How to Tell If Your Groin Pain Is Hip Impingement, Not a Strain

Again, all of these should not work with hip impingement or a hip flexor problem or a adductor strain. They shouldn't work. I think we're all in agreeance to that. So if you're able to reduce your problem as a patient by slightly giving support to the area, I think you're a rehab case. Does that make sense to everybody, okay? If you do not understand it, again, the best, this is the month of giving, okay? This is December. I want to give back, and clinical pearl-wise, the dynamic aspect of hip testing, especially scourism for bears, will blow your damn mind. You're listening to the Restoring Human Movement podcast, where movement experts discuss the latest evidence-based practices to help you and your clients move with mastery.

And now, your host, Dr. Sebastian Gonzales. Hey, everyone, it's Dr. Sebastian Gonzales, your host with the Restoring Human Movement podcast. Thanks for joining the Movement Movement. This is your first time. Welcome. This podcast is about a 45-minute, hour-long format where we cover things movement-related, as you heard in the introduction. It's where movement providers come together to improve and level up. And considering of that, if you're a lay public or a patient or a quote-unquote client listening to this, you still will get an information from it. It's not for the people who are just kind of starting out and just learning stuff about their body.

It's people who have kind of gone through some rehab and PT already or had a problem, and they're trying to learn a little bit more. And so some of the episodes are way more friendly to just patient understanding, and other ones are a little bit more comprehensive for the people who want to learn a little bit more or for clinicians to go and level up. Now, I usually don't create content in a certain format, as in, like, this is the first podcast of the month of December for 2019. I usually don't formulate things for certain times of the month or certain times of the year, and I run a full-time practice.

I like to go do other things, and I just really enjoy interviewing and sharing with everybody. And so I've done a really bad job of actually curating content and packaging things up, other than the fact that I think the last few months we've done those student interviews the last session of every month. So this one, and actually this entire month, except for the very last one, which is going to be a student interview again, I'm going to do my very best at giving back. I'm very thankful for the listeners. I've heard, I've gotten many messages from you guys, and I'm very thankful for you guys listening and supporting.

And I know that over the last few handful of months, I've said I really need a little bit of validation to confirm this is still a podcast, which is helpful to everybody, because this is going on two years, and it's a long time. It's a lot of work put in, and I just wanted to make sure everybody was still getting information. So a lot of you did reach out independently and let me know that you still love it. And so thank you very much. So I thought I would give back. And as I go into the topic of the day, just know that there will be, at the very end, a way to get this information on your desktop, on your phone, on a video.

And so I'm going to be talking about some hip examination today that I typically do. I feel very good with hips. And I know a lot of PTs, chiropractors might not feel very good at hips. And I feel very confident in the way I assess them, as well as I can test them out and suggest for them too. And so I want you guys to feel that as well. This works very well for me in my clinic. And so I already put together a worksheet of a rough flow, as well as some ideas you can use for rehab and a video which demonstrates the examination in real time. And so if you guys are looking for that, there will be a link at the very bottom.

Actually, it's in the show notes part. So whatever media player you're on, scroll on down, and there will be a link right there which takes you to a sign-in page, which all these are going to be disseminated via email drip. It's just the easiest way to do things. So just sign into there. You're not going to be spammed with a bunch of stuff. I promise only high-value things for you clinicians out there. Now, if this is your first time in the podcast, again, I like to share a little bit about myself via personal story. And so I'll get right into that, and then we will go into the content for the hip.

Now, recently I decided that I think I should create a law of the universe, let's just say, a universal law of the universe, which is about saving spots or saving seats. And so I know that a lot of times we get to places and it's like, hey, you know, we've got a party at 10 coming, you know? And so recently I went to something. Hey, we've got a party at 8. And so we were kind of hanging out there. Me and a friend, we were there about 30 minutes early to get the table right as the place opened. And so we had a lot of people who were wanting to come that we'd spoken to for weeks for this thing. It was a great event, by the way.

It was the Huntington Beach, or sorry, the Pacific City? Pacific Coast Air Show. Anyways, it was great. And so it's really hard to get seats for these things. So we sat there, we were in a restaurant, and we were right on the patio, and so we had these seats. And so we were kind of hanging out there. An hour goes by. The air show was already going on for an hour, and only two people showed up of those eight so far. And so I texted other people and was like, hey, what's going on? Like, are you close? Like, oh, yeah, we're trying to find parking. And, like, the other guy's like, oh, you know, I'm down the street, and I'm walking, and, you know, we'll be there in, like, an hour or so.

In the meantime, though, people were walking up and like, hey, you save me seats? Like, can we sit in these seats? Can we sit in these seats? All around, like, was a big old area of, like, crowd of people, and we had this little oasis of seats. And so I decided at that point, because it's really stressful to share seats. So the universal law, my law of the universe is that thou shalt not save seats beyond 15 minutes from expected time of arrival. Meaning, and I mean, it's a nice way, I'm going to save seats if I can. But I don't think it's fair to stall, you know, like, the restaurant's making money.

Also, the people don't sit there, you know, they were there. And so, hey, I'm going to be there at 11 o'clock. I will then put my cell phone on a timer on your seat that says 15 minutes, and it's counting down. And so when someone comes up and says, hey, are you saving these seats? I'll be like, I'm going to hit my phone, open it up a little bit. I'll say, well, they got three minutes and 27 seconds left. Come back in about four minutes, and you can have this seat. And so when someone asks, like, hey, maybe you can save, you know, like, what time are you going to be there? Can you text me when you're there?

It's like, no, I'm going to be there at 11. You can be there anywhere between 11 and 11.15. That is my seat-saving window. So I propose everyone use the same law of the universe, and then I think we can get people on time. Come on. Now we get into the content. Now, I gave this presentation recently at California Chiropractic Sports Symposium. Honored to be there. Thank you very much, Lisa Thompson and Michael Fanny, for suggesting me, actually. My first time presenting, I was a little nervous. I'm not going to lie. I was towards the end of the day, and I was, like, some of the students were there.

I'm like, hey, did you go yet? And are you going to be nervous? I'm like, kind of, after listening to everybody else's, everybody else did a pretty good job. But I was trying. I'm like, hey, I've got to go sit in a corner for about 30 minutes and just not listen to these presentations. They're good. But then I feel like I'm going to start using their terminology, and I'm not going to actually use my own stuff. Kind of, like, thinking, oh, that's a good idea. Maybe we should add that. I'm like, no, I'm not going to do that. So I think the presentation went really well. And the way I started it off was basically saying I wanted to propose that everybody level up and everybody improve.

And the way I tend to suggest care to not only my patients and categorizing what I think they should do, as well as other clinicians of learning, is the four-block system, four-bucket system, which I did talk about on a podcast probably about, like, two months ago or so. So here's – I'll propose it right now because I want you to understand that as I start going through this that there is not necessarily anything harmful in doing manual therapy or I don't think it's – it's not useful. But when I go through this, it seems like I'm really much a poo-poo on manual therapies, and I'm not. So the first one is first aid.

First aid, the whole point of first aid is to be first aid. First aid is to reduce symptoms. It's to allow the area to heal itself, and it's only supposed to be around for about five to ten days. If it's going on longer than that, I think we've got a different problem going on. Box two or bucket two is your corrective exercise or your buttressing effect. And this is basically all those little exercises you see people do on Instagram and YouTube, and they have bands and balls, and they're balancing on stuff, and it looks like, hey, I've never seen that exercise before. How come my therapist doesn't give me that exercise?

Those are corrective exercises, and they're intended to build a bridge going from box one to box three. Box three is your strength conditioning resistance training block. I tend to use this because I remember I had this one lady who she came in, and she was – she had some pain in her – I think it was her arm. And so she was an older lady, and she wasn't driving anymore. And so I said, hey, why don't we carry this 10-pound weight? Or can you carry this 10-pound weight around the office? She said, no, no, no, it's too heavy. I said, okay, how much weight do you want to pick up? And she's like, that five right there.

I said, okay, so the 10's too heavy. All right, got it. And I said, are you still – how are you getting your groceries back to your house? She's like, oh, I'm carrying my bags of groceries back to my house. I'm like, oh, okay. So I'm like, you know those are probably heavier than 10 pounds. And so this is an example of that people will encounter load at some point throughout their day just through their ADLs. And so resistance training or your strength conditioning doesn't have to be anything that you might think it might be. And so patients might say, well, your resistance training, you're talking about, well, I don't want to go to CrossFit.

I don't want to get buff. It's like you won't. Just we're going to start exposing you to some weights that you – and loads that you will encounter throughout your day. So that's the ADL version of it. Excuse me. However, sometimes they're going to get a little bit higher in that too. And so I don't tend to think my patients are – they're not fragile. All right, they're anti-fragile. They're resilient. And so when you go into this block 3 resistance training actually too, it tends to teach them how to pick up objects, how to squat to a toilet, how to reach and grab something. And so it starts to build a little bit more of a resiliency to rotational patterns too.

When you use single arm, single leg variety. And so I tend to have my patients not necessarily come back as a maintenance care for first aid or corrective exercise, mainly for strength and conditioning if they can be in there. However, a lot of times when they'll come back, they'll have a little ache and boo-boo. And sometimes I got to change their box too or their corrective exercise that they use the warm-up prior to resistance training. I typically tell them that in the resistance training element, you can do it with me. You can do it on your own. You can do it with a strength coach. You can do it with a trainer.

I don't care who you do it with, but you have to do it in my opinion. There's very few cases where I've said, yeah, you know what? You don't need to be strong or exposure to your ADLs with different types of load. No, don't worry. And so usually that's how I'll proposition people like that. Box four is a more return to meaningful play or kind of like a movement variability aspect. A lot of times through block three or resistance training or strength conditioning, you'll tend to get people who move – you'll train them to move like robots. I don't want them to move like a robot. I want them to get strong kind of robotically and then exposure to lower loads through a variation of movement, which is not perfect postural movements.

So let's frame that right there. Box one is your first aid, and that's where I would put a lot of your manual therapies, your ice heats, compressions, your bracing, your positions of comfort, some of your McKenzie exercises, orange range loading, some of your neurodynamics, all that kind of stuff I'd throw in that bucket right there. And so when I'm going through examination, a lot of times I'll look for that first aid or that box one that I can use as a movement-based correction that they can decrease the possibility of having a triggering response. And so the reason why I started doing that or the way I started doing my examination, which I will talk about in one second here, is because I was continually looking for that first aid.

I'm looking to see what could possibly give me a clue of what their first aid might be. So I suggest that you dynamically test things, and that means not just going through your standard orthopedics test, but putting them in the orthopedics test position and then giving them something a little bit effortful to do in that moment, which changes their positive to a negative. All right? And so if you ever notice, a lot of the tests, especially the hip, are passive. And so for using the ones I'll use is passive hip range of motion, scour's test, circumduction, axial compression tests in different quadrants, Faber's test.

These are the battery tests that I use just mainly looking at the hip joint in particular. But there are other things, resisted ranges of motion that I'll use, or actually I'll have them do closed chain movement too. So, but a lot of times when you go through and you're examining to figure out what these, what's going on here, a lot of these orthopedics tests are passive. And I propose that we can make some of them active. I think we can do it in the shoulder as well, which I'll be covering next week. So here's what I'll typically do when I'm looking to see what's going on. Number one, I'll consider what are our possible differential diagnosis here, which is creating the person's problem.

Number one is typically I'll screen out central base problems first, and I'll look to see if the lower back, neither disc, segment, or nerve is creating a referred symptom to the area. There's ways to test this beyond reasonable doubt, and I think if you've experienced people with sciatica-like symptoms, you're probably going to know kind of what I'm talking about. Consider these like a low-grade sciatica, and they can refer to the back of the hip, the front of the hip, the side of the hip. Don't be confused when someone points to a quote-unquote tight muscle because it still could be derived from the spinal-based area.

And so usually I'll do some tests for the lumbar spine, the knee, some neurodynamic tests, some slumps tests, some foot-ankle if I need to go that far. And so make sure that you're not forgetting about these. I'm not going to cover them in particular in this talk here, but examine those because they are part of the puzzle. I like to do general screeners as well. Also, one more thing. If you're not already, I suggest that you do upper and lower reflexes, pathologicals as well, and strength test every single time with every single person. If you're thinking, man, that seems like a lot of work, you should be doing it anyways.

Just get quick at it. It doesn't take that long. And especially when you go into the upper, like I usually tell people that I'll say, look, I'm going to start doing some tests that are seemingly very unrelated to your problem. All I want you to do is just patronize me, you know, just humor me. Allow me to do it, okay? I'm looking for information to help you. And so they're going to seem unrelated, but let's just, like, if we end up talking about it, like, why are we testing the shoulders when I have a hip problem? Just if we talk about it, it's going to take longer, all right? I promise I'll get there.

And so when you screen those things, I think the first time you find a positive Hoffman, you're going to think, wow, I'm really glad I did that, all right? So check those things. It's important to make sure that you're guiding the person correctly. So usually with back and nerve and slumps or femoral nerve or femoral bias slumps test, I'll test those things out, but I won't be covering them in this one. The hip joint in particular, I'll be looking to see at least the most common diagnosis, and that'll be hip impingement, labral pathology, and I guess your tendonitis is quote-unquote. Or let's just say joint passive structures and then active ones.

I want to see which one triggers the person. I was reminded very recently, actually, that I think I could still improve on my hip examination some. And you know how on the shoulder they have, if you're not familiar, they have what they call lag test. And so you put the shoulder in a certain position to tell them to hold it, and if they drift out of that position, there's a possibility that they have a pretty significant cuff tear. And so to my knowledge, I haven't seen one for the hip, but if you think about it, the hip and the GH joint, their glenohumeral joint, they're kind of the same. You know, they're the ball and socket.

I know they have a little bit different anatomy, slightly, and a little bit different geometry. However, the hip is to the back that the shoulder is to the neck. So remember that. And I need to get better. I don't think I'll have anything for you guys in this go-around, but I'm considering developing some lag tests. If you guys know of some for the hip joint in particular, mainly the small muscles of the hip, you know, the deep stabilizer ones, then I would be very interested to see. I don't know how to isolate those things down as a thing. So, I mean, I think the glute max is still going to win with external rotation.

It's going to get them there, but maybe other things pop up. Anyways, please help me on that part. So in general observation testing is the first thing I'll cover there. Standing observational tests are usually the best ones for me, and I get to see not only what or how they're feeling with these movements, but also, too, if there's any movement compensations or just generalized things that it's like, huh, that's interesting. And so usually I'll do a standing global flexion test. And so I think someone else, maybe in FMS, they call this a standing flexion or intersegmental flexion test. I don't know.

I'm just going to tell them to reach towards their toes, okay? So I tell them to reach down towards their toes because if I tell them to reach and touch their toes, they will force to try to touch their toes. And in that moment, is there anything that bothers them? I don't care if it's in the hip or the leg or the back or the neck. Tell me anything that bothers you, okay? So I'll have them do it a couple times. Also, we'll go over standing extension, global extension test. Typically, I'll first start with hands on the chest and have them bend backwards and just see. A lot of times this will allow them to really extend a little bit further in the low back, which I don't necessarily want, but I want to see if that's a dominant pattern for them.

Also, too, I'll usually tell them to put hands on hips and push their belt buckle towards me to see if that changes their symptoms at all. If there is a problem in there, sometimes I'll go into a standing source test. I'll have them take one foot, not off the ground, but just a tippy-toe as a balancer, and I'll have them bend backwards, same arm position, whatever one was the triggerable one. And I'll have them go through and do the other side and see if it changes as well. Also, if this improves it, it could just be that the frontal plane was challenged or buttressed in that to where it improved what their hip was feeling, whatever reason why it was a problem.

Next, I'll do a standing rotation test, just globally, hands out to the side. Go ahead and look over that shoulder as far as you can. I think the FMS did it a really good way, where you stood behind the person and you told them to look at your hand, or if you snap your fingers, on the other side of their body, they'll have to look all the way across midline. I don't tend to use that cue quite as much. I'll stand in front of them and make sure they have their feet together on all of these tests, by the way, because I want to see if they are dumping into—it'll narrow their base of support, and it'll allow them to drift into whatever compensated movement they might be doing, rather than keeping them wide, and then they might be able to support it a little bit more.

I want to see the outliers here. So let me reiterate that one more time. There's three of them. There's bend forward in an attempt to touch your toes. You don't have to touch your toes, but bend forward toward your toes. Next is—you might want to have them do it a couple times just to see. And I usually look from the forward and from the side. Next, I'll say go ahead and—hands on chest, go ahead and bend backwards as far as you feel comfortable. And again, forward and side, feet together as well. Go ahead and put your feet together, arms out to the side, look over your shoulder as far as you can, and try to look across the room to the other side.

Again, feet together. And I'm looking at global movement. Usually on these things, I'll look at a couple different things. I'll look to see, number one, is there a white elephant asymmetry bilaterally, like—or unilaterally, unilaterally, single side? Are they doing something really odd on one side versus another, and does it make sense with the problem that they're talking about? An example is if they're like, hey, my left hip hurts, and they tend to load into that side. It doesn't make sense. However, if they stepped on a tack, and they have a left foot problem, and they stepped on the left foot with a tack, or the left foot stepped on the tack, and they didn't want to put weight on it, that makes sense due to the acute nature and timeline.

Me and Dr. Cody Dimak talked about this a while back when we were talking about, I think, hamstrings. I want to say it was around 140 or so. Cody Dimak is the co-host at times, and so we'll usually have a little bit of discussion on this stuff. But it's actually surprising how many people drift into the side of complaint. So the white elephant in the room. Also, two other white elephants are, do they bend their knees excessively? Are they resistant of actually bending the spine at all? Do they move more about the low spine, and then their hips actually don't really even move? You'll see this sometimes with rotation, is that they'll leave their zipper facing you, and their chest will turn to the side.

And they'll say, yeah, you can't really turn that far. Well, you lost some rotation in that, in the hip area. Maybe this is part of their issue right here. And in that case, maybe their hip issue is actually, maybe even that there's too much movement in the low back, and it's just segmentally referring there. Also, look at the feet. Are they getting a little wishy-washy with their base of support? When I see them turn, sometimes you'll see one medial arch, inner arch, unload, and the other side will stay fixed. Maybe this means when they're rotating over that side, they're trying to avoid the turning, the internal femoral rotation about the hip above it, and their foot is flaring out to allow a little bit more drift into neutral or disallowing that internal rotation.

And so I'll look at a lot of these areas. I do have these written down on the document as well. And so those are the global patterns. Next, I'll go into just a couple different tests still observationally. By the way, I don't think I mentioned at the beginning, we're collecting information. We're collecting data. And so although we have a theory of what could be going on with this person, it's best to not really jump the gun too much and just observe what's going on. I was at, again, I was at a workshop where we were doing an overhead reach test. And so someone turned to me and they said, well, I can't reach overhead.

Do you think that's my tight lat? I'm like, I think it could be a lot of reasons. Maybe your lat is tight, but we don't know until, this is one test. It's an observational test, and all we know is that they couldn't reach overhead, all right? It could be a lot of different reasons why. And we're going to battery those concepts together with other tests, which are the ones we're going to come up with later, okay? We're just collecting information, collecting data, and clustering it into groups, which mean that we're chasing that differential versus a different one. Now, Y excursion test is a really easy one to do.

I tell them to stand on one foot and try to dip their heel into the water in front of them and then a little bit off towards the side, like a Y formation. I think they did this test years ago when they're looking at ACL recovery on people or if they had a tendency of maybe having a predicted ACL injury. I don't recall. However, usually with this test, I'll see it's kind of like a dynamic stability test of the stance leg hip or the stance leg in that case. And I'll usually tell them, like, if you're drinking a cup of coffee and it's hot and really brimmed out, if you start spilling it, then this is a positive test for you on either side.

And so, again, I'll tell them what I'm looking for because usually this one's a little bit hard to cheat. Sometimes they'll squat it versus actually reach it, or sometimes they'll actually put their foot on the ground when they're reaching to stabilize themselves before they come back. I tell them to tap it, all right? You got some nice shoes on. However, the heel is waterproof, but the rest of the shoe is not. Do not put your foot into the water, okay? The last one is a best squat you've ever seen test. Go ahead and I want you to put your hands behind your head. Squat down. Show me the best squat you've ever seen in your life.

And so, yeah, we could do the overhead squat, but I'm not really looking at overhead considerations right now. I just want to see can they get to a certain depth, and I want to see if they shift to a certain side, all right? And usually a lot of people with hip impingement, they won't like going to a certain depth. Interesting, though, is that so when they have tension and they're trying to fight gravity in that depth, it's painful. Like say you have your CrossFitters with groin pain at the very bottom of a squat. However, if you tell them to relax and act like they're smoking a cigarette and put zero effort through this deep squat and just let your butt go to the ground and let your back round a little bit, a lot of times they don't have pain if that is that FAI.

Someone asked me a question of why with that, and so I can think of a couple theories why. However, probably the easiest mechanical one that everyone's going to get is that if we have hip impingement, we have the acetabular rim hitting the ephemeral neck, all right? Whether it be pincer or cam or whatever, like the approximation is a little bit too much. And so with an anterior tilt coupled with lumbar extension, then usually that roof of the acetabulum or the rim of the socket will drop a little lower. They did a radiology study where they saw that a posterior tilt actually had about five, I think it was five more degrees of pain-free movement on people with FAI or femoral acetabular impingement than those with an anterior tilt.

And so if you allow that passive posterior tilt, sometimes they just get way more free range of motion there. And these people who suffer with pain at the deep part of a squat is they just have, in my opinion, insufficient stabilization down there to allow them to go to that depth with that tension or that load. Now, another reason why that could possibly happen is maybe we have referred from the mid to high lumbar spine via the clunial nerves, the superior clunial nerves that's wrapped around the anterior side of the body, the front side of the body, into the groin area. And then we're just relaxing the spine right there and allowing the intervertebral foramens, the holes that the little nerves go through to open and let the nerves actually just quote-unquote de-swell.

So it could be a lot of reasons why, okay? However, I just fish to see what is this person showing me to collect the information that maybe is helpful for development of a first aid. So recap that one more time before we go into local examination. And again, I'm not going to pretend to know it all on these things. However, these are just things that work well for me in office. First is bend forward, go backwards, look over your shoulder, dip your heel into the water in front of you and show me the best squat you've ever seen. Now, when we get into local regional testing for the hip, again, remember you had to screen out the other stuff too.

I would definitely start with the spine. I like to go into first to figure out, number one, does the person think they have something? And so a lot of times people will come in with groin pain or pain within the groin region, the middle or the inner part of the thigh and think they have some type of strain or tendonitis for some reason. They'll say hip flexor tendonitis. So is tendonitis. Adductor tendonitis. Scar tissue in their adductor region. And so they'll be, not that I'm, I'm not bashing them for this, but this does happen a lot, is hey, I've been trying a lot of mash work and a lot of tissue care into my hip flexor and my adductor and it just won't go away.

It feels painful in my adductor so it must be my adductor. No, incorrect. It could be that the adductor is a problem. However, most of the time in my experience it's not. These are referred symptoms and I remember about three, I don't think I learned about femoral acetabular impingement until the first, until about three, four years out of school and then I started realizing, holy crap, I've been mismanaging these cases for a very long time. And so when you first find your first incident of this, this is going to be, this is my proposition to you, the very first win you guys are going to get. I want you to attempt to actually trigger that person's groin or hip flexor problem, quote unquote, with a passive test.

I like to use scours or some type of range of motion into flexion. It's not always in flexion, it could be in different positions too, but if you find that and it's like, wow, that's, wait a minute, there's an active component which hurts with a passive test. Okay, okay. So maybe this is, maybe this is still something that, maybe it's an outlier. Okay, cool. And so usually then, I'll take them into a resisted test for that area, for that muscle they're talking about and I'll load the heck out of it gradually and I'll say, slowly start pushing in my hand, don't let me pull you. We'll do like an isometric.

And so we can do that for the adductor, you can do it for the hip flexor, you can do it for probably most muscles of the hip. And so when they say, yeah, that didn't hurt, and say, huh, that's interesting. Loading the muscle that is the quote unquote problem doesn't hurt, but me putting you into a position where the muscles are off does hurt. What does that mean? And so there's ways to test this again to see if we're still looking at this acetabular drop. By the way, I guess I've migrated towards FAI in this case rather than the other differentials because the other differentials for the spine or nerve, those would be addressed in a low back or a neurodynamic type of examination.

And the active stuff, I guess we're kind of ruling in that out right now. I don't find it that often. I guess I should do a caveat real quickly is that when someone does have an active component that's pain, I would put them into a different position which puts the muscles into a better strength curve position. I think that's what it's called. An example would be like a bicep curl. From the bottom could be painful. Mid-range, it's not. And the top, it's probably not. And so you could probably find that position where they're at a mechanical advantage and then pull the holy heck out of them. Obviously, make sure you've screened to make sure it's not a large tear.

They have Popeye sign in that case. But just gradually start to load them. And so it could be a non-painful manual muscle test in a different position than a different one. And so that doesn't make any sense either. So you can even take them into an eccentric version of that and actually win, slowly let me win. And I bet still they feel fine. A lot of times when you put them into a position which is for the hip, if you put them into more hip flexion and that allows them to get a little bit more belly co-contraction and then that will decrease the amount of anterior pelvic tilt. That's in my opinion.

So there are cases where that does happen where they do have an actual active component to it. However, it's less frequent than I ever thought. Now, the testing that I'll typically do, I'll go through the list right now because I got on a little bit of a tangent there, is at first I'll usually have them laying supine, face up. And I'll say, look, we're going to screen out all of the different types of conditions that you might be concerned of. Which one are you concerned of? That one. Okay, cool. We're going to screen that thing out. And so first I'll do resisted hip flexion, resisted knee extension, resisted knee flexion.

And if I really have to, I'll go into a prone version of hip extension, push the heel through the ceiling. I don't do that quite as much anymore. I don't know why. However, a lot of times, if I don't have enough information through the original test, I'll start to explore more zebra types of tests, I guess. I know a lot of people lack hip extension or they lack glute strength. However, usually when I'm doing this battery test, I find enough information in the original ones. And so I'm also screening out some myotomes as well with this, by the way. And so any test that you find to be positive, that's active, remember that.

And you can come back to it later as an outcome measure for them. So usually I'll do resisted first. Then I'll do supine passive hip range of motion. I just want to see. Usually I'll move them in towards flexion and just see. Typically, by the way, I talked about this in the workshop, is that people will tend to help you if they don't feel secure that you have them. Don't grab them creepy-like. Grab them with authority, but nicely. And so I'll tend to put their shin under my armpit and I'll tend to guide them that way so they know that I have full control of the hip and they can relax because I want it to be passive.

If I was doing active testing, then I would do active testing. And so I'll tend to guide them into flexion a little bit, bring them down a little bit, bring them into flexion a little bit and start to move a little bit more into adduction just to see. I don't blow through that part, adduction or cross the body, mainly because a lot of times that will be positive. So I'm just kind of testing it and looking at their face at the same time. Then I'll get them down into hip at 90 if they can attain that. Most people can. I'll go into internal rotation and external rotation. With external rotation, the foot goes across the midline of the body and usually I'll find the point where there's the first amount of resistance.

And so I'll stop right there and let the heel slowly drop towards the other thigh just to see where it measures at. Usually I'm looking for about mid-thigh femur or mid-thigh quad. I'll go into external rotation. Roughly I'm looking for about 10, 15, 20 degrees and compare bilaterally obviously. And lastly, I'll go into some dune. I would not load the foot into dorsiflexion, but I'll slowly see what their hamstring length, I guess would be, or their hip flexion with knee extension as well. And so obviously this could be coupled as a straight leg test for nerve-based problems, but I'm not loading the foot.

I'm not dorsiflexing them, so I'm not putting the nerve at tension. So I just kind of want to see if there's anything in that range. I did have someone recently who should have been way more flexible, but they weren't really that flexible. And so it was interesting to see that one side was dramatically different than the other. So these are the kind of outliers we're looking for. And so when we're looking at, I guess, quote-unquote hamstring length or hip flexion in some of these people, we have to consider also what their sport is if they're generally flexible. If they're generally flexible, you'd expect them to get higher than most people or higher than most sprinters.

And so if it's kind of different for, it's an outlier for what their actual sport or typical flexibility is or mobility is, then I think this is noteworthy information. So that's typically most of what I'll do for passive hip range of motion. Then I'll go into some orthopedics. This is where things typically get fun. Probably of all the stuff that you heard throughout this podcast so far, if you just only did these parts on your hip patients, it would blow your mind. So the gold nugget in this is, the other stuff is actually very useful. It's like icing on the cake, but these ones right here are the cake, okay?

If you don't know what I'm talking about or if you cannot visualize this, I strongly suggest you go through and scroll down to the show notes on your media provider or you can go to the website and just search this podcast. It's going to have a link to an opt-in to get this video. And so the video is me examining this and showing these parts of the dynamic test. This is not what you're going to get in school. I don't know any person who came out of school who actually had the knowledge to try this. Not that I'm any good. It's just that this is something that's typically not taught. And a lot of other seasoned providers haven't tried this either.

So I strongly suggest you try it. This is one of those tests or those moments that when you find it for the first time, it's going to challenge the reality of what you're doing in your practice, okay? So scour's test. Find your positive scour's test. If you don't know scour's test, again, this is something you should probably look up on that video. And so once you get there and you get towards the positive finding, you want the person to tell you when you're right on the edge of the positive finding or in their main complaint. And so when they say right there, good. Okay, now we're going to dynamically test this.

Do not move. Do not change position. This is why you had to have a secure handle on the person's thigh in full control of their legs so they're not helping and so they don't drift out of position. At this point, take your free hand. In this case, it's my outer hand. I typically put my hand on their belly a little bit just with fingertips, not creepy. And I say, look, I want you to do something for me. I want you to push your guts into my hand. Good. How does that feel? And they say, oh, my problem went away. Oh, okay, cool. And so usually I'll play devil's advocate in this a little bit. I'll say, oh, that must have been a coincidence.

Let's try that again. And so we go through the test a couple more times. And so two times a coincidence, three times a pattern. And so if you can keep reduplicating the same type of response with them, beyond reasonable doubt, their problem is not a structural-based one that, in my opinion, needs any advanced type of passive care, tissue work. And it's certainly not surgical because they can reduce their problem by having, by buttressing or improving support of that area via a slight posterior tilt to the pelvis. All we're doing it, all we're doing with it is improving anterior wall tension. Or I guess if you're in the DNS world, this is intra-abdominal pressure.

Or I guess we can say in the McGill word, we're talking about bracing. So either way, though, we're improving support via the center. Okay? So when you do this a couple times, again, the hand one, push your guts into my hand, is the easiest way to, it's the easiest way to make the test very clean. The other suggestions I'll make are, they're useful, however, sometimes the person moves and it muddies the water. Again, I could trick patients when doing these other ones because I move a little bit away and they are, because they're doing effort and they don't tend to notice. But it's not my job to trick them.

It's my job to collect information. And so I'll do the other ones only if this one doesn't work or if they're still questioning, yeah, it might be my hip flexor. And I'm like, hmm, well, it's not. Let's try something different, okay? And so as I described scour's test really quickly, by the way, note, it's called scour's test because you're scouring the rim of the acetabulum. Do not quickly go into that range. It's exponentially painful. And so you creep into hip flexion. You find the end point or you watch the pelvis. Is the pelvis moving? You find a slight bony end feel and then you start to move inward across the rim of the acetabulum, okay?

If you do not reach the highest point, you will not get anything productive from this test. And sometimes you have to cross midline a little bit more until they find their problem. You can do the same thing with the circumduction test, which is kind of like the outward version of scour's test. And also for bears, you all should know for bears test. If you don't, again, this is all in the video. These are good ones to use dynamic testing with. The last test, which is not one I usually use dynamic testing for, there's axial compression in different quadrants. I'm finding the posterior aspect of the capsule and just kind of axially compressing through the femur in a hip flex position.

So posterior, inferior lateral. Well, shit, I'm not even going to go through that. Different quadrants. You know what quadrants are? They're parts of squares. And so those three tests, scour, circumduction, and dynamic testing are usually the ones that are the best. Find the position, hold it, and get them to make a slight change. The four changes I like are these four. Okay? Push your guts into my hand. That's my absolute favorite. All right? It's very clean. It shouldn't make any sense to the patient. And it's an easy way to slightly unload the rim if that is part of the problem. Next is, I have them put their hands up kind of like by their face.

And I have them kind of pulled down. Imagine you seated here. You put your hands up kind of like on a, let's just say, a door of a car and your window's down. You put your hand on the windowsill and you're trying to pull via your ab wall and your lats pulling the door off the frame of the car. And so, I'll do a light version of this because if they pulsed into it, they'd push me away. And so, I'll have them slowly push into my free hand. This is why you've got to have full control with the left hand. And then see if that changes it too. They're using their ab wall to slightly raise the pelvis.

And so, they'll be like, yeah, that helps too. I'll say, great, cool. Another one is, this isn't, I just added this right now. Suck the belly button into the back of the spine. Sometimes that works, sometimes it doesn't. I'll have them do a light quarter sit-up, not a full sit-up, just to kind of put in their ribcage down towards the table. But you can have them just do a quarter sit-up. It's the easiest way. Most people know what a sit-up is. By the way, you should have screened low back to make sure that flexion was not painful on them. And the last one is, you can use the other side leg that is straight on the table.

You can use that and try to push their calf into the table and slightly dent the table. Again, all of these should not work with hip impingement or a hip flexor problem or a adductor strain. They shouldn't work. I think we're all in agreeance to that. So, if you're able to reduce your problem as a patient by slightly giving support to the area, I think you're a rehab case. Does that make sense to everybody? Okay? If you do not understand it, again, the best, this is the month of giving. Okay? This is December. I want to give back and clinical pearl wise, the dynamic aspect of hip testing, especially scours and for bears, will blow your damn mind if you have not tried it already.

You will spend less time doing adductor tissue work. You will spend less time doing pectineus tissue work, less time attacking the anterior or posterior capsule of the hip, and you will spend less time doing manual therapy on the hip flexor. Not that they're not useful at some point. However, I'd say if I had to guess, and I'm going to do a random guess here, just observation. And of course, I had a hip the other day that did not respond like this and I did send them for an image and it actually found something that I didn't expect to find, but I'm glad I sent them for the image. I'm just showing you how confident I feel with this.

Okay? Because I do, I really want you guys to try it. If I had to guess, I'd say easily 80 to 90% of the people who test in this manner respond very, very well, very well with non-manual therapy types of techniques. Okay? You might wonder, well, what are the techniques then? Well, finding the first aid, number one. The first aid might be, in my experience, I use a lot of end range loading as well as neurodynamic openers as well as door jam squats or kind of rounded positions for these people. Again, it depends what's driving their problem, but I'll find a position of comfort or I'll do two of those things, which is end range loading in extension for the lumbar spine or an opener.

Okay? If you haven't been to Michael Shacklock's neurodynamic course, he covers it in there. I won't be covering either of these or any of these in the document or the video that you're going to look at. Okay? We're mainly going to be covering the examination. If you guys are interested further in the actual exercises and the way I demonstrate them, I can do that on a separate video at some point. And also, too, I can do a video on how I would patch in strength conditioning considerations, too. And usually, by the way, again, I just didn't clarify in that, is that I'd say 50% change in probably about a week and a half, two weeks with these people easily without doing any manual therapy.

Usually in that time, again, I'll give them one first aid and then I'll give them some type of corrective based upon the theory. Usually, it's going to be targeted at some type of ab wall or anti-extension or it's going to be some glute thing. And I do mean it's effortful, very effortful, all right, because I've already screened them out for other things. Usually, I'll get them into strength conditioning probably within like the second or third session. However, a lot of times their pain is reduced so far at that point that they're like, hmm, I don't need to come back, which I need to do better communication with people on this front because I think I'm not doing them any, I'm not doing them a big service just by first aiding and giving them some exercise which is an intermediate to actually get into strength conditioning or block three.

I think it's a good starting point and I understand that everybody has, we're meeting them at different points in their life. Some people are really frustrated with stuff coming back and they're willing to actually go a little bit further with you. These are my favorite people but sometimes, like I've had patients who come in one or two times for the same problem in different years and finally, in the second or third year, they say, you know what, last time you talked about doing some squats. Do you think that'll really help it not come back and say, yeah, I think we should try it. I'm not gonna harp on them and make them feel bad about failing because I think everybody has their journey to realization on these things.

I can feel like their father and just bother them about it and then they might not come back or I can just be a guide when they're ready and say, hey, come on back when you're ready to try X, Y, and Z if you wanna try it. And so, for those people who are ready to try it, again, I'll consolidate this down. The first aid, they have first aid, one first aid and one or two corrective exercises based upon what I'm looking to accomplish. What am I looking to use to support? In this case, with those examinations, with dynamic testing, I think that gluten, ab wall, or anti-extension are probably good calls in this case and there's various different ways to do it.

I don't think, by the way, I don't think everybody needs to have a knowledge of 5,000 different corrective exercises. 10 to 15 are probably good. Bias them different ways. You'd be surprised as how good you can get at those ones and getting different things that you need out of them to improve somebody based upon biasing certain muscle groupings in the way you cue it. Usually, on day one, they'll get those two things or those, sorry, first aid as well as one or two corrective exercises. Depends how I feel and what their comprehension is to do them. And then, usually, the other time, the second time, I'll start going in strength conditioning.

Usually, I'll start with a high-tension push-up plank or a hinge or a single-leg deadlift of varying weights, a suitcase carry, maybe a variation of a squat, and sometimes into a horizontal pulling movement. In my experience, a lot of these people have pain with deep squatting, so I won't start with squatting. I'll start with the hinge. The hinge is a little bit more, it's a little bit more, it's hip-dominant, okay? It's a hip-dominant movement. And so, I tend to train that first, and I do remember I had this one guy, he had knee pain, but he had knee pain with squatting, so he came in and he wanted to fuss about it a little bit, and I said, man, don't worry about it, let's just go into the hinge, let's go into a squat, sorry, into a carry, let's go into a push-up plank, let's do a single-arm pulling movement, and let's just come back to it, okay?

And so we did, and he squatted, and he said, hey, my knee doesn't hurt anymore. And I said, yeah, it's pretty cool, huh? And so sometimes, we need to scale back a little bit on the thing that is bothering of them and then slowly expose them to more range with a little bit more direct cueing, all right? These exercises you give people, they need direct assistance, okay? I can't stress how important this is, and I've met so many people who have tried the quote-unquote correct exercise for their problem, and they come in and they say, I've tried this before. I say, well, you haven't tried it this way.

So the exercise is not the magic, it's how it's cued and the effort that you're getting out of it, okay? And so I don't suggest anybody manage their own problem. I've met so many people who have tried to manage their own problem, including myself, and it's been crappy, okay? You get very close to the problem. You can't see a bird's-eye view of what's going on, and Dan John had a really good saying. He said, if you're training yourself, then your client's an idiot. I love that, okay? I've told all of my patients who want to do their own training, especially early in the beginning, I do believe they can do it later.

However, in the beginning, I suggest that they don't when we're trying to troubleshoot a problem, and I tell every single one, I say, look, I had a back problem, and I realized I couldn't manage it myself, and I tried for about three weeks or so, and I finally went to Dr. DMACC. By the way, students over at Parker, I don't think you know what gold you got there, okay? I would stop him in a hallway and tell him to start assessing people that you're watching, okay? He just dripped gold nuggets. You gotta get it out of him, and so just bug him a little bit. I know he's willing to help everybody, so just bother him.

He went over there to help students get better, and so really ask him. You got some gold gems in there. So he was the one who managed me, and then I went straight over to a strength coach, which I've had on a couple times, is Brennan Gassamia, and so he loaded me through strength conditioning, Dan John's style protocol, for about two months or so, two times a week, and I was willing to pay the money. Cody didn't want to have me pay anything. Thank you very much. Brennan gave me a steal of a deal, and so both good friends, and so I'm very thankful that I have a team, okay? Be a team for your people with these hip problems.

It's very hard. They've been going through the same type of rigmarole for I don't know how long, and they haven't had success yet, and so just tell them what they need to do. Tell them there is stuff to come, and if they're willing to accept that stuff to come and just talk about those corrections and strategies or interventions when they get there, then they won't have to worry about it quite so much, all right? If they're coachable, they'll do very well with this, all right? If they keep asking questions, about why are we doing this or what muscle does this work, I would probably have a little bit of a one-on-one conversation with them in a way that is conducive to addressing their really deep-down question.

Now, if they're hesitant about really doing this stuff, I try to hit home really quickly on why that is. I want to dig down to the deep-seated problem, and I think I've got to be a little bit of chameleon when I address this one with people because it's, I don't want to seem like I'm being an a-hole or I'm trying to avoid the questions that they're asking. And I know that recently, I've talked to a couple interns and students about this, and I sound like I'm being kind of an a-hole when I'm talking about it, just because I'm being direct when I'm talking to them. But either way, with patients, it's really dependent upon my relationship with them.

And so, if I know them pretty well, I'm saying, hey, man, you keep asking these questions, I'm down to answer them. However, it's really cutting into your time because you're only here for about 30 minutes. And so, do you want me to address those? Or do you really want to know? Or are you just questioning because it just seems different to you? Because I can explain them or you can just trust me and do it. Like, we can do either one. And so, if they tend to choose the, hey, I really want to know, I'll say, okay, cool. maybe we can set up a call where we can talk about all your questions as well.

I'll address this question right now. But I think for the sake of today, can we actually just, we'll do a couple exercises, see if it makes you feel better. And if it does, do those ones. And I want to set up a call where we can talk about some of your questions. And usually, I'll do this as a third person thing. I'll say, look, there's this guy that came in one time that he came in like three, four times. And so, he would sit here and talk to me for like 30 minutes about his stuff. And lo and behold, the next person came in and we never really did anything. And so, he really had a deep desire to understand, which I get.

I like it. I encourage it. However, it cut into his time. And so, I decided to call him. We called it a separate time. Spent an hour on the phone and just got it done. Is that something that sounds good to you? You know? And so, I think kind of deflecting it as somebody else, because there really were people like that, I think it's helpful to give them the option. They can choose A or B. And so, if they choose, if they choose to talk about it every time, that's okay. That's where they're at. And so, I'll do that, but we'll get less work done. And so, I forget how I got on this topic. Either way.

So, I'll recap one more time and everything. Number one is we're doing standing observational assessment. You do bend forward, bend backwards, look over a shoulder, best squat you've ever seen, and why excursion test, tap your heel into the water. Next is we'll go through regional assessment of the hip. We'll do resisted hip range of motion, passive hip range of motion, scours, circumduction, fa bears, axial compression, different quadrants, and dynamically test them out. Okay? After that, I did not mention this, but I should have. Find a movement that bothers your hip now if you can. Squatting deep, crossing your legs, whatever it is.

I tell them, find a movement, not a stretch. If you find a stretch, it's really challenging, and I don't really want to use an orthopedic test to see outcome measure. I want you to find a movement which is meaningful to you. Well, every time I do the dishes, it hurts. Okay, cool, got it. Every time I run, it hurts. Good, you have two minutes. Can you go out there and make it hurt? These are things that make it so the person is like, ah, gosh, I feel bad. That's good. I'm glad we're doing this. Okay? So, pick something meaningful to them. The test doesn't mean much, and so I try to steer clear of it.

Also, too, with stretching, you can always blow through some physiological range of movement, and then the range, we don't know if it's actually improving and so I want to make sure that I'm not getting 10 more degrees of motion and they say, oh, it hurts now. I want to know that I'm actually on to something here. And so, I hope that was helpful to everybody. And so, I do plan on, again, during this month, we are going to go through giving back. I'm going to give back as much as I can. I want you guys to become badass. I'm not badass yet, but I really want to become more badass, and I really hope that you enjoy and get some useful gems out of these documents I'm putting together for you as well as the videos.

Again, it will be disseminated via email. It's just easiest that way. And the hip is going to be first. So, in case you listen to the shoulder one next week, first, hip is going to be first just because that's how I'm putting them out there. So, I would love some feedback on that. Please email me back and tell me how things are working. I really want you to try, number one, if you don't try anything else, try that scour's test with the belly gut thing. I want it to blow your mind. And, these are the types of things I presented in a workshop that I did this last year in April. And, I know I can come up with some more.

I want to be challenged to come up with some more. And so, even the shoulder one is challenging for me to organize and I think I feel responsibility to the interns that come in and shadow me or are with me for months at a time. I want them to be better than I was. When they exit school, I want them to be better than I am now. And so, I want to accelerate them getting to the point. I feel like, as a profession, we can really all improve if we pass down knowledge that has worked for us. And so, I want to make sure that I'm patching stuff down so the next group of clinicians that come out, they put me in shame.

I think as a coach, I want, you always want your athlete to be better than you. And so, I hope that you guys are better than me. I want you to be better than me. And so, if this, again, give me some suggestions of things that have worked for you. Show me, share a story of the person that you tried that test with and it just, and it helped. I want to know all these really cool stories so I can know that this is being taught in an appropriate way to get you the results that you're looking for. Okay, I think we all want to make our patients better sooner and make people happy and active, you know, sooner.

I love empowering my patients and I hope you do too. And so, everybody, again, if you're looking for those, go to the show notes. There'll be a link at the bottom and just pass it on to another clinician who you think will benefit from it. Okay? And so, as always, thank you for being listeners to the show. Thank you for sharing. Thank you for reviewing and thank you for being part of the movement. See you guys next week.