that I'm aware of. So I've been trying to get a deeper dive and just get, get my head wrapped around. And that can be relatively complicated at times about what's going on there. Cause I think there might be something there. I can't definitively say that, but that's what I've been really kind of putting a focus, kind of looking at what the, that, that kind of the growth in that literature that's been out there. I think it'll be great too. And you know, why not the hip, right? It's, it's, it's same thing, right? So I apply all that same stuff. So it'd be great. Um, what's one thing that you recently changed your mind about? Specific to me, it's my own criticism. You know, I used to look at the issues I would see in the hip and say, these people are either hypermobile or hypomobile. They have one end, you know, osteoarthritis, very little movement. Impingement probably means you don't have enough movement because your end range is quicker. You're just plastic and you're all over the place. So I thought I used to look at it a linear type of, you know, kind of a spectrum, if you will. And I still, some of that exists, but now I'm starting to realize, and this is, you know, it's what we learned, that these things can coexist. You can have someone with impingement that is hypermobile. It's a great clinical challenge. But I'm trying not to, uh, I'm trying to look at this at multiple layers now, um, and it makes it more complicated, more challenging at times, but I think, you know, to give to be most effective in intervention, we were going to have to start looking at this way. So I'm trying to challenge myself and that's. That's been an involvement over time. I look at my old grass from teaching. And I'm like, well, I used to represent it as a line and that's just not true. And he, it wasn't true then. I just didn't know it. Yep. I love it. That's a great one. Uh, what's your favorite piece of advice that you like to give your students? Yeah. You know, I tell him this is going to sound cliche almost, but. I can only tell you from personal experience to take advantage of every opportunity that presents itself, no matter how small or, uh, maybe not particularly exciting or not profitable because really those cascading into bigger and better ones. I've really, you know, I've only been very fortunate to be amongst individuals and, and opportunities, uh, given by those individuals to, to. To kind of get where I'm at at this point, and a lot of these were just based on really small might seem trivial at the time opportunities, but I tried to make the most out of them because I think they're cumulative. And, you know, you really can't underestimate the cumulative impact. Just kind of grinding it out there when you're kind of earlier in your career. I love it. Great one. Um, other than the third revision of the CPG, what's coming up next for you? Yes, I'm on a bit of a breather here because I, the fall and you were at one of the conferences that, you know, it's been a big conference time, both stateside and in Brazil and Africa. So, I'm getting a little bit of a breather here. I have a few presentations coming up. A lot of them are based on the CPGs. Other than that, you know, typical grind of patient care, some teaching and some manuscripts. I'm really, uh, um, Trying to kind of kind of reorient here and get my get back on my feet and hopefully going into, you know, the new year here. Um, I'm kind of in a, I could say, kind of a self examination phase of trying to look at some topics that I think are not covered with what I do. And it's something I can contribute to kind of at a system level where we're at. You know, I work at UPMC, but also just in the literature and such. So I'm kind of doing a little bit of kind of re examination self, uh, you know, self assessment of where I'm at and hoping that I can. Thank you. Find some, uh, some new paths to go down related to hip related issues, but that haven't been explored yet. Awesome. Well, if anybody wants to learn more, obviously they can go to the CPG article that we'll have in the show notes, but anywhere else that, that they can learn more about you and what you're doing. Yeah, it's funny. I think I could say this pretty confidently. You know, I'm the only Keelan and Seki on the planet that I know of. So if you literally go through, I checked it last night. If you Google me, you'll actually come up with like kind of some of our academic work, our research, research gain and sites like that, along with social media sites. You can get a pretty good idea of what I'm up to. I'll also put a plug in, you know, one of my roles at UPMC, our rehabilitation institute is kind of oversight, administrative oversight of all five of residency programs, but most directly involved in orthopedic sports residency programs. If you're a young clinician, student, you want to learn more about it, it's literally, you can Google it. You can find all the information on our programs. We're taking applications now. We'd love to have you if you're interested and come talk to us. Uh, so, you know, feel free to contact me or any of our program directors, um, because these are the types of things that we talk about, you know, and discuss amongst our residents. So, if you were, if you find this information that we discussed interesting, and maybe would like to get a little more kind of a deep dive into it, among other things. Feel free to check out our program if you were looking at that route, you know, or going down furthering your training and education. Great stuff, Keelan. Thanks so much for coming on the episode today and sharing all this and digging in deep on that CPG. And really, thanks for doing that. Because again, that's a lot of, of, uh, of effort that not a lot of people realize that you put into that. So thanks so much for all your efforts for putting that together. Yeah, thanks for having me and giving me a platform to kind of spread the word and discuss it.