Help! I Have A Snapping Hip

Yesterday, I saw a 13 year old boy who was brought to our clinic by his parents as he had knee pain as well as a "snapping" hip on the same side. After joining the school's softball team earlier this year, he had trained a fair bit more than in primary school.

He recently developed right knee pain and had a year's history of pain and "snapping" in his right hip. He had previously seen a chiropractor for the last few months. Treatment consisted of  stretching the hip flexors, the Iliotibial band (ITB) and manipulating his hip and spine. He did not get any better after all the treatment with the chiropractor.

I assessed him and confirmed that his knee pain was coming from his tibial tuberosity and indicative of doing too much too soon. That's not too difficult to manage. He definitely had a case of Osgood Schlatter's in his right knee.

There was no pain with clicking in his hip. Nor was locking observed at end of range hip flexion with added internal or external rotation (this rules out hip labral tear). Range of movement in his back, hips, knees and ankles was normal and symmetrical.

There was weakness in his right Gluteus Medius muscle, also his painful knee and snapping hip side, despite that being his dominant side. This greater contralateral pelvic drop was confirmed while watching him run.

The "snapping hip" sound was reproduced over his right greater trochanter when he was in left side lying when I straightened and bent his right hip. It was a fairly loud "clicking" and/or "snapping" sound each time I bent and straightened his hip. There was some local tenderness over his Gluteus Medius, Gluteus Maximus and Tensor Fascia Lata muscles and over the greater trochanter itself.

Snapping hip on outside part of R hip

This explained his "snapping hip" on the outer part of his hip. While my young patient did have pain over his outer hip, I've treated other cases where patients did not complain of pain there with the exact same condition.

Following treatment, my patient was pain free and I taught him and his parents what to do to maintain that.

This "snapping hip"condition is also known as Coxa Saltans, can also happen in adults. My young patient described above has a extra articular or outside the hip joint condition.  It can also be intra articular or inside the hip joint.

It's Psoas Major/ Iliacus if inner part of R hip

If the condition occurs on the inner part of the hip, extra articularly, it is usually due to the Psoas Major or Iliacus muscle. A snapping hip inside the hip is usually confirmed by an MRI. Those who have intra articular hip snapping will usually complain of hip catching, painful clicking or locking. And that will probably have to be another post.


Reference

Winston P, Awan R et al (2007). Clinical Examination And Ultrasound Of Self-Reported Snapping Hip Syndrome In Elite Ballet Dancers. AJSM. 35(1): 118-126. DOI: 10.1177/0363546506293703.

Still Getting Messages While I Am Away On Holiday

Even when I'm not in Singapore, I still get messages from patients asking about their pain or condition. After a patient sees me in our clinics, I normally give my personal number to them to let them know that they can reach me if they have a question. 

Of course I tell them I will not answer the phone if I'm treating patients, but I will always reply or call back after if the need arises. Except for once, I don't remember patients abusing that privilege. Don't get me wrong, I'm definitely not complaining, I do think it's great the patients trust me enough to ask me when they feel something is not right.

If I'm travelling, I will normally divert my phone to our clinic, but patients can still reach me with their messages or WhatsApp etc.

Of course after a particular posting that is popular, I get readers from overseas asking about the condition as well. Especially after this post on shin splints which is still our most popular article. I've politely declined offers to try and diagnose them. Even though some of them write and say that they'll be happy to pay me to describe what I did for treatment or chat to them via Skype or Facetime.

Accessory navicular bone?

There are currently a few telemedicine apps available in Singapore, MaNaDr, White Coat, Dr Anywhere, MyDoc and HiDoc. Majority are for patients to consult a  doctor through video-conferencing or messaging. Common health issues that come through these apps include upper respiratory tract infection, headache/fever, gastroenteritis and skin conditions. It also means you can stay at home when you're sick to get a medical certificate from the doctor.

I remember discussing with Aized quite a few years ago if we need to go this way as well after reading about about Dr Jay Parkinson and how he writes and talks about the future of primary care, healthcare delivery, healthcare entrepreneurship and healthcare business model transformation.

But then again, Dr Jay Parkinson writes about the United States healthcare system where patients may have to travel far and /or wait for days before getting an appointment. In Singapore, we have a different healthcare system altogether.

Convenient these apps may be for the patient, especially when it comes to the common cold/ cough and fever etc. However, I can definitely assess a patient much better in person when they tell me their neck or knee hurts. On the phone or email, it depends on how well the patient describes their condition. Of course I listen to my patients, but I definitely trust my hands more.

For those of you reading this, yes I'm away on holiday. But I will still try to answer your questions if I can get access to an internet connection. Thank you for putting your trust in us and our clinics.

My younger boy enjoying the sunset with 2 furry friends

Never Give Up!

Chapeau to  Ronald Susilo. This guy just keeps on going and going. After suffering many potential badminton career ending injuries while at the top of his game, he has always managed to bounce back.

After winning the Japan Open Grand Prix and then beating World Number One Lin Dan at the 2004 Athens Olympics with a torn shoulder labrum, he went under the knife.

More heartbreak followed after coming back from that when he tore his achilles tendon at the World Badminton Championships in 2005.

Yet he persisted. Tragedy again at the 2007 Sea Games when he tore his right forearm muscles playing against Vietnam. Again he managed to bounce back and we went to our second consecutive Olympics together in Beijing in 2008.

His wife sent him to Sports Solutions in this 

Even after retiring from national duty, he kept playing after he started coaching. And subsequently ruptured his patella tendon while tearing his ACL and medial meniscus at the same time. He needed 2 operations after this. Attaching the patella tendon first before repairing the ACL almost a year later.

And now this right shoulder again .....

Well, Ronald we've done this together too many times before. But I know you'll be back once more. You can do this!! Want to be a champion? Passion for the sport and persistence is what you'll need. Lots of it.

In the picture below, you see me celebrating and more excited than Ronald Susilo himself after he defeated Lin Dan in the 2004 Athens Olympics.

Yes, I used to sit on court with him and his coach every time he played.

Does Weight Training Stunt Growth In Young Adolescent Kids?

14 yo Miles with Dad Ving Henson at The Pit

I remember clearly being told by my teammates as a young runner at twelve that I should never do weights as it would stop me from growing taller.

This misconception about weight training often comes from fellow teammates, well meaning parents, physical education teachers and even some coaches. Actually, the sport your child participates in (sprinting, jumping or contact sports) will generate greater forces than training in the weight room.

This widely held belief that weight training especially when performed during puberty/ adolescence stunts growth still persist in the present day. Due to this, young athletes and children should only perform body weight exercises and not do any training with barbells, kettlebells or even dumbbells.

Fret not if you're a parent or teacher of a young athlete. There is simply no evidence to support this belief at all. Many studies have looked into this topic and found that weight training has no negative impact on skeletal growth. It will not stunt growth.

Actually, studies show consistent findings that young subjects have increased strength, speed and power, while losing weight, gaining muscle and stronger bones. There is also a reduction in injury rates. Good news for parents if your child keeps getting injured. This is especially true even when the young subjects have not reached puberty.

So it makes very little sense from a bone stress point of view if you stop your child from going to the gym but allow them to participate in sports.

So how soon can your child start weight training? We do not have any suggestions from any local authority but the Australian Strength and Conditioning Association suggest that a child can start weight training at six years old. As long as he/she can follow clear instructions and understand the dangers when training.

If you do send your child/ athlete for weight training, make sure the learn the correct techniques by a good strength coach who has experience working with young athletes. Remember, don't force the young athletes if they are not keen.


References

Barbieri D and Zaccagni L (2013). Strength Training For Children And Adolescents: Benefits And Risks. Collegium Antropologicum. 37(2): 219-225.

Faigenbaum AD and Meyer GD (2010). Resistance Training Among Young Athletes: Safety, Efficacy And Injury Prevention Effects. BJSM. 44(1): 56-63.

Falk D and Dotard R (2019). Strength Training In Children. Harefuah. 158(8): 515-519.

After seeing 14 yo Miles training above, my 9 yo was inspired to do the same

Is Your Running Style Causing Your Running Injury?

How's my running gait?

I saw a patient yesterday who was training for the upcoming Singapore marathon. He started having knee and heel pain after doing a long run of 22 km over the weekend. Upon assessment, he definitely demonstrated a greater contralateral (or opposite) pelvic drop (CPD), indicating Gluteus Medius muscle weakness.

Picture A- Injured runner with CPD and right hip adduction 

Last week we discussed whether doing clam shell exercises was still relevant for someone with Gluteus Medius muscle weakness. Turn's out that this week's post is related to that.

The referenced study (Bramah et al, 2018) investigated and identified certain faulty running gait patterns that contribute to running injuries. In all, 108 runners were studied, including 72 injured runners and 36 healthy runners in the control group matched for age, height and weight.

None of the injured runners received any prior treatment for their injury. Those with an increase with more than 30 percent in training volume were also excluded from the study. The control group of runners ran at least 30 miles (or 48 km) a week.

The injuries the injured runners had were patella femoral pain (PFP), Iliotibial Band Syndrome (ITBS), Medial Tibial Stress Syndrome (MTSS or shin splints) and Achilles Tendinopathy (AT). The injuries were selected as they are most prevalent among runners.

All the injured runners showed a greater contralateral (or opposite) pelvic drop (CPD), demonstrating Gluteus Medius muscle weakness. They had a more extended knee and dorsiflexed ankle (heel striking) at initial contact and a forward trunk lean at the midstance phase of running. These patterns were consistent across each of the four injured groups.

Contralateral pelvic drop

CPD was found to be the most important variable predicting whether the study participants were healthy or injured. For every 1 degree increase in pelvic drop, there was a 80 percent increase in the odds of getting injured.

Injured runner (L) heel striking, forward trunk lean vs normal

Those who had more knee extension makes the patella (kneecap) more vulnerable to lateral tilting and displacement. This may affect knee joint contact areas and increase stress when the foot strikes the ground. If a runner heel strikes with the knee extended, their center of mass is further away from their foot. This leads to an increase in knee joint loading and a increase "braking" forces (imagine applying brakes on while you're running).

Those with a forward trunk lean may have weakness around the back and gluteal muscles as shown by previous studies. The injured runners with PFP and ITB problems had more hip adduction than other runners. More female runners were also found to more hip adduction compared to male runners.

So make sure your Gluteus Medius muscles are strong enough so that you will be less likely to have a running injury.


References

Bramah C, Preece SJ Nimh G et al (2018). Is There A Pathological Gait Associated With Common Soft Tissue Running Injuries? AJSM. 46(12): 3023-3031. DOI: 10.1177/0363546518793657

Lessi GC, Dos Santos AF et al (2017). Effects Of Fatigue On Lower Limb, Pelvis And Trunk Kinematics And Muscle Activation. J Electrom Kinesiol. 32: 9-14

Clam Shell Exercises?

Clam shell exercises?

My patient came in complaining of knee pain after running. She had seen another physiotherapist who after treating her knee, prescribed clam shell exercises for her to do as well. But she still had knee pain after running and climbing stairs despite doing them regularly.

How many of you have been asked to do clam shell exercises to make your Gluteus Medius (or hip) muscles stronger? If you have, maybe you need not bother any more.

Latest research (Moore et al, 2019) shows that clam shell exercises do not activate your Gluteus Medius as much as you think.

Right Gluteus Medius muscle

The Gluteus Medius muscle is very important for female runners, especially if they have knee pain. You can treat their knees but their pain will not go away until you have addressed the weakness  in their Gluteus Medius muscle.

View from the back, Left Gluteus Medius

In that small study, three sets of six common lower limb exercises were performed by ten healthy adults after a short warm up. They did single leg squats, single leg bridging, hip abduction (lifting) in side lying, clam shell exercise in side lying, running man exercise (simulates running motion of running one leg at a time) and resisted hip abduction-extension exercise.

The participants had electromyography or EMG electrodes to measure muscle activity attached to all three parts of the Gluteus Medius muscle (in front, middle and posterior).

Results showed that clam shell exercises were not effective in activating any part of the Gluteus Medius muscle. Highest levels of overall activity were seen in the single leg squat, single leg bridging and the resisted hip abuction-extension exercise.

Other than the knee, you need to know that weakness in your Gluteus Medius can also contribute to pain or problems in your Achilles. Make sure you are doing the strengthening correctly.

Reference

Moore D, Pizzari T et al (2019). Rehabiliation Exercises For The Gluteus Medius Muscle Segments: An Electromyography Study. J Sp Rehab. DOI: 10.1123/jsr.2018-0340.

Head, Neck And Jaw

Taking turns for a quick assessment

After Aized last week, yours truly attended the Head, Neck and Jaw course yesterday and today. This is the next course offered after we did the Shoulders and Arms course earlier in April this year.

Wow, time really flies, it's already October today.
It was a really interesting course looking at everyone's head, neck and into their mouths. Yes, you read correctly, we got to stick our fingers inside each other's mouths.

All five different necks

We learnt about the Masseter and Temporalis which are on our face and skull, we also learnt how to treat the Medial and Lateral terygoids, which are inside our mouths and how they connect to the neck.

Showing me my Lateral Pterygoids

Yes, we got right into each other's mouths.

Medial , Lateral Pterygoids

Back to work tomorrow. And if you need to get your head, neck or jaw treated .....