[Physio Explained] Navigating hip dysplasia rehabilitation with Andrew Wallis

In this episode with Andrew Wallis, we discuss:

• Importance of posture in hip dysplasia
• How to treat posture in hip dysplasia
• Strength training for rehabilitation of hip dysplasia
• Importance of patient based assessment and treatment
• Radiology in hip dysplasia

See Part 1 of Andrew’s podcast here - https://open.spotify.com/episode/4CE24YTyQUXByJAlTl9Q1y?si=QEeV68kcST-Bd5qoYynuxw

Andrew is an APA Sports and Manipulative Physiotherapist who is currently employed at St. Kilda Football Club (since 2007) and works privately at Melbourne Orthopaedic Group Sports Medicine. Over the last 20 years, Andrew has worked in both a clinical setting and within the elite sporting environment at Melbourne Victory, Adelaide Thunderbirds, SACA Redbacks, V8 Supercars, triathlon and athletics.

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Our host is @sarah.yule from Physio Network

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Transcript

SPEAKER_02 0:00

If someone is restricted into one direction and they have an increase in the other, but still globally have that total of 90, they are more likely to have a version. Something's twisted, whether it be the femur or the acetabulum, and it might be twisted forward, which would bias more internal rotation and less external, or it might be turned backwards and they have more external and less internal. Or if they have a block in one direction, but normal range the other way, it suggests there's some sort of, you know, bony outcropping. So like a CAM lesion, which we see a lot in males, which might restrict internal rotation, but they have normal external, or it might be some increased bone population. posturally or anteriorly on the femur, which might give the same results.

SPEAKER_01 0:50

How do or should we treat posture in relation to hip dysplasia? What does a strength program typically look like for dysplastic hip presentations? What functional exercises are relevant? And when do we refer onwards? We are lucky to have Andrew Wallace back to join us for part two on hip dysplasia, this time focusing on treatment. Andrew Wallace runs the Hip and Groin Clinic in Melbourne And over the last 20 years, he has worked in both a clinical setting and within the elite sporting environments at the St Kilda Football Club, Melbourne Victory, Adelaide Thunderbirds, SACA Redbacks and V8 Supercars. You're going to love today's episode with plenty of clinical pearls that will hopefully make an impact on your treatment of those with hip dysplasia. I'm Sarah Yule, and this is Physio Explained. Well, Andrew, welcome back to the podcast for part two on treatment of dysplasia. We're in for a treat today.

SPEAKER_02 1:51

Excellent. Good to be back. This is the fun bit, treating them.

SPEAKER_01 1:56

So, to give a little bit of a recap, we've done a great subjective assessment, we've peeled out the relevant parts that might be quite familiar for people with hip dysplasia, namely what you've mentioned earlier about or on the last podcast about extension-based issues and sort of that history of perhaps a little bit of instability in that subjective. And then you've rolled through into your objective exam where you're testing fader, faber. You've done the modified Thomas test, some Craig's tests, internal, external rotation ranges and strength testing. And you mentioned posture as well. And I'd love for you to talk to what your thoughts are on posture and how relevant is it?

SPEAKER_02 2:45

Yeah, I'm glad you started with this one, Sarah, because I think most people go straight to strength. I think we're all a bit guilty of that, oh, you've just got to get stronger. But when I talk about posture, I think about resting at end of range. And if I could summarize what dysplasia is and the biomechanical faults that are incurred because of it, really it's Because we've got poor coverage of the head of the femur, it's because effectively the hip center of rotation is lateralized because it sits closer to the margin. And therefore, we've got a smaller contact area for the dysplastic acetabulum to concentrate its force on the head of the femur. And that's really a crux of it. That's what the issue is. We just don't dissipate force. And then we said earlier that there are situations where if it's combined with femoral anteversion, we have a functionally shorter lever arm for the abductors, which means that it can't stabilize. So what we need to do is we need to be really cognizant of what the issues are and the fact that that marginal... stability is challenged. And therefore, if it is that we're resting at our end of range, we're irritating all of those structures that we mentioned in the first podcast, the labrum, the synovium, the capsule, and by extension, the tendons around there. So when I talk about posture, and I spoke on the first podcast about sway back, I really try and correct that. The swayback that we tend to see, and I'm going to, again, just reference females because we see it more in that. I think females have much better extensibility of their collagen. We know hormonal influence at certain times can influence biomechanical control through motor control. We know that females may choose to get pregnant and therefore that displaces their center of mass anteriorly. And we know that If you then have to push a pram or other things, it means you tend to operate at an isolated hip extension because it's very hard to push a pram without a bad sort of posture. So all of those things lead us to a displaced center of mass or a sway back. And just to clarify that, we find a situation where people move their pelvis forward of where the center of the shoulder, so center of the croman, if you like, and the lateral malleolus is. I think people are often incorrectly told that, oh, you've just got a big arch in your back. And it's either diagnosed as they have an increased anterior pelvic tilt most of the time. And people are told, oh, you just need to posteriorly pelvic tilt. But the definition of sway is you are in maximal posterior pelvic tilt. Like if you ask them to posteriorly tilt, they can't. So I think that we're in a situation there where we actually truly have to correct their sway. So posture is the number one thing. We need to offload those overloaded anterior structures. And the overload comes from two things. One is stretching of the soft tissues. Literally, as you're going into extension or posterior tilt, you're stretching up all of those anterior structures. And the fact that if you like the ball or the head of the femur is protruding forward and pushing or contacting the posterior aspect of all of those anterior structures. So we give the cue of a tray of drinks on your pelvis, sliding that tray of drinks backwards in space without moving your acromion or your lateral malleolus, which hopefully is on the ground anyway, and getting a much better alignment of that. And I think that's a really good starting point for any of your listeners is to try and get that nice alignment. We then go on to making sure that you can then do that on one leg. And I'm sure we'll get to training functionally later. But if they could get double leg sway correction and then progress that to single leg, it's a really, really good start. There are, of course, those there that, you know, sort of bump the hip out to the side. And again, if I could reference mums, because mums are doing 4,000 things. We know mums are superwomen. And they are carrying shopping, bumping a hip out to the side while they're doing something on a computer or a phone as well. So while they'll nurse that bub on the side, they're in a lateral sway position. The problem is, I think, whenever you stop being a mum and having to carry babes... I think you're left with that posture sometimes. And so you'll see people at parties with that sort of lateral bump, if you like. And if they're laterally deficient, I think much the same as we said about the anterior sway, they need to correct that. So I think that's a bit easy. You just tell them not to bump out to the side.

SPEAKER_01 7:06

That's absolute golden advice. There's nothing more powerful in clinic than if we can collect the low-hanging fruit and address the habitual things. It makes the rest of the program so much easier. You can have a golden strength program, but if we're not addressing those things that are repeatedly being done, we're losing our effectiveness, I'm sure.

SPEAKER_02 7:29

Absolutely. For me, my thought process is To avoid sustained end of range positions, and we have to minimize transient end of range positions. And I think stopping sustained end of range position is changing posture. But I think that's a really good way for listeners to think about it, that posture is related to sustained end of range position. Let's try and keep them off that. And then what we try and do with the strength work, if we talk about that, is we're trying to stop them dropping into transient positions that might be provocative. either going into isolated hip extension or dropping into fader positions as they lose lateral pelvic stability and femoral rotational control.

SPEAKER_00 8:13

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SPEAKER_01 8:47

So talk to me, what does your strength program typically look like then?

SPEAKER_02 8:52

It's based really around the identification of what we find in the screening and we tend to find, as the evidence is really strong on, that the abductors and the internal and external rotators are really weak. With FAI, we see a recognition that the abductors and external rotators are weak. What we see in addition to that with dysplasia is we see the internal rotators are weak. You'll notice I haven't mentioned adductors. I think there's two things to say about adductors. One is we tend to find that when you take away the cause of someone's pain, then pain inhibition settles and adductors, which we know are supplied by the obturator nerve, which supplies half of the inside of the hip, tend to settle and their strength comes back. The other thing is I think adductors are named anatomically. They're named because they're on the medial aspect. People assume that to strengthen your adductors, you need to do adduction. But the reality is their biggest functions, which shows on EMG and other things, is control of terminal extension and initiation of flexion, so work in the sagittal plane, and rotation. They're big rotators, particularly internal rotators. So our focus is on the adductors and the internal and external rotators. So we tend to think about strength maybe a little bit differently. I tend to think about getting some preliminary strength and the preliminary strength normally is, say, a side-lying abduction and prone IR and ER. And I'll just quickly talk about the rotation. I would always look at rotation in part of my assessment. And I think there's a couple of things to think about that might lead us to think about dysplasia. We like someone... in supine, so with the hip at 90 degrees, or in prone, in full extension, with the hip at neutral, to have 45 degrees of internal and 45 degrees of external. We're pretty happy with that, and obviously we recognise some biases towards each of the sexes. What I think is if you have an increase in range of IR and ER... You know, it's leading to us thinking potentially that they may have an architectural issue. So morphologically, they might have dysplasia. So some undercoverage and that ball can turn further. But they might also have some connective tissue stuff. We need to be aware of that. But our rule of thumb is if someone is restricted into one direction and they have an increase in the other. but still globally have that total of 90, they are more likely to have a version. Something's twisted, whether it be the femur or the acetabulum, and it might be twisted forward, which would bias more internal rotation and less external, or it might be turned backwards, and they have more external and less internal. Or if they have a block in one direction, then it suggests, but normal range the other way, it suggests there's some sort of, you know, bony outcropping. So like a CAM lesion, which we see a lot in males, which might restrict internal rotation, but they have normal external, or it might be some increased bone posteriorly or anteriorly on the femur, which might give the same result. So that's a good way for your listeners to sort of think about it. So we're big on prone IR and ER. And as I alluded to before, we do our strengthening and our testing in that position because we think the external and our internal rotators functionally work well. That's the first stage is to get some global strength, if you like, get some strength in the muscle. The problem is that I think a lot of people stop there. And so stage two really needs to be a functional application of that strength. If you think about all of those exercises, they're either working in outer or inner range, like a side-lying abduction is very much inner range abduction. Prone IR, ER could either be internal or external rotation. We train, sorry, inner or outer range, and we go through full range. But the reality of walking or running or something like that is, if I am a runner, I don't actually AD or AB duck very much. My foot comes to the midline, so I have relative adduction. But when I hit the ground, I'm very much bordering on an isometric contraction. So we need to train them in a position where their pelvis is level and we're training internal and external rotation in that position. So we do what we call twisties and internal rotation twisties. I'm sure people do that and call it different names. And we do a drop down, not a hip hitch because a hip hitch would mean your abductors are contracting and lifting your pelvis up and you're probably using your abdominals. We actually go from neutral and drop down. And what that tends to do is then train them in a functional position. But then we talk about the actual function of the muscle, not just the position. And if I can diverse for a little reason to explain this, but if I'm a marathon runner and someone says, you know, your calf takes 30% to 60% of your shock absorption, I'd say, yep, I agree. And if they said we should be doing more calf raises, I'd say, yeah. I think they're kidding themselves because we know that elite athletes only do about 30 calf raises before they're fatigued. So they're not going to be able to go and run a marathon and hit the ground 20,000 times. and have a concentric and eccentric phase. It is more likely that we have more an isometric contraction of that calf and we get some stretch, relaxation, storage and release of energy of the non-contractile tissue. So my feeling is that when we then go to strength work, we need to actually look at doing that. So maybe some of those positions, the functional positions we saw before, but challenge them with perturbation type moves. And then I think, you know, the final piece of the puzzle is we need to go into positions that challenge the athlete. So even running, when the foot hits the ground, I'll have horizontal ground reaction force, a braking force, which will spin me into internal rotation, and I'll have a vertical ground reaction force, which will drop me into adduction. So I need to be really good at controlling flexion, adduction, internal rotation. And then the final piece of that is I think we really need to retrain the movement patterns. You can take this as strength. You can take this as something else. But a lot of these, if we're talking dysplasia, a lot of these people will function in what we call isolated hip extension. So they run or they walk with a very vertical body. But the hip going into a lot of extension. And I always sort of say to female patients, it's very hard for a male to walk with females because you guys are so fast and you have such a long stride length and you're amazing with your walking and we have no chance of keeping up. But I think it comes through a long stride length. And I think that normally if you look though, and we've all seen these people walking when you go for your morning walk. They walk with an incredibly long stride, but that trail leg is in isolated hip extension. So what we'd like to train, and your viewers can Google what triple extension is if they don't know, but it's a shorter stride. You lean forward more from the ankle, and you have a line, if you like, between your shoulder, your hip, and your knee and ankle. It's a dead straight line. It's almost that line we discussed earlier about in the sway correction. But they learn to walk on a slight incline. But the key is with a smaller stride length. I describe to my patients, if they don't get it, that they're walking into a cyclone or a hurricane and they have to lean forward from the ankles because you wouldn't bend from the waist and take a smaller step. And it seems to get across. But we actually break it down at work. And there's some really good online training of triple extension. But I think in hip extension... If I could give one tip, that's really what I would look at for retraining that purpose. And if you feel you need to train the hip flexors, I think that's a really valid point as well because those hip flexors working eccentrically control the hip from going into hip extension. I know that's a whirlwind and it's a really quick summary of the strength, but that's what we would do.

SPEAKER_01 16:33

That's a fantastic progression from lying on the bed all the way through to function. So you've done 8 to 12 weeks of rehab. who do you typically refer on from there

SPEAKER_02 16:47

that's a really good question too because it's a bit of a vexed issue look if i could sort of just go a little bit to radiology with this as well a lot of people come in and sometimes we're lucky enough to see someone as a third or fourth opinion or more and they've often had the radiology so if someone has really poor coverage, and we haven't got time to talk about radiology, but they don't have great coverage on what we call a lateral center edge angle or an anterior center edge angle, and your viewers can look at that. Or they've got a tonus angle, which is basically how much the ball would slide out of the socket that is significant and over 10 degrees. Or they've got a broken Shenton's line, and again, just look those things up, that says that there's a migration of the head of the femur in the socket. Then I would always engage a good orthopedic surgeon that sees dysplasia and they've got to be high volume you know surgeons of seeing that because it'll be poo-pooed a bit otherwise and I think that my take is that I always think if this was a family member of mine what have I got to lose by getting an opinion if you see someone who's very good sees a lot of it and is very conservative and I always refer to if you're buying a second-hand car you'd get a mate who's a mechanic to check it You'd ring the police and make sure it wasn't stolen, and you'd ring the rego board and make sure it was third-party insured. Under no circumstances are you obliged to buy that car, but if you do, you are making an informed decision on the purchase of that vehicle. I think too many clinicians hold things too close to their chest. I think I can provide a service, but an orthopaedic surgeon or a sports physician can provide a different bias to it, and together we work as a team to come together to give that patient the best care we can possibly give. and I don't understand why people don't get that opinion. The beauty is that these surgeons are normally booked up for three to four months, as we know. We get an opportunity to work for three or four months, which is, I think, how long it takes for the strength work or the motor patterning, the correction of posture to take effect. So by the time they actually get to the surgeon, they can give a really good opinion on, I think this is actually really working well for me, or Yeah, I'm getting there. I've been a bit slack with my exercises or no, this is having no effect and I've been really diligent, which then gives a bit more power to the surgeon to help give some input and then ultimately that decision is made by the patient.

SPEAKER_01 19:09

That is absolutely stellar information. I really do think you have mastered the art of subtraction. which is distilling what's a really complex topic into plenty of clinical gems for us to take away and implement in practice tomorrow. So thank you so much for your time today, Andrew. That was absolutely fantastic.

SPEAKER_02 19:33

Thanks very much for the invite. Always love talking about this stuff and you're doing a great job with the podcast. So keep doing them. Thanks very much.

SPEAKER_01 19:39

Thanks, Andrew.