Nonarthritic Hip Pain with Keelan Enseki - Episode 42 - The Sports Physical Therapy Podcast

Episode Transcript
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(00:00):
On this episode of the sportsphysical therapy podcast, I'm
joined by Keelan and Secchi.
Keelan works at the universityof Pittsburgh medical center is
currently the director ofclinical practice innovation and
the administrative director ofphysical therapy, residency
programs.
He's also an adjunct professorat the university of Pittsburgh.
We're going to talk about hisrecent publication in JSP.
S P T a clinical practiceguideline on non arthritic hip

(00:22):
pain.
Welcome to the Sports PhysicalTherapy Podcast.
I'm your host, Mike Reinald fromMike Reinald.
com.
how's it going?
Thanks so much for joining us onthe 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 sometime up in Boston at the

(00:44):
Orthopedic Summit and I reallyloved your talks.
I really loved learning fromyou.
I mean, a bunch of greatinsight.
You're doing a bunch of greatstuff, um, that I'm really
excited to talk about today.
We got some big topics becauseyou've got some really big
publications out there, but, uh,this is pretty exciting.
I've been looking forward totalking to you for a bit.
Great.
Thanks for having me.
I think it's, uh, this is agreat, uh, a great, a great

(01:08):
medium to talk about this, thesetopics.
And I hope I can, uh, providethe audience with a little bit
of, if not clarification, alittle bit of structure and how
you can use them in clinicalpractice.
I think that's great, right.
So Keelan just recentlypublished a clinical practice
guideline in JOSPT onessentially non arthritic hip
pain, and I guess, I think for alot of my listeners, I'd like to

(01:30):
go, before we get like too deepinto the paper, um, which I'm
excited about, um, there's somuch work that goes into a CPG,
and I'm not sure people realizethat, right?
So I feel like, like, to give alittle clarity in terms of like,
what it takes to make a CPG andhow in depth and valuable these
things are.

(01:50):
Why don't we start off, beforewe get into the actual meat of
the, of the paper and what weactually do with non arthritic
hip pain, why don't you tell usa little bit about the process
behind creating a clinicalpractice guideline and what goes
into that?
Yeah, absolutely.
And you're right.
It's a, it's, it's a labor oflove.
And sometimes, you know, by thetime we finish one, I always
say, I'm not going to do anotherone, but you know, here I am

(02:11):
again.
So, you know, I guess I, I, I'mnot always truthful with myself.
You know, we started, not we,but the, um, the APTA.
And at the time it would havebeen the section.
Now the academy, orthopedics,along with at times, uh, the
sports academy, uh, was thesection at the time.
Sort of these CPGs relevant tomusculoskeletal conditions in
2006 with the idea that, and Ibecame in 2007 with an arthritic

(02:34):
one, uh, arthritic, uh, hip painCPG, um, that has been published
twice and we're in the, we're inthe third revision stage now.
But, uh, the idea was to, uh,um, provide evidence based
guidelines for clinicians toknow with common musculoskeletal
conditions, just where we're atwith the literature.
And then over time it's evolvedto make.

(02:55):
Recommendations to and strengthof recommendations, meaning
that, you know, based on theamount of literature, it's
available.
What are the things that youshould be, uh, in most cases,
definitely be doing.
And what are the things thatmaybe don't have as much
evidence doesn't mean youshouldn't do them.
It just means that maybe at thispoint, we just don't have, you
know, much to say about it.
And it's quite an involvedprocess because for each 1 of

(03:15):
these, there's a systematicreview, um, uh, looking at,
Diagnosis, intervention,prognosis, um, and outcomes.
And then we even have morescoping reviews and often, uh,
statements that are not, maybenot as heavily researched, but
related to that.
And, uh, it involves, you know,a heavy literature review
amongst a team of authors.

(03:36):
There's.
We have three, you know,editors, I believe, um, we have
external reviewers that aren'tall physical therapists.
This includes our surgical andphysician colleagues, even, uh,
other individuals and healthcare providers and people within
the health care system.
So, they undergo thiscomprehensive review, numerous
rounds of that, and theneventually what we want to do is
produce a product, if you will,that is a snapshot of where the

(03:59):
literature lies and given in theidea, you know, in general,
again, is to give ourclinicians.
Uh, an idea of, you know, whatis out there, because many of
us, I'll include myself, justdon't have the time to go
parsing through the literatureto look for all of this.
Right.
And you know, I think thecomment that you said that I
really liked here was that thisis a summary of what we

(04:21):
currently know.
And sometimes we know thingswork.
Sometimes we know things don'twork.
Sometimes there's a lot of gray,right?
We kind of, you know, we teachthis to our students, uh, um,
and our, our, our people onlineis kind of like our light
system, right?
The red light, green light,yellow light, right?
If we have firm evidence thatsomething doesn't work,
obviously that's a red light.
If we have firm evidence thatsomething does work, that's a

(04:42):
green light.
But the majority of what we dois yellow, right?
The more we, we don't haveenough overwhelming evidence on,
on much to do it.
So to, to put together a summaryof, of everything we know, not
only is a huge task, but such anamazing thing for clinicians to
learn from, because you have tobe sure that you understand
those red and those greens, butthen more importantly, that you

(05:04):
understand some of the contextof the yellows.
And I think when you put thatall together, that's when you
start making some really gooddecisions as a clinician.
Yeah.
And I think that's, that's avery good analogy and really to
me, often with these guidelines,the yellow is the most important
part because reds, I mean, ifyou're doing something that's
red based, you probably bettersecond, there's a lot of second
thoughts.
There's not a lot of reds outthere though.

(05:24):
I mean, other than things thatare probably contraindicated.
Uh, that you probably alreadyknew, right?
You probably learned that in PTschool, the greens, many of us
know that because we get so muchof that, but the yellows where a
lot of your practice lies in nonarthritic hip pain specifically
is an example.
That's where we have a ton ofyellows that you would see.
It's better than we had before.
And I think that in one way weshould say, you know, that

(05:45):
shouldn't scare you away fromusing that.
That's all we have.
So use good clinical rationale.
No, it's not a red.
Um, on the other hand, ifthere's a green in there and At
times, there's not a lot ofthose, and you should really
question yourself at timeswhether, hey, at least I should
be doing the greens, right?
And then, you know, and then theyellows, you have to use your
clinical decision making, whichis, that's what we do, you know?
Right, exactly, right.

(06:05):
And, you know, there's, I getit, like, if you're an early
career professional, there's alot of paralysis by analysis,
right?
There's so much information outthere, 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 liketo talk about like what doesn't
work or what we shouldn't do.

(06:25):
Right.
And I think sometimes that justleaves more doubt in people's
mind that they don't know whatto do.
So this is such a valuableresource to try to, I think
actually shed some light thatnone of us know exactly what to
do.
We're just trying our hardestwithin the available evidence.
Exactly.
Yeah.
Yeah.
So what do you think here?
So clinicians have seen CPGs fora long time.

(06:46):
There's, we've been, like yousaid, we've been publishing, uh,
as you know, our academies inthe APTA, we've kind of had an
initiative towards this for thelast couple of decades or so.
Um, there's a lot of informationin a CPG.
We've kind of hit on this alittle bit, but are there any
other tips you think cliniciansshould know about how to best
use the CPG to, to guide whatthey do in their practice other
than what we've already talkedabout?

(07:07):
Because I do think sometimespeople see these, these.
beast of a documents in JOSPTlike I think the one we're about
to talk about was like 70something pages with all the,
with all the references andstuff in it is, you know, what
would you recommend to some ofyour students or early career
professionals that are justgetting started?
How do you use the CPG to getthe most out of it for your
clinical practice?

(07:28):
Yeah, that's a very goodquestion.
I think you can look at usingthe CPG on multiple levels and
depending what your intendedpurpose is, uh, you can give it
a more Kind of, I don't want tocall it a glancing look.
You know, I never want to tellanyone to just go to the
summaries, but at times you'rein the clinic, grab it, go to
the summaries.
If you just want to checkyourself or get a, just a
general direction, right?
And that's the term I wouldtypically use.
If you're a researcher or you'rea paper, or you just want more

(07:51):
information, go a little deeperinto it.
Then, you know, we have thatinformation there.
So you can kind of adjust theway into the extent that you use
these in clinical practice.
And that's, there's, there'snothing wrong with that.
Right.
When we, we published these, wedidn't, we knew not everybody's
going to go through and checkour literature review, which is
clearly spiraled out.
You have to do that in a goodCPG, but you know, I don't do
that with every CPG that I use.

(08:11):
So I would say, I wouldrecommend that clinicians use
these in the manner that bestfits them.
They were kind of designed thatway.
I would also caution people, uh,against, uh, thinking they're
going to open this and get acookbook, right?
This is not the same as gettingjust your, not just, but your
post operative protocol that youmay, You know, get with a
patient or a non operativeprotocol where everything is
very specifically spelled out.

(08:32):
We don't call out many various,very many specific exercises or,
or very specific timelines.
There's not a lot of evidence ofmost 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 aguardrail to check yourself if
you're way off course.
Maybe you're on course and thisjust reaffirms what you already
know and what you're alreadydoing.
So I would say adjust your usageof these to your intention.

(08:54):
Um, you know, that's how theyare designed to be utilized.
And they're not designed toreplace solid clinical decision
making.
We always make that, maybethat's a liability thing, but we
always make that disclaimerbecause really, it's there to
help make those decisions.
But the document never makes thedecisions for you.
That's the way you, I, and allour therapist colleagues are
trained.
That's, that's great.

(09:15):
And I think for middle and evenlate career professionals like
myself, sometimes I use CPGs toalmost like check my biases,
right?
Just to make sure that thethings that I've been doing for
a particular topic, maybe arestill using best practices.
Uh, evidence and maybe there'ssomething new that came up.
Maybe there's, there's newinformation, you know, good or

(09:37):
bad about some of the thingsI've done.
So I've also used it, you know,as I evolve with my career to
make sure that I'm staying onpace with, with as much current
evidence as I can.
Yeah, I know.
But, you know, I I've seen, youknow, probably 80 90 percent
knee or hip patients, but I willsee knees and shoulders.
Everyone's on despite whatpeople might think.
And often I that's where I'mgoing to the CPGs for the knees
and shoulders because I know,you know, I'm just not up to

(09:58):
date on some of that evidence orI may or may not be.
But I want to know and this is agood way for me to go.
Okay, I'm doing this now andI've been doing this for 5
years, but maybe that's not whatI should be doing now.
And maybe there's somethingthat's, you know, a better fit
in regard to evidence.
So I'll often use it to check mypractice just as you described.
Thank you.
Yeah, it makes sense.
Especially when you don't, likeyou said, you're, you're, you do
a lot of hip when you're, youhave something new in front of

(10:19):
you that you haven't seen in awhile, that's a good way to kind
of just check and say, wow, youknow, 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 knoweverything.
It's just that you know how tofind the answers.
Right.
You know, and what you don'tknow.
Right.
That's a big, that's a big partof it.
So, yeah, absolutely.
You've actually alluded to this,but the current CPG that you

(10:39):
published is actually an updateto one you did in 2014 and
you've actually already outalluded to the fact that you're
already working on the nextrevision, even though this one
just got published.
Tell me a little bit about yourthoughts on that.
Like, like what, what's your,what's your cadence for that?
Like, is there a specificcadence that you'd like to do?
And, and, and tell me a littlebit about the rationale behind
that.
Yeah.
So, you know, when we, whenthese, these.

(11:00):
When the, when this, uh, theCPGs were in development, it's
much, and you're always very, asa group, you know, you're
pretty, uh, um, you know, youthink big, right?
So the thought process, andthere's some organizations that
can do this, you know, theseevery five years.
That's really a challenge, a bigchallenge, they take several
years to do, and especially ifyou're authoring more than one,

(11:21):
and many of us are to someextent, and of course, you know,
these, the authors, uh, youknow, for most, it's volunteer,
right?
You do this in, uh, It's so itis for historical context when
we did in our non arthriticpain.
Uh, in 2000, it's published in2014.
2013 was the literature.
We stopped the literaturereview.
Uh, you can look at thatdocument.
Uh, I said, look at it now.

(11:41):
I'm like, wow, we really notwe've just collectively.
There wasn't much out there.
We have all these F levelrecommendations.
So that was kind of one.
You know, it, it's, it's a goodway to, to, to uh, uh, uh, keep
yourself honest in how much youdo or don't know and how much we
do or do not know.
And then, you know, you fastforward to 2023, which isn't
five years later, right?
It's nine years later.
Right.
And we have some betterrecommend, better in terms of

(12:02):
stronger recommendations, saybetter.
Some of'em are the same justwith higher grades.
There's a little historicalcontext there.
When it came to 2018, uh, I felta number of us fell a little bit
behind Covid hit.
Where we thought we'd be lessbusy.
It was actually more busy justfrom having to integrate a
telehealth system together.
Um, and so by circumstances wegot delayed, I would say in this

(12:24):
case, and not that I want to dothis all the time, we might've
been fortunate a bit because itpassed the 2018 mark when we
updated our literature view,which we had to do going into
this year before we publishedthem, there's been some pretty
big studies, some SRs, a numberof SRs came out, but also some
clinical trials.
Some of them are.
Even comparing surgery againstP.
T.
But you can glean P.
T.
Information from that.
I think in this case, it justworked out that that, you know,

(12:46):
publishing it this year and alittle bit of a delay allowed us
to capture, uh, this this kindof large body of information
that that allowed us to makestronger recommendations.
It won't be our goal to alwaysdo that.
I think it's just by chanceworked out that way.
Um, But I do think it's a, ifyou ever want to see a CPG where
things have changed a lot, thisis one of those where you can
see the amount of evidence whichhas grown substantially since we

(13:09):
published in 2014.
Yeah, I mean, you could argue in2014 what your CPG showed was
that we have a lot more to learnstill, right?
Yes.
That's a big deal.
With non R30k, you know, I'dhate to say that.
You know, we're, we're notbehind with the hip, right.
But like a joint like theshoulder with arthroscopy
starting, you know, decadesearlier than the hip.

(13:29):
I just feel like we learned morefaster about some joints.
And you know, the hip issomething that we're starting
to, to learn more and moreabout.
So, uh, definitely timely to getthis out.
And I'm already excited for yournext revision.
And the goal is like to have arevision 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.

(13:49):
We just fine tuned our thoughts.
Um, you usually see there's thevery few instances in a revision
for those that were revisionsexist.
You're not usually taking oneeighties, right?
You're kind of doing this a bit.
Very rarely you're going theother way and say, no, I was
completely wrong before, which Iguess is good, but it's
subtleties and strength ofrecommendations that sometimes
you know what I was doing that Iwas right.

(14:09):
Because now there's moreliterature to support it.
Love it.
Love it.
Well, the topic of the paper isnon arthritic hip.
I want to start with thatbecause I think we all deal with
a lot of non arthritic hip pain.
Hip pain's huge, right?
We're seeing this a lot aspeople become more athletic in
the sports world and not evenjust like professional
collegiate athletes, but justlike our everyday athletes
playing pickleball and golf andeverything else that they're
doing now.
We're seeing so much more hippain 20 years ago, just for me

(14:34):
personally.
But, um, to me, non arthritichip pain, that's a, that's
pretty big.
Like what, what exactly doesthat?
statement mean to you?
What are the diagnoses that youwould include in a non arthritic
hip pain?
Yeah, that's a very goodquestion.
And it's a question we get allthe 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

(14:58):
call it discussion and debate.
You know, you'll see in theliterature, 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 prearthritic.
Displasia, probably we have apretty good idea there becoming
more accepted, but so the termitself has been somewhat debated
at times when we use that termand in particular, this
guideline, but I think ingeneral, in the literature, it

(15:18):
is pretty encompassing, youknow, sometimes I'll tell my
residents and students, youknow, I think of anything that's
in that joint, you know, thatisn't losing joint space and the
cartilage is intact or you know,Majority of the majority of its
attack.
That's your non arthritic hippain.
But to be more specific, youknow, we define it as an
intraarticular condition.
So that's the main thing.
It's, you know, all our extraarticular issues are not counted

(15:38):
here, though they may existalong with it.
Um, and it includes now I willnote, I should note this too.
If you look at our guideline, weare talking about for the most
part, the skeletally maturepopulation.
So we're not going into the veryyoung Children, infants and such
for displays is an issue.
But I only say that because wedo mention dysplasia
developmental dysplasia is partof our non arthritic You know,
kind of umbrella under theumbrella, if you will.

(15:59):
The big one is F A I S.
That's where most of theliterature is.
Femoral acetabular impingement.
We use the term syndrome to saythose 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 usuallycome along with all these other
issues.
You can have them isolated, butusually there's an underlying

(16:20):
cause.
Uh, osteochondral lesions, loosebodies, 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 whatwe're doing with the hip here.
So, especially because, youknow, I consider myself more of
a shoulder specialist to myself.
Um, I don't want to say we mademistakes with the shoulder, but
because I don't think we reallydid.

(16:41):
I think the shoulder expertskind of had had a thought in
their mind, but we tried to getlike very specific with our
pathology, our diagnoses, right?
You know, the whole concept ofimpingement, what does that
mean?
You know, slap tears, likelabral tears, same kind of
concept.
And I, when I teach people whatwe do for the shoulder, again,
we take a huge step back and saylike, I'm not sure it matters,
right?
If you have a slap tear versus acapsular tear versus this, you

(17:04):
know, it's almost the same thingwhere we have shoulder pain.
And we're going to have the sameconcepts of how we help people
kind of get back from that aslong as like you said, it's not
arthritic.
It's not something that needssurgery tomorrow, that type of
thing.
It's, it's, it's, it's kind ofgoing together.
So I feel like you guys aredoing a better job at the hip
than we did initially with theshoulders.
We tried super hard to havelike.
Specific distinct diagnoses andsay with shoulder impingement,

(17:26):
you do this with instability,you do this.
And realistically, there'sprobably a lot of overlap
between all those differentdiagnoses.
And I really like the way youguys are laying it out with the
hip because I think it makesmore sense that way.
And we were fortunate.
Part of it's because it's justa, if you want to call it a
younger diagnosis, that, youknow, we, we, surgery usually is
ahead of us in terms of puttingout anatomical terms, and it's

(17:48):
very important than what they'readdressing.
But they gave us, for lack of abetter term, kind of a, us just
being collectively, you know,rehabilitation clinicians, a
seat at the table to kind ofsay, okay, how are we going to
define this?
Like, femorocetabularimpingement is anatomical,
morphological.
syndrome qualifies it as beingan issue.
And so, so some of thatterminology, we've luckily been
able to, to get a kind of a, uh,an agreement upon, not always

(18:11):
agreement, but, uh, we, we'vekind of been able to interact at
a level that has allowed us tocome up with terminology, which
I think is, is friendly toeveryone involved.
And we have arguments, noteveryone, even our PTs on this.
CPG.
Some are much more anatomical,biomechanical based.
Others are more, you know, it'smovement dysfunction.
That's not as important.
Uh, so we had to go throughseveral rounds of voting and

(18:31):
discussion to come up with someof these terms, but I think at
least, you know, we, we, we tryto make it clinician friendly
and clinician useful.
Right.
Yeah.
I mean, if I use the wordshoulder impingement on Twitter
right now, just, just, you know,go, go hide.
Right.
You can't, you can't, use thatthing.
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.

(18:52):
I mean, you have, you havecontact every time you move your
arm.
It's when that becomessymptomatic that.
You know, that's what we'retalking about, but you know,
it's, it's a nuance type thing.
So again, like kudos to youguys.
I think you're doing, you're,you're, you're learning from the
mistakes of the shoulder.
I think, you know, better waysthat we can articulate this and,
and diagnose it and label it sothat way we can get better
outcomes.
I think that's the intent.
So, you know, again, kudos toyou guys for doing that.

(19:14):
You know, being late to the gamehas, at times, has advantages.
Well, we can see what everyoneelse has been doing.
You get yelled at on Twitterless than I do.
That's perfect.
Yeah, well, yeah, we see it.
We're like, oh, yeah, I don'twant that to happen.
You know, that's awesome.
So I love asking this questionbecause whenever I talk to hip
people, because I, I personallydon't see a ton of hips.
I do see some hips every now andthen.

(19:34):
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 NHLand the hockey world, stuff like
that, they say, if.
The majority, if not all oftheir athletes have.
changes.
They have changes in their hip,especially if you do imaging on
everybody.
They all have changes.
Uh, they're not alwayssymptomatic.
Sometimes they are, maybethey're about to be, who knows?

(19:56):
My question I always ask peoplelike yourself here is that, are
any of these changes normal,accepted?
You know, how often do theyprogress to symptoms?
Those types of things.
Are we over diagnosing, whichthen leads to over treatment and
over surgeries, that type ofthing?
Like, like where are we with,with what we understand about
these?
bony changes, the labralchanges, the FAI type things,

(20:17):
like how much of this is normalwithin our society and how much
of this is going to lead tofuture pathology.
Yeah, it's a great, very goodquestion.
It could be a charge question attimes.
Um, and hockey is the perfectsport to bring up for this
because that's where we have alot.
We do have a lot of data onthat.
Um, you know, and it is a, ifnot the prime example of this

(20:38):
discussion.
And, you know, it's interesting,you know, if you compare it to
like displays or where you wereoften we talk about display that
there are various reasons, butoften that's that's determined
very early development that hasnothing to do with athletics
that you're in.
It may later on affect that.
But we do know with theseimpingement, impingement
presentation, right?
And when I say that, I shouldsay, not the clinical
presentation, impingementchanges, um, these can happen.

(21:03):
There's plenty of evidence tosay that, and Hawk is the
perfect example, that, you know,it's a response to loading.
And, you know, we, I think thegeneral consensus is now we
should be very cautious about.
Tagging a pathological term ontothat just because you see it,
right?
You have an image.
I've got, um, Freddie foodpassed away a number of years
ago.
I don't think anyone would saysurprise if we were doing a case

(21:25):
in rounds of someone was andthey said, I think I was tagged
on and it wasn't what they werethere for.
He said, now you're kind of, youknow, 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 wantto know these things because
they are relevant, but I thinkwe have to look at it as a
morphological and this way ofdescribing our guidelines.
There are morphologicalvariations that have been

(21:47):
described and some of themshould be looked at often think
of hockey.
It's a response to loading.
You're not going to avoid it ifyou play enough hockey.
And at the same time, no one'ssaying don't play hockey because
you see these changes.
I think, uh, when we look atthose people that have become
symptomatic, For as much as weknow, and some of this we don't
know, because you can see thesame radiograph of someone who
does the same thing, and they'renot, uh, so not saying that we

(22:08):
have this down perfectly, but Ithink there's kind of a balance
there, and it's a balancebetween those changes that have
occurred.
Do they get to a certain extent?
So there is some literature outthere on, think of a CAM
impingement, the degree and howmuch excessive bone is there,
and the prognosis related tothat, and not that this is
radiology, but again, alphaangles that are very big.
But 60 degrees, they're morelikely not to do well and made

(22:31):
it may be an issue where they'remore likely to go to surgery.
And then you have to look at thefactors intrinsic to that
individual.
So, you know, one of thestatements we make is Yes, we
know we talked about themorphological component.
If someone presents to you withsymptoms, when you evaluate that
individual, thus the importanceof a thorough examination, are
they shown impairments?

(22:51):
Do they have strength, range ofmotion, movement, quality
impairments?
If they do, That's low hangingfruit.
You should at least address thatbefore you make a clinical
decision.
And, you know, as a team, isthis person, you know, a
surgical candidate?
And then, of course, there'smany other factors that go into
play to the level of theathlete.
Um, in the example, I will giveif you have a pristine athlete

(23:12):
in front of you, in terms of nophysical impairments that are in
a They played a high level.
Think of your division oneprofessional level athletes, um,
you know, no physicalimpairments, uh, they're showing
definitive hip pain, everything,you know, fits the picture.
Um, and then the radiographs andimaging shows giant cam lesion,
you know, tears limb thatindividual, there's probably

(23:34):
gonna be a lower threshold ofthem going to surgery for all
those different reasons.
And probably some, I didn't evenmention, we get our other
individuals who may have some ofthose 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 highschool kid, it may not be, you
know, an elite level.
I think, but he plays and wantsto keep playing terrible motor
quality, terrible relativestrength.

(23:56):
Um, you know, uh, terrible justdoesn't work out right to begin
with, you know, saw somethingon, uh, you know, uh, uh,
incredible Instagram account,where they should exercise.
You know, there's a lot ofthings there we can change.
We can get them out.
We might be able to get them outof this.
They would probably be theservices that go to surgery
right now, when there's a lot ofthings that we can actually
change with those individuals.

(24:16):
You know, it's funny you saythat too, because we, we,
there's a lot of things onsocial media that I see that I'm
like, Ooh, they're, they'regoing to regret that hip
mobility drill one day, right?
We have a, we have a lot ofpeople forcing hip mobility
online right now, and you'relike, wow, that's, yeah.
I mean, just because oftentimesyou don't have mobility in your
hip for an anatomical reason.
So if you just push it, that'sgoing to be a problem, right?

(24:39):
But yeah, that's how they learn.
And that's where Wes, you know,is, is the.
You know, uh, you know, physicaltherapists and certified like
trainers and licensed.
We have a little more knowledgethat we we should we can help
them make those decisions.
Yeah, it's hip mobilitysomething you need and can get
safely or do we maybe have tomake some concessions here at
least, you know, uh, notwithstanding surgery that that,

(24:59):
you know, we're gonna have tolook at other ways of getting to
where you need to be becauseyou're never going to get
through that bone to get thatextra hip mobility or you're
going to cause issues in doingso.
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 bringup the argument that, well, if I
did an x ray on, you know, awhole team, half the teams,
let's say they all have the samelesions, they all have the same

(25:20):
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'tblame it on that.
Then if, if, if not everybody'ssymptomatic, then it can't be
from that.
Like, what do you, what do yousay in that search circumstance?
Transcribed It's a, it's a validargument, right?
Why would I, you know, if thebaseline is everyone has it, um,

(25:42):
and then, you know, why should Ibe paying attention to it?
And to some degree, when youlook at it from a rehabilitation
perspective, there's somevalidity to that argument.
It probably won't, knowing thatsomeone has, uh, a radiographic
Evidence of, you know,impingement probably won't
change directly the things youwould do, you know, in a solid

(26:03):
rehabilitation program.
What I would tell thoseindividuals is just think about
it as a, uh, at the time offootnote, right?
But look for the impairments,look for anything that is
treatable that we can address inthese athletes.
Once you have done that, and,and so I always, this is what we
tell our patients, right?
I've identified impairments herethat I think are related to, you
know, whether it's movement,strength, what have you, related

(26:24):
to your current condition.
If we make improvement of allthese impairments, but your
condition is the same or worse,I know there's an anatomical
underpinning there that could beresponsible for it.
And that would be our next levelwe drop down.
It's, you know what, maybe thisis the time to refer further,
refer back.
You know, now we startconsidering the anatomical
issue.
Um, so that's the way I wouldlook at it.
You don't have to put it.
at the forefront, and maybe youdon't even want to present it to

(26:45):
the athlete that way, but youshould take note.
There may be a reason whythey're not improving despite
everything you do, especially ifyour reevaluation shows they're
improving and all those othermeasurements that were deficient
before.
That makes sense, and you saidit earlier, but tell me again,
so what's the percentage thatprogress on to further either
symptoms or worsening of thepathology?

(27:05):
You said it, I think, earlier.
Yeah, you know, it's not reallyknown, and the reason I say that
is because I don't even, I maybe off a little, a little bit on
the literature here because someof our colleagues, you know, in
Europe, I think have a littlebetter idea of this, or could
probably state it moregranularly, but, um, we don't
really know for sure.
Uh, what we do know is that wesee trends.

(27:28):
So in certain sports, theindividuals that show these are
probably more likely to go on.
And I think a lot of it is justthe demand of the sport, to be
honest with you.
It may not be the pathology atall.
Um, the other thing we don'tknow, but we are seeing, and I
think this is what you're askingabout.
You know, when you have theselarger, more prominent, uh,
alpha angles, cam, cam, uh,impingements where it's been
most, uh, we'll see the mostevidence.

(27:50):
There is data that is emergingto show that beyond a certain
point, some individuals are morelikely to develop
chondrolesions.
And that, that may not even besymptomatic, just that, that
their joint health may be at ahigher risk.
So there is, you know, I thinkthere's probably an anatomical,
I, I think, I feel prettyconfident saying there's an
anatomical threshold.
We don't exactly know what it isyet, but.
We're getting closer to it,probably defining that that

(28:11):
helps drive, not only, you know,uh, physical therapy
intervention and thresholds orreferral, but obviously our
surgical colleagues are lookingat that as well.
Yeah.
So maybe a sneak peek at thethird 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 thisparticular topic, we, we
probably will, you know, justbecause people are really

(28:32):
focusing on, this is big insports right now, among other
topics, this is a big one.
Yeah, I mean, we deal with ittoo.
I mean, you know, relating backto the shoulder again, you have
a lot of people like in their40s that are super active doing
like aggressive stuff in thegym, stuff like that.
And yeah, they have a smallrotator 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 toget bigger.

(28:56):
Like, I don't know, I wouldn'tjust like ignore that if I were
you, but you know, I think atleast if anything, it can be
used to educate patients.
Where, you know, and again, somedon't listen to us, but you
know, like, okay, yeah, we'renot telling you not to do
things, but you might want to atleast, uh, you know, take this
as a precautionary, uh, youknow, warning that there's some
things maybe you don't want todo adult don't tempt fate.
Right.
For sure.
For sure.

(29:16):
All right, let's, let's get intothe meat of the paper,
obviously.
And, um, I thought for thelisteners, cause there's even
more than what we're about totalk about in the paper.
So you should check it out.
Uh, I'll put a link in the shownotes, but, um, uh, let's break
it into three buckets.
Like, so what are the CPGrecommendations for let's say
Diagnosis diagnosis, and thenexamination, and then treatment
right that's that's whatclinicians deal with every day

(29:37):
like what are therecommendations let's start with
diagnosis but like what's thesummary what you guys come up
with and how you would recommendwe diagnose this non arthritic
hip pain.
So diagnosis and this isprobably the trickiest part and
it seems so simple because youalmost you know you kind of call
it out in the In the title, butwe looked at the diagnostic
criteria as in terms of so theone thing we don't put away.

(29:58):
We don't do formal reviews onimaging for these because we
don't typically make imagingdecisions.
So, again, that's another topicand physical therapy, but we're
usually not we, we, we go inwith the assumption that.
That imaging is not part ofreview.
We do speak to it.
We have a, we have the imagingsection, 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

(30:19):
don't add it into the literaturereview.
So if you look at our diagnosticcriteria, we give these C level
recommendations.
That's basically saying that.
Uh, it's it's it is weakevidence, and I don't want to
put that in a negative lightbecause weak is better than
none.
You know, we had before.
Um, but when you look at this,we have, uh, the clinical
presentation, typically groinpain, though it can be others,

(30:40):
but groin pain is kind oftelltale.
We have the idea of this anatomyunderpinning, which we've just
discussed.
And then when you look at mostof the special tests for, FAI or
FAIS, particularly, they're notas special as we might think.
They are much better suited torule it out, right?

(31:01):
Because they're positive on alot of other conditions.
I just saw a stress fracture theother day, which was a positive.
So when we look at this, that'sthe reason we give this kind of
C level recommendation.
It basically says we have to goon a constellation of symptoms
and signs, but we're much bettertelling when it's not there and
when it is there.
Luckily, I would say, in, in, incases, this is not a, this,

(31:24):
these diagnoses, and I'm usingFIS as the example because it
has by far the most literature,dysplasia is, you know, a far
second, um, you know, we can getan idea, and then, which I think
we'll probably discussmomentarily, you know, the
impairment component, where weassign, let's just call it the
physical therapy, or themovement assistant diagnosis, as
we'll discuss in a minute, Ibelieve, we have much more, um,

(31:46):
The literature is stronger forthat.
We have some B's, even A levelrecommendation.
It's kind of a funnel.
We get this idea of what isthere.
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 movetowards kind of verifying the
impairments, which we make partof the diagnosis or movement

(32:06):
diagnosis as we move along theexamination.
Yeah.
Great.
I mean, great, great way ofsaying it there too.
And, and, you know, we're, youknow, 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 yourecommended it.
It's sometimes special tests arehelpful to rule out as much as
they are.
That was, that was a reallyneat, um, you know, summary of

(32:27):
that.
I like that.
Well, we tell our residents andstudents you get that positive
impingement test.
Uh, don't, don't, don't fullyinvest in the diagnosis of
femorostatic impingementsyndrome, but if you don't get
it.
You might wanna be suspicious.
Are you looking at somethingelse there?
Because it's pretty rare.
That's right.
You know, the literature saysthat, that you're not gonna get
somebody symptomatic without it.
So it truly does help rule out,you know, more than, than rule

(32:48):
in That makes perfect senseactually.
You know, and when, when youlook into it, and again, what
are you gonna do for non-art,hip pain?
You're, you're gonna take a stepback 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 andthen, 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

(33:09):
jumping to another form oftreatment.
Anyway, they were probably goingto be in a conservative bucket
with you, uh, in rehabilitation.
So you, if you missed.
Or, you know, radiographs lateron, they get radiographs and
you're off with anotherdiagnosis other than take a
stress fracture or somethinglike that, you, low risk, right?
You would have been treatedconservatively anyway.
Exactly.
Right.
We say that all the time.
You know, we always, people askabout imaging all the time.

(33:31):
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 tellthem we're not going to treat
the image.
A big part of it, we're gonnatreat them.
But, you know, but for me, Ijust, uh, you know, I, I wanna
understand, but if it, if it'snot gonna change what I do, I
tell'em that.
I'm like, look, exactly.
Yeah.
I don't really, it doesn'treally matter if this shows your
ligaments torn or not.
I'm gonna, I'm treating underthe assumption that it, it's at

(33:52):
least damaged and we're gonnawork around those parameters
anyway, for example.
So.
Exactly.
You know, it is what it is.
So that's how I discuss it withpatients too, because they
always ask you about imaging.
Oh, yeah, always.
I mean, it's just what what theydo.
Everybody, everybody's their ownadvocate now in such an amazing
way.
I actually love it.
But you know, we're just thereto guide them.
And I think that's what we dowith our with our experience.

(34:12):
But exactly.
All right, well, let's get inthe big one.
Talk about treatment, right?
Yeah.
So okay, what do we do withthese people?
Right?
So what do we know works?
What do we know doesn't work?
What you know, where are we atwith the with treatment
recommendations based on theCPG?
Yeah, this is where we had themost notable change in terms of
the amount of literature thatcame out there.
I mean, you can look at ourintervention from 2014 and it

(34:33):
was a report cards all out.
So it's basically I was saying,this is what we do.
You know, it is absolutelyexpert opinion.
And I don't, I use the termexpert again, very loosely in
2014.
Probably still today, but thisis where we've had some solid
evidence to show, uh, you know,what we do.
And it is interesting if youlook at this in kind of a
hierarchy, and this won't be asurprise.
I think this is great.
I'm glad I can explain this herebecause I think people get

(34:54):
confused.
Um, you look at our, our, ourevidence recommendations.
We have everything from a Wedon't have any A's, but we have
B level down to F's, which someof those refs, and they were
asked before, and you may get alittle bit surprised when you
see some of those F's becauseyou're like, that's what I do,
but people shouldn'tmisinterpret this finding.
The multi modal intervention,which is a term I should
probably explain in this case,has the highest rating.

(35:15):
It's a B.
The reason it has that Is thatmost studies that looked at
conserve the physical therapyintervention 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 thefocus point is lies the most,
um, most of those protocols weremultimodal.
So they involve strength.

(35:36):
It's what we do in the clinic.
Most of the time strengthening.
Often some component, manualtherapy, education, um, uh, you
know, in a, in therapeuticexercise, of course, you know,
other therapeutic exercise,neuromuscular control and
movement.
Pattern training is a specificterm.
Mona, many of our studies, mostof our studies just use it all
combined.
So we are basing our, our, uh,recommendations based on the,

(35:58):
the, the, the.
The strength of evidence fromthose studies, when we look at
studies that specifically try topull out very specific, the
effects of very specificinterventions while controlling,
you know, not having no otherinfluences, there's not many,
right?
And then what you see is you seethese C level recommendations
where we, I would say that's,that's a success for us.

(36:18):
There's nothing like that.
So you will see education,movement, pattern training,
which.
Some people's confusing, butthat is a term of the wash you
group.
Uh, I don't want to say theycoined it, but that's really
where it comes from a veryspecific, uh, you know, uh,
training with with queuing ondaily and other activities.
Um, and then, um, you know, uh,then as we go down the line, you

(36:40):
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 atit and say, don't do these
things.
It just says we don't haveevidence right now that it
specifically tried to pull outthat intervention.
But that makes sense too,because I don't remember the
last time I had someone come inwith an FAIS or non arthritic
hip pain diagnosis and the onlything I did with them was manual
therapy.

(37:00):
So it's hard to pull that out.
Studies just aren't there.
Right.
Right.
And you know what I, I, I have asuggestion 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 Fright?
When,'cause when we talk aboutf, F sounds bad, right?
F sounds bad.
Yeah, it does.
F stands for, for, for expertopinion, right?
So that's why I think it's abetter E right?
Because expert e you know, Imean that type of thing.

(37:22):
Yeah.
But, um, I, I switch e f inthere.
Um, I'm gonna bring that up inthe next meeting.
All right, but you know what,let's, let's change the system
together.
Uh, you know, I, I hate to, Ihate to have pessimism with this
here, but like, we're, we're notgoing to get anywhere as a
profession if we do studies thatsay that, and we're starting to
see these, like does manualtherapy work for non arthritic

(37:43):
hip pain?
You're like, wow, that is, youcan't make a study that shows
that, right?
And then you look at themethodology.
You have 10 different diagnoses.
You have subjects from age 18 to65, right?
And, and no definition of manualtherapy, right?
So of course, you're not goingto find that anything.
that, that anything works.
You're just going to keepfinding vague that there's no

(38:04):
evidence that it does or doesn'twork if we keep doing that.
So, I don't know how we controlthose studies better, right?
If that's even possible, butthat's the reason why there's so
much, you know, vagueness to it.
So, people just have to realizelike we're, we're humans here,
right?
We can't, you don't want tosacrifice the quality of the
care that you're giving yourperson here to, to produce a
well designed prospective study.

(38:24):
So, you know, we have to takethat with a grain saw and just
realize that.
We're not going to always havethese 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 someof we couldn't include, so we
couldn't just because of thetime frame.
This is some, but a number of,uh, publications that came out
from various groups asinternational groups that have

(38:45):
noted just what you said there,that when we look at the quality
of how these studies are evenoften describing what they're
doing, manual therapy is a goodexample.
Even our exercise.
interventions as they'rediscussed.
It's hard to sometimes, it'shard to interpret these because
you couldn't reproduce what theysaid.
It's just not there.
So what type of exercise werethey doing?

(39:05):
They'll call it optimalexercise, but it's not listed,
you know, and in the same amountof 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 goingwith our analogy on this
episode, but like, you're almostlooking for green lights in
those studies because it's goingto be really hard to say that it
didn't work because man, thatwas, you know, you're throwing
darts at the wall almost.

(39:25):
Right.
And that's, right.
That's the hard part.
So for me, I, if we'repleasantly surprised that a
study like that shows.
Uh, a positive effect, that's awin, 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 thathasn't ruled it out yet.
In my mind, at least it'sinteresting.
There's a study.
I always say where I.

(39:46):
Uh, I use it to justify andthere's others out there, but
why we utilize movement qualitytraining.
So it involves a step down andsingle leg, um, squad.
And if you prove those, youimprove individual heroes,
including sports specific heroesfor impeachment.
I think this is a great study.
One of my co authors on theMartin on the, um.
TBG wrote it, and I said, thisis going to really drive her.

(40:08):
It does drive my decisionmaking.
However, just because due tothe, you know, the way that we,
you know, grade these, if youlook 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'swhere you have to think that
that's where sometimes diving alittle deeper saying, I see the
studies listed there.
I'm going to go look at it.
It could still help drive yourclinical practice.
Don't think a C or even an F,you know, should scare you away.

(40:31):
It just may tell you that wehave more to learn on it, you
know, but, but it doesn't meanthat you shouldn't do it.
I love it.
All right.
So quick summary then based onthe CPG, um, what, what do we,
what do we know based ontreatments?
What, what should peopleincorporate into the treatments
for non arthritic hip pain?
So luckily a lot of people aregonna look at this and say, you
know what?
I've been doing that.
You know, I've been doing right.

(40:51):
I've been I've been measuringimpairments and I've been
treating them appropriately.
And this just makes sense.
So I think you're gonna get alot of people in a great way,
you know, let's say I've beendoing that.
I think the way you look at itis where we are now with the
evidence.
there is, um, it still supportsan impairment based approach,
right?
So what we know is that, youknow, some form of the treatment

(41:14):
will usually involve some formof strengthening.
Now we do have the, we do knowwhat the strength patterns Most
often look like an individual.
So you might want to check itand see are the weaknesses I'm
finding for this individual.
What we know about thepopulation.
They probably will be most ofthe time, but it's always good
to check against.
We know activity modification.
There's probably a role in that.
Probably been doing that allalong.
I hope we have been, you know,um, you know, but, but there's

(41:38):
a, you know, that's an educationcomponent.
Movement quality is probably,it's really come to the
forefront in that, I don't thinkof what we all, many of us,
right, have been looking at.
But if you weren't, if youweren't looking at the quality
of movement, not just thestrength, not just, you know,
mobility, but what do they looklike when they move?
And now we even have somevalidated tests to assess that
that are common in otherconditions, but single leg step
down.

(41:58):
Single leg squat star excursionbalance test.
There's some literature tosupport that in this group.
It's a correlation with strengthdeficit such.
So, um, again, many of us havebeen doing those things, but we
should take that kind of truemulti modal approach to
treatment impairment based.
And then I think the other thingis we were discussing, you know,
a number of minutes ago whensomeone doesn't improve and
we're doing the things we shouldbe doing, right?

(42:19):
anatomical underpinning.
There may be a discussion there,right?
There may be a threshold andthat threshold can vary.
We hit where, where we may wantto get further consultation.
Um, and the other treatmentneuromuscular education, manual
therapy, of course, if it'sindicated, go ahead and utilize
it.
They're low risk too.
I mean, there may be somecautions and someone displays

(42:39):
you, but.
Your clinical reasoning wouldtell you not to do that with
someone dysplasia anyway, youknow, so, uh, you know, joint
mobilization, someone who'shyper mobile.
So again, I think, you know,this multimodal strongest
recommendation we make probablyfalls in line with the
impairment based approach thatmost of us that I would just say
that we now have more evidenceto show how we can assess and
treat movement quality, uh, forindividuals, you know, who have

(43:01):
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 tonof hips yet, you should check it
out even more, right?
So that way you're prepared forwhen, when, when they do come to
your clinic the next time.
But, um, we're going to see thismore and more in sports.
So, so it, for me, I thoughtthis was a very helpful thing to

(43:21):
do.
And like Keelan said, I, youknow, I, um, I would.
Consider myself an experiencejust for tenure, like an
experienced clinician andreading it.
It actually actually made mefeel better about myself that
you know what there wasn'tsomething magical.
I was unaware of this.
This it's just the basics.
It's you know, the multimodalbasics and I think you said that
really well.
So check out the link to the CPGin the show notes and then

(43:42):
Keelan before I let you go.
Got to go with a high five, fivequick questions, five quick
answers.
Some learn a little bit aboutyourself.
Um, I like these because youknow, it's, it's, you get, you
go into, into people's minds alittle bit.
So it's always fun.
But first question, what are youcurrently doing for your own
professional development?
What are you doing for yourself?
So I'm trying to take a deeperdive and it's not even to the

(44:03):
hip right now because there'snothing out there on it, but I'm
hoping to pull it over that onthis, the whole neurocognitive
aspect of orthopedicmusculoskeletal injuries in
athletes.
You always talked about itbefore, right?
But I think of the work thatgrooms and others have been
doing, seen in the ACLpopulation, and it just piqued
my interest.
I wonder if I can pull it overinto what I do.
You know, and there's nothingout there on it that I'm aware
of.
So I've been trying to get adeeper dive and just get, get my

(44:25):
head wrapped around.
And that can be relativelycomplicated at times about
what's going on there.
Cause I think there might besomething there.
I can't definitively say that,but that's what I've been really
kind of putting a focus, kind oflooking at what the, that, that
kind of the growth in thatliterature 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.

(44:45):
So it'd be great.
Um, what's one thing that yourecently changed your mind
about?
Specific to me, it's my owncriticism.
You know, I used to look at theissues I would see in the hip
and say, these people are eitherhypermobile or hypomobile.
They have one end, you know,osteoarthritis, very little
movement.
Impingement probably means youdon't have enough movement
because your end range isquicker.
You're just plastic and you'reall over the place.
So I thought I used to look atit a linear type of, you know,

(45:09):
kind of a spectrum, if you will.
And I still, some of thatexists, 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 withimpingement that is hypermobile.
It's a great clinical challenge.
But I'm trying not to, uh, I'mtrying to look at this at
multiple layers now, um, and itmakes it more complicated, more
challenging at times, but Ithink, you know, to give to be

(45:32):
most effective in intervention,we were going to have to start
looking at this way.
So I'm trying to challengemyself and that's.
That's been an involvement overtime.
I look at my old grass fromteaching.
And I'm like, well, I used torepresent 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 pieceof advice that you like to give
your students?
Yeah.
You know, I tell him this isgoing to sound cliche almost,

(45:52):
but.
I can only tell you frompersonal experience to take
advantage of every opportunitythat presents itself, no matter
how small or, uh, maybe notparticularly exciting or not
profitable because really thosecascading into bigger and better
ones.
I've really, you know, I've onlybeen very fortunate to be
amongst individuals and, andopportunities, uh, given by
those individuals to, to.

(46:14):
To kind of get where I'm at atthis point, and a lot of these
were just based on really smallmight seem trivial at the time
opportunities, but I tried tomake the most out of them
because I think they'recumulative.
And, you know, you really can'tunderestimate the cumulative
impact.
Just kind of grinding it outthere when you're kind of
earlier in your career.
I love it.
Great one.
Um, other than the thirdrevision of the CPG, what's

(46:34):
coming up next for you?
Yes, I'm on a bit of a breatherhere because I, the fall and you
were at one of the conferencesthat, you know, it's been a big
conference time, both statesideand in Brazil and Africa.
So, I'm getting a little bit ofa breather here.
I have a few presentationscoming up.
A lot of them are based on theCPGs.
Other than that, you know,typical grind of patient care,
some teaching and somemanuscripts.
I'm really, uh, um, Trying tokind of kind of reorient here

(46:58):
and get my get back on my feetand hopefully going into, you
know, the new year here.
Um, I'm kind of in a, I couldsay, kind of a self examination
phase of trying to look at sometopics that I think are not
covered with what I do.
And it's something I cancontribute to kind of at a
system level where we're at.
You know, I work at UPMC, butalso just in the literature and
such.
So I'm kind of doing a littlebit of kind of re examination

(47:18):
self, uh, you know, selfassessment of where I'm at and
hoping that I can.
Thank you.
Find some, uh, some new paths togo down related to hip related
issues, but that haven't beenexplored yet.
Awesome.
Well, if anybody wants to learnmore, obviously they can go to
the CPG article that we'll havein the show notes, but anywhere
else that, that they can learnmore about you and what you're
doing.
Yeah, it's funny.

(47:40):
I think I could say this prettyconfidently.
You know, I'm the only Keelanand Seki on the planet that I
know of.
So if you literally go through,I checked it last night.
If you Google me, you'llactually come up with like kind
of some of our academic work,our research, research gain and
sites like that, along withsocial media sites.
You can get a pretty good ideaof what I'm up to.
I'll also put a plug in, youknow, one of my roles at UPMC,
our rehabilitation institute iskind of oversight,

(48:02):
administrative oversight of allfive of residency programs, but
most directly involved inorthopedic sports residency
programs.
If you're a young clinician,student, you want to learn more
about it, it's literally, youcan Google it.
You can find all the informationon our programs.
We're taking applications now.
We'd love to have you if you'reinterested and come talk to us.
Uh, so, you know, feel free tocontact me or any of our program
directors, um, because these arethe types of things that we talk

(48:25):
about, you know, and discussamongst our residents.
So, if you were, if you findthis information that we
discussed interesting, and maybewould like to get a little more
kind of a deep dive into it,among other things.
Feel free to check out ourprogram if you were looking at
that route, you know, or goingdown furthering your training
and education.
Great stuff, Keelan.
Thanks so much for coming on theepisode today and sharing all
this and digging in deep on thatCPG.

(48:47):
And really, thanks for doingthat.
Because again, that's a lot of,of, uh, of effort that not a lot
of people realize that you putinto that.
So thanks so much for all yourefforts for putting that
together.
Yeah, thanks for having me andgiving me a platform to kind of
spread the word and discuss it.

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Nonarthritic Hip Pain with Keelan Enseki - Episode 42

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.css-14f5ked{margin:0;word-break:break-word;display:-webkit-box;-webkit-box-orient:vertical;box-orient:vertical;-webkit-line-clamp:2;overflow:hidden;}Nonarthritic Hip Pain with Keelan Enseki - Episode 42