Dr. Jared Powell:
Today's guest is Dr. Charlotte Ganderton. Charlotte is a physiotherapist and researcher based in Melbourne, Australia. Charlotte is a senior lecturer at RMIT University and works clinically at Elton Sports Medicine. Charlotte did a PhD in gluteal tendinopathy and has produced some very highly impactful publications on the subject. More recently, Charlotte and her colleagues have published a wonderful paper exploring some common myths and misconceptions associated with gluteal tendinopathy.
Dr. Jared Powell:
Is imaging needed? What is the role of corticosteroid injections and should we ban the clam? Are just some of the topics discussed. Charlotte expertly weaves together clinical pearls with scientific facts, and I dare say you'll learn a ton from this episode. Without any further delay, I bring to you my conversation with Dr. Charlotte Ganderton. Dr. Charlotte Ganderton, welcome to the show.
Dr, Charlotte Ganderton:
Thank you very much, Jared. Great to be here. Charlotte,
Dr. Jared Powell:
I've been trying to get you on this show for a long time, and you've been very selfish in having children and being on maternity leave and sorting out yourself, so I'm very glad to to get you here. I'm just kidding. You definitely need to do all of that. But Charlotte, can you please tell me a little bit about yourself and what you like to do both professionally and personally, if you don't mind?
Dr, Charlotte Ganderton:
Absolutely. well, as you said, I have returned from parental leave. I don't feel like it was much leave, but I've got a three and a half year old and a very boisterous 14 month old that keep me very busy. I do professionally, I work for RMIT University in the Master of Physiotherapy course. There I also work as a clinical advisor for WorkSafe, and then clinically I work at Uffington Sports Medicine Center. So I, I really have like three hats, educator, researcher, clinician. But I think what's really, like the common thread through those roles is an educator, an educator of fellow clinicians, an educator of patients, educator of students, but I also learn just as much from them as they learn from me. Yeah, absolute kind. A very rewarding me.
Dr. Jared Powell:
Yeah, that's good. And how did you get into, like why physio and why did you do a PhD and how did you choose the route, the route that you chose?
Dr, Charlotte Ganderton:
Yeah, interesting question. I've actually wanted to be a physio since I was about seven. So I'm one of those diehard physio fans that wanted to be a physio from a very young age, playing lots of sport, frequently getting injured and attending my local physio, which thinking back on it was probably not the most evidence-based treatment of a series of therapeutic ultrasound, inferential hens, massage, all those sorts of fun things. And I just grew a passion for the area and continued to sort of follow that path. I did my undergraduate training at Latrobe University that led to undertaking honors, and I looked at electromyographic activity of the shoulder, the rotator cuff during the various exercises, and then I decided pursue the academic side. I, it was certainly not something I planned on. I guess the opportunity arose to do a PhD in gluteal tendinopathy, and I thought, why not? Let's give it a crack. And it's led me to where I am today.
Dr. Jared Powell:
Awesome. And it's probably a bit of a spoiler, but we will be talking about gluteal tendinopathy at length today. Before we do that, Charlotte, what do you do for fun? What gets you outta bed in the morning apart from your children screaming ?
Dr, Charlotte Ganderton:
I still enjoy a lot of exercise, love going for a walk, passionate about coffee. I definitely need my coffee each day to keep going and I really enjoy it. I'm spending time with the kids and just enjoying them as as youngsters, even though they drive me completely mad. There's so much joy out of seeing them learn and develop and play.
Dr. Jared Powell:
Yeah, for sure. I I share a similar sentiment, so I completely agree. Okay, so let's get into the, to the meat of the chat. So you've just published a, a really wonderful paper in musculoskeletal science and practice with a stellar co-author team, including Allison Grimaldi and Anthony Nassar. And this paper has generated a fair bit of discussion online, which is always good. That's the whole point of science, I think, to generate discussion. So can you give us a bit of background sort of into the paper, how the paper came to be, how it was formed, why you did it?
Dr, Charlotte Ganderton:
Absolutely. I think the word stellar is perfect here. Like what an absolute amazing team to work with. Alison Grimaldi and Tony Na, I hadn't actually worked with them prior to putting this together. And what joy it was to work with them. Both all of us shared the common narrative of a patient coming in to the clinic, having Googled their own condition, having a little plan of exactly what they were gonna have a series of injections and associated imaging and just had an, an inaccurate, or oftentimes they have an inaccurate understanding of their condition and the evidence-based treatment that goes along with that. And I think as clinicians, we spend a lot of time sort of unraveling the myths, and that's where the, the idea kind of grew from there. Let's identify these common myths and unpack them and debunk them.
Dr. Jared Powell:
I love it. Yeah, it's such a, it's a really powerful way of writing a paper where you sort of present a myth and then go through the evidence either refuting or supporting that myth. So I think it made a really sort of compelling paper to read, which is a challenge in scientific literature. So well done there.
Dr, Charlotte Ganderton:
Thank you. To be clinically relevant as well. So really have that clinical application and write for clinicians as opposed to write for just the research or the researchers out there.
Dr. Jared Powell:
Yeah, a lot of it can be a bit of like academic grandstanding, not your paper, but the literature itself. So it's really good to come back to the target audience, which often should be the clinician. So yeah, I, I really rate that. Charlotte, can we start with a really simple question, and I hope it's simple, but it's never simple because musculoskeletal pain is not simple. What is gluteal tendinopathy? How is it caused? Is it the same clinical presentation as label, such as greater reenter pain syndrome, for example? What is this? It's, it's, the term itself is simple gluteal, we turn it off. What does it encapsulate? What does it include?
Dr, Charlotte Ganderton:
Yeah, it's a good question because we've sort of evolved from tro enteric bursitis to tendonitis and all of the inflammatory connotations around itis through to glute tendinopathy, then progressing to lack an umbrella term with a greater trucker pain syndrome, which was sort of the most, I guess the most recent term. But I think we're now actually moving away from that. Back to glut tendinopathy. I think there's a couple of reasons for that. The first one is syndrome has a various connotations to it, and you could arguably say yes, it is a, a combination of, of structures that lead to this condition, but I'm not sure that the diagnosis of a syndrome often helps the trajectory of patients on this journey on the treatment journey. So we'll stick with gluteal tendinopathy and that basically involves a series of structures, almost always is gluteus minimus and medias tendons having tendinopathic or tendon biology, but it can't be a tendinopathy without clinical symptoms.
Dr, Charlotte Ganderton:
And we'll talk a little bit later I think about the role of the bursa, but certainly there can be coexisting or concurrent bursitis within that clinical presentation. But just like other tendinopathies, you have a change in cellular function, an increase in ground substance disorganization of the collagen, potentially some neovascularization. So you've got a tendinopathy process occurring at the gluteal tendon, specifically media sim minimus plus or minus sub bursal involvement. If we are classifying someone with gluteal tendinopathy, not only have that pathology on imaging, but they also have symptoms such as pain reduced exercise tolerance and reduced function, so their functional activities are reduced. It can also, we also know that this condition has significant impact on someone's ability to work and also participate in sport or their their hobbies.
Dr. Jared Powell:
Yeah, so do, I'm just gonna pivot for one moment. Do you reckon a gluteal tendinopathy is a different beast compared to patella tendinopathy and achilles tendinopathy, for example, in terms of, you know, diagnosis and management principles? Or is it managed fairly similarly? If you could just spitball here for a moment, what do you reckon?
Dr, Charlotte Ganderton:
Yeah, absolutely. So I think there are aspects of the management that do crossover to other lower limb tendinopathies, but I also feel that the glute tes are a little bit like the shoulder in the sense that they are exposed to compression forces in addition to the tensile loading, which I feel as much as, you know, you can have insertional achilles and, and that's got a compression component. I think that the main or the key driver for the gluteal based presentations is a compression or a, a compression load where the gluteal tendons just don't have the capacity to tolerate that load. And I feel like there are some parallels with rotator cuff tendinopathy in that sense. The other thing about the glutes, and, and you could even liken it a little bit to the elbow and the shoulder, is that this presentation affects people's quality of life. It doesn't just affect their ability to bounce, jump hop and participate in in sport or higher level sport. It actually affects their ability to function in day-to-day life. They often can't sleep. They choose the lift instead of the stairs. So I think fundamentally it affects their life. I shouldn't say it affects their life more than the other pathologies, but think at its most basic level we are talking about someone's quality of life and their ability to participate in their day-to-day activities as opposed to their sport.
Dr. Jared Powell:
Yeah, you're absolutely right. I totally agree with that. Let's, we're gonna come back to compression a little bit later. I want to start with some myths and misconceptions. So you mentioned a moment ago, trocanter bursitis, and that's pretty much when I graduated 15 or so years ago, trocanter bursitis was pretty much everyone who came in with lateral hip pain. Was was a trocanter bursitis in, in my mind. And clearly when you start saying bursitis, you Google it, things that come up are injections and anti-inflammatory treatments that are sort of, you sort of get led down this road of, of medicalization. And we'll touch on that in a minute. I wanna ask tra enteric pain, is it related to trocanter bursitis or is it not? Or lateral hip pain? What is the relationship between experiencing lateral hip pain and having trocanter bursitis? Must it be there?
Dr, Charlotte Ganderton:
Sometimes , sometimes it is present. I think we have to appreciate how closely they are located anatomically and the whole role of the bursa, it's right adjacent to the tendon and, and muscular tenderness sort of junction. So if we've got tendon pathology, it could no doubt impact the structures that lie next to it. So we know from the data that you can have pathological enlargement and distension of the bursa, but this only occurs in around 20 to 30% of people with choric pain. And what we also know is if we look at isolated changes to the bursa, they're extremely rare. So we don't really see bursitis on its own. We see it coexisting with tendinopathy and when we do see it in isolation, it's sort of two to 8%. So it's so minimal that you could almost say that it doesn't happen. Obviously there are rare cases it does, but if you are thinking or if the individual comes to your clinic saying, I've got bursitis, you can almost guarantee that they, if if that diagnosis is so-called correct, they've probably got glut tendinopathy plus or minus bursa involvement.
Dr. Jared Powell:
Yep. Awesome. So bursitis exists. It, it is a clinical phenomena, but probably can't say it is the primary cause of somebody's lateral hip pain. It usually will come in conjunction with some gluteal tendon pathology.
Dr, Charlotte Ganderton:
Yeah, absolutely. And it might be that like the 10, the combination of tenile and compression compressive loads around the hip, that obviously has an influence on the tendon. Maybe it's actually having a similar influence on the bursa because of where they lay anatomically.
Dr. Jared Powell:
Cool. Love it. Let's, I'm gonna talk about injections in a moment. I want to go to diagnosis. So to diagnose gluteal tendinopathy, is it just palpation? Is that it? Mm-Hmm . Tender, tender on palpation on the, on the greater truant. Surely that's it.
Dr, Charlotte Ganderton:
Well, there are a huge number of tests that are performed around the hip. I think the most important thing though, with flute tendinopathy, just like the other tendons, there should be pain localized to the greater truant. There has been some work by researchers that have looked at the pain mapping and Melanie I probably will mispronounce her name, but Pinga has done some work around pain mapping and found that people with this condition do actually have pain that does transcend further down than the greater Durant and some sort of down the lateral thigh and even below the knee in certain circumstances, thought to be due to the innovation of the bursa. I tend to, in my own clinical caseload, really look for the pain to be very laterally and for the most part localized. I'm not saying it can't move, it's different certainly to the presentation that you might see in Achilles or color.
Dr, Charlotte Ganderton:
I think that it definitely does differ in terms of its diagnosis. Look, there are bucket load of tests. I think at this stage we are still using palpation and we are using that as a diagnostic tool. And it is fabulous to rule out the presence of tendinopathy. You know, if you've got pain-free, greater cancer palpation and you've got pain-free, resisted hip abduction, you've got a much less likelihood of having ute tendinopathy. And in fact, there's been some work done by Rita Kinsella and her team undertook a study that basically combined tests. They established a pre-test post probability of having the condition, remember it was around 54% or something like that. But that actually the likelihood of them having it after those two tests, so pain-free gt palpation and pain-free hip abduction actually reduced the post-test probability of that condition to 14%. That's a massive reduction.
Dr, Charlotte Ganderton:
So it, it's a, those two tests are wonderful in saying, all right, this person is highly unlikely to have this condition. On the contrary though, if there's positive paying on palpation and there's positive pain with resisted hip abduction, it increases the post-test probability to 96%. So that cluster is fabulous in also ruling the likelihood of the condition in. And if we wanna add a third test to the objective assessment, if we also add pain with 32nd single leg stance, you further increase the, the post-test probability to 99%. So 99%, that's a pretty good guarantee that they've got the condition or at least likely to have the condition. So, but there are so many other tests. There's the external de rotation test, there's the modified version of that external de rotation test just to name a few. And, and they, they are in the literature as having good sort of clin metrics. But I think the study by Kinsella is game changing because it fundamentally has three tests and it really gives you a good indicator of do they have a condition or do they not?
Dr. Jared Powell:
Yeah. So the, so the tests are positive palpation plus resisted abduction is, is that in sideline?
Dr, Charlotte Ganderton:
Yes, yes. Down sideline.
Dr. Jared Powell:
Is that taken down into a abduction adduction or is that in neutral or,
Dr, Charlotte Ganderton:
Yeah, so the way that the image was shown in that particular article suggests that it, it's slightly a deducted, but then when you combine it with the pain with 30 seconds single leg stance, you then further increase the likelihood of that condition. Yeah, so they're the three tests
Dr. Jared Powell:
And that comes up to 99% post-test probability, which
Dr, Charlotte Ganderton:
Is massive. Yeah, pretty good. You can't really get better than that.
Dr. Jared Powell:
You bank on that. Cool. So that's, so that's the diagnosis. I like how you mentioned at the start the pain distribution as well. 'cause You know, typically you do look at, look for it to be localized to the lateral hip, but it still could be a gluteal tendinopathy if there is some vague distribution down. Is it the lateral part of the leg that's, does it follow the I TTB ish or
Dr, Charlotte Ganderton:
Yeah, that, that direction, yes. That's the pain mapping pictures that include on that particular study suggests that it was, it was more lateral and then some participants had it further distal to that be below the level of the knee. But I think clinically I look for pretty focal as the main area and that is confirmed with the palpation. But then if they do have that vague sort of distribution of, of discomfort, obviously making sure that we're clinically differentiating it from, you know, a lower back referral for example, it's not, I wouldn't be ruling out the idea that it could be gluteal tendinopathy if they do have a, a wider spread pain mapped area. Yeah,
Dr. Jared Powell:
We see the same in the shoulder too, where a typical rotator cuff related shoulder pain presentation will be sort of anterolateral shoulder pain, but it does occasionally refer down the arm as well. So something to be careful and cautious of. Uimaging for gluteal tendinopathy. Do we need a radiological imaging verification of a gluteal tendinopathy presentation in order to rule in or rule out this diagnosis? What's the role of radiological imaging?
Dr, Charlotte Ganderton:
So clinically, no. If you've got someone presenting to you in the clinic and they've got positive tests on those three tests we talked about earlier all of their subjective examinations suggests that it is a probable diagnosis. They might have pain going up and down stairs, pain lying on the side of their hip pain walking up hills. Then I think you can be pretty confident that you don't need to go ahead and pursue imaging. The gold standard though, at this stage is still from an imaging perspective is still MRI. I think what's concerning about going ahead and doing an MRI is an MRI shows a lot of pathology and it shows a lot of pathology on people that are completely asymptomatic. So having a look at the literature, you know, after 88% of asymptomatic hips can have changes in the peri enteric region, and it's, that's just not the only study that's been done. We had a look at a group of individuals in 2017 and 63% of people with rock andary pain had pathology versus 24% without pain. So obviously that's a, a a different amount of people in the study, possibly different age groups, but it's still showing you the presence of pathology in asymptomatic individuals. So yes, imaging can play a role in research studies to include, we often use imaging in association with clinical tests and clinical report of pain on sub subjective activities, but it's not needed to manage someone. Well
Dr. Jared Powell:
Agree. Yeah, it's sort of following a lot of other tendon clinical presentations and, and the lateral hip seems to be no different. So that's good. There's some synergy there. There, there's often not a lot of synergy in Ms K care, but that's, so that's good. The ITBI wanna go to the ITB first. So the ITB demonized and blamed for everything far as my university training went. And then in the first five to 10 years after as well, foam rolling, stretching, massaging, brutal massaging of the ITB. What was that all for? Nothing. Is there any evidence to support ITB stretching and foam rolling from the management of lateral hip pain?
Dr, Charlotte Ganderton:
I think with the ITBI go back to my time sort of in the anatomy labs going through undergraduate training. That's a really thick, strong structure and without a scalpel, I'm not sure that it's moving very far. So I think about the lateral structures as a potential source of compression. Like you think about the, the OS test or something like that, you are like likely to be causing compression over the lateral hip that's putting the hip into an hip a bit, sorry, a deducted position. And we know that tendons don't like compression. So when you think about so-called ITB stretching, it's likely to need a hip aid duction moment and therefore you are probably feeding a load into an area which doesn't like that load. So I don't clinically use ITB stretching. I do question the surgical intervention of, of doing a lengthening. If you can keep someone out of that compressed position functionally and it stops the need for a surgery, then wonderful.
Dr, Charlotte Ganderton:
Is it harmful? If I think about, you know, a clinician prescribing foam rolling to the lateral thighs at harmful, probably not, but it's the position that the person gets in that could provoke symptoms. So, you know, I don't think, you know, using a foam roller we're actually really massaging the ITB. I mean, yes, it's got compression over it, but you know, what about the vasts laterals, the lays underneath that and you know, perhaps they have some increased tone through there. I don't think that's harmful, but how do you roll that lateral thigh without hip abduction? And I think that's where we have to think about it as a clinician. What are we actually aiming for out of doing that intervention? Totally,
Dr. Jared Powell:
Yeah. Like these things ITB foam rolling might, it might give the ceremony of, you know, doing something and it, it feels good perhaps because it's sore and you feel like you're getting into that spot and there's nothing really harmful about that unless the narrative is kind of overtly false and you know, they're thinking they need to lengthen this piece of tissue, which really doesn't need to be done, or perhaps implausibly can't be done. It's not really something that's designed to be stretched. So I guess there's a little bit of nuance and detail to consider there. And in terms of treatment targets, there's probably a bunch of other things that we could be doing that sort of may help someone's management rather than wasting our times with things that may or may not be working. Let's go back to corticosteroid injection. I mean super common, right? People come in, they've often had an ultrasound scan, they've seen their gp, some sort of bursitis is present on the scan, the radiologist mentions may be amenable to a corticosteroid injection in their report. Of course, this is all, the patient then starts to think about what should we say?
Dr, Charlotte Ganderton:
It's very challenging, particularly when there's a medical directive on those reports. It's fair enough to report that there might be some bursal distension or, or changes in the bursa. But I think when it directs care, I mean that's a whole ethical argument, isn't it? But it is a bug bear of mine. Absolutely. And you spend most of your consult explaining the background behind corticosteroid injections and there's no doubt that there's a potential of pain reduction if someone goes ahead and has a cortisone. The problem is though, where is that cortisone going? Is it going into the bursa? Is it being injected into the tendon? Is the person willing to have short-term improvement knowing that, that the cortisone can be sort of cytotoxic and actually harmful for their tendon in the long run, potentially leading to rupture later on. I certainly see that in the achilles as well.
Dr, Charlotte Ganderton:
There was research done in the LEAP trial led by Meor who looked at the long-term benefits and found that they usually know better than a wait and see approach. That's a tricky one to sell because oftentimes people have had enough waiting and they're looking for a quick fix. However, if we go ahead and say, all right, well you go and have your cortisone, I think it downplays how recalcitrant this condition is and how much management is actually required, how much empowerment of the individual is needed to self-manage so that when it comes around again that they actually can do that. So not only does it, is it not supported in the literature. Further to that, the LEAP trial actually demonstrated superior outcomes with education exercise over cortisone for global improvement of GTL tendinopathy, both short and long term. So the literature doesn't support the use of cortisone. Where the literature does support it is short-term pain relief, but if you can give the individual strategies to reduce their pain initially, then you've got buy-in and then they're likely to participate in their rehab and therefore they've got strategies ongoing how to, to manage it in the future. Yep.
Dr. Jared Powell:
Agree. Again, it's started, it's, it's really common in the shoulder. I mean the, now I think about it, the rotator cuff in the lateral hip are, are very similar in terms of the issues plaguing both conditions. We do see a short term effect with corticosteroid injections and that seems to washed out though when you check back in six weeks later and it tends to be worse longer term compared to just non injection based care with exercise. So yeah, it's not our job to tell patients what to do though. It's sort of shared decision making. You present them with the data you are well and we would encourage you to pursue short-term pain relief if it's really affecting and disabling for your life for sure. But just be aware that in the long term it's probably not going to be any better. It always comes back to these tricky conversations about short-term pain relief versus the long term effect. I don't have any solutions to that conundrum, do you?
Dr, Charlotte Ganderton:
No, I, I definitely don't. And I think the wording you used there is perfect, like shared decision making in the end it's their body, they can decide what they wanna do with it, but it's really important that we inform them of the short term and a long-term impact. Because if you don't, and then they go and have it and then they rupture their tendon and it doesn't, we don't have to be talking about ute tendons here, any tendon and or they have significant pathology following that, then you are the first one they'll come back to and say, why didn't you tell me? So I think it's our duty of care to inform and then it's the patient's decision as to what they do from there. But we, we do know like cortisone has adverse tissue effects, you know, it reduces the cell viability, it reduces like the cell proliferation, collagen synthesis, you know, and increased disorganization of collagen. So further to that potentially necrotic tissue. So if you outline that and get them on board, I feel like that gives them a, a much better platform to start their rehab from.
Dr. Jared Powell:
Yeah, I totally agree. Charlotte, do we ban the clam
Dr, Charlotte Ganderton:
? Well it depe, this is another area that I find it almost frustrating because I think people prescribe clams for the wrong reasons. So if your reason for prescribing a clam is the glutamine and the glute meat, then get rid of it out of the program because we know that it does not do that. We look at electromyographic studies and we, we undertook a intramuscular electrode study in 2017 and yes, intramuscular electrodes do have their limitations like it, it's picking up muscle activation from exactly where you put that needle and the wire. When we look at the activation with intramuscular electrodes, it's the anterior glute. So if you think about anterior glutamine and anterior glute mean, they're down at about two 3% of activation and that's compared to a maximum voluntary isometric contraction. So that's to help us sort of normalize it. So what are we actually getting out of that exercise for, for the anterior glutes?
Dr, Charlotte Ganderton:
When we look at the posterior glutamine and posterior glute need, it's a bit more, you know, you might get tenish percent, but it's not really getting bang for buck. So if your purpose is glute meat and glutenin, then take them out of your program. If your purpose, perhaps, and we didn't look at glute max specifically, but even just kind of deducing from what we found anteriorly, it's not activating posteriorly, you get a little bit more so maybe glute max you might get more activation with your clam. You know, it does feel like your leg burns when you do a clam. So something's happening. I think it's just the misunderstanding that the clam is a glute me exercise. I think that's where people go wrong. So would I give a clam to someone with lateral hip pain? I personally wouldn't. But it's not to say the clan exercise is the worst exercise on the planet, and you know what?
Dr, Charlotte Ganderton:
Some exercise is better than none. Then if you were to give it, think about the position that it's being given in. So if you are moving into say hip adducted internally rotated position, you're likely to be feeding that compression issue, which we keep coming back to. The tendon doesn't enjoy being squashed and so the position that someone is laying in side lying with their knee sort of across midline, then yeah, you're gonna get compression during that exercise. And so that won't help either and it quite possibly make them soer. So it's up to you as listeners as to whether you use the clam or not, but certainly for glute meaning and gloo in, I'd be avoiding it.
Dr. Jared Powell:
Yeah, I'm with you. It's, it's an option. It's, it's a movement. I don't, movements aren't inherently good or bad. It's sort of context specific, isn't it? If your goal is to get a stimulus to that glute mead and glute min tendon, you are not getting a ton of that with the clam. What are some variations that, that may provide more of a stimulus?
Dr, Charlotte Ganderton:
Yeah, so when we did our electromyographic study, we looked at like a hip hit, so standing on the affected leg and increasing I guess lifting the contralateral leg off the ground by about a centimeter. So we weren't wanting sort of a lateral trunk movement, we were simply wanting a weight shift onto the affected leg as an isometric loading exercise. And when we looked at the activation of anterior glutamine, it's, it's around 60, 65 in terms of amplitude or a percentage of maximum voluntary isometric contraction. So, and 60 percent's not bad. And then you look at the posterior glutamine and it's up at nearly 80%. So, and that those sort of numbers mirror what's found in the, in the glute medias as well. So we know that single limb loading has a, a massive increase in how much muscular output there is.
Dr, Charlotte Ganderton:
And it makes sense because those muscles are supporting lateral pelvic stability. So if you stand on one leg, you will get recruitment of those muscles. What we do need to be mindful of is if the individual can actually tolerate that load. How is the exercise actually being performed? Are they dropping into compression? Are they, are they so weak that they actually can't maintain the position required to do that isometric? So I think there's a number of things that I'd be thinking about when I'm prescribing an exercise, but certainly if we can load that affected leg, again, just like the patella tendon or the, or the achilles single leg loading is very helpful if the tendon can tolerate the load.
Dr. Jared Powell:
Yep. Cool. Beautiful. Charlotte, can we get into the compression a little bit more, if you don't mind? Is compression sort of perceived to be always a bad thing that will inevitably lead to a gluteal with tendinopathy? Or is is it always provocative or is it just something that we should be aware of that may be an aggravating factor for a person with glute, with tendinopathy and being careful of being in this position for an extended period of time is probably the most prudent thing to do. Is compression something that we should avoid for normal pain-free people? Like if, because we're scared that we may develop lateral hip pain or is it just sort of an everyday norm that you'll get into and we should only really be worried about it if we're symptomatic? What's your thoughts on that?
Dr, Charlotte Ganderton:
So absolutely, I wouldn't be avoiding compression in a asymptomatic individual. The all of our body structures are responsive to load in some way, shape or form. And it isn't a bad thing. It helps to maintain form and maintain cartilage. So that's helpful. We know tenile loads maintains fibrous tissue and we know the combination of compression and tensile load actually helps to maintain bone. So are those types of loads bad in the body? No. Would I be avoiding compression in someone who didn't have pain? No, but what we do know is that seems to be a very common theme that if someone does have tendinopathy, particularly around the glutes as we're talking today, their complaints of things that aggravate it involve a compression based position, a a hip ad ducted position. And from the work that I did with my PhD, we had a look at the impact of education and exercise in a large cohort of, of post-menopausal women with gluteal tendinopathy. We had them divided into an education group with sham exercise, sorry, exercise that wasn't thought to load the glute tendons.
Dr. Jared Powell:
I'm gonna intervene here and tell everyone that this is such a good study and it's pretty much the only study that has compared exercise with sham exercise rather than just like sham ultrasound. So there's the credibility aspect of the control group there, which is super important. And we're involved in a study at the moment applying similar principles to the shoulder and re we can really only find your study. So I wanna give you a huge shout out for doing that study a long time ago, actually, not, not a long time ago, but it wasn't like it was last year. Was it 2017 or something like
Dr, Charlotte Ganderton:
That? 2017, yeah. Yeah, that's right.
Dr. Jared Powell:
It's so I wanna give you a huge shout out for pioneering that work and I don't know why we've all taken so long to sort of repeat it, but yeah, well done.
Dr, Charlotte Ganderton:
Well thank you. Thank you very much for that. I mean there's certain things I would change if I was to do it again. I think the, the most important message that came out of it is when we compared education and sham exercise to education and tendon loading exercises or exercise that we believe loaded the tendon, we actually didn't find a huge difference between the groups. But what was so amazing about the outcome of that study is that they all got better. And people came up to me after they read the paper and they said, I'm disappointed that your PhD showed nothing. And I thought, what a peculiar thing to ask. This PhD showed the power of education. This is what physios should be and are amazing at communicating with people, changing the loading of their activities of daily living and making their quality of life better.
Dr, Charlotte Ganderton:
Like what, how could this be a bad result? And to be honest, we actually had difficulty publishing it. Some of the bigger journals didn't want to publish it because the results weren't quote unquote sexy. And I thought how peculiar, like this is a really incredible intervention that every single physio out there can do. You know, every allied health professional can provide education. Getting back to the crux of it with the compression, if we can educate around for someone who is painful or has a painful lateral hip, if we can educate them around compression in their, their environment, we can have a massive impact on their quality of life. So someone who has pain or, or we'll call it a reactive tendon Yeah, absolutely avoid anything that is abusive load and, and in this situation, compression is abusive load when it is a painful tendon.
Dr, Charlotte Ganderton:
But we have to introduce or reintroduce compression based activities into their rehab. Once they're under control, they don't have night pain, they can walk up and down stairs or in fact stairs is introducing compression, but they're back to their daily activities, then yeah, I think we need to think about, well, how do we slowly introduce compression to build capacity in the tendon to manage that compression? Things that I do try and avoid, I almost try and avoid them lifelong. If someone has had a presentation of lateral hip pain, I do try and stop them from prolonged crossing of their leg. I think that's something that we don't need to do. I'm I do it, but we, I don't need to do it. There's no need in or functional requirement to have to go into that position, but you will likely get some compression going up and down stairs, but that's actually a functional activity that's really important for locomotion. So let's introduce compression through tasks that they need to do in their in life.
Dr. Jared Powell:
Yeah, compression is a physiological norm, we can't escape it. Mm-Hmm. But that's right. But when it's, when it's symptomatic or provocative or irritating of somebody's presentation, we can modify it until we start to reintegrate that person to being exposed to those loads again. It's a very similar thing that we do on the shoulder. Same thing probably with the Achilles as well. It's no different than that, but compression isn't an evil, it's just something that we may wish to modify, sort of adapt or change in order to change that person's pain experience.
Dr, Charlotte Ganderton:
Absolutely. That's correct. Good.
Dr. Jared Powell:
So for treatment now we're gonna, there's a bunch of different ways we could go with treatment actually something came into my mind a moment ago, apologies, Charlotte, this tends to happen when I talk with really intelligent people like yourself in the shoulder. We have a lot of issues with psychological variables as being really predictive of, of bad outcomes, specifically self-efficacy, expectations of recovery, kinesia phobia as well. Do we see the same thing with the lateral hip as well, or gluteal tendinopathy as well? Are there sort of baseline variables that predict better or worse outcomes in terms of psychological features?
Dr, Charlotte Ganderton:
In terms of the literature, and I might be incorrect here, but I, I don't think there's been a lot of investigation with respect to psychological measures. It's an area of significant interest for me. What I noticed, and this is obviously anecdotal, but when I was going through the individual responses to the questionnaires of the study that we undertook the randomized control trial, when there were questions around mental health or anxiety self-harm, those sorts of things, I was quite alarmed at the types of responses that we were getting in that particular study. We haven't written it up and nor could we really, because we, we didn't specifically perform psychological outcome measures that would give us a real indication of the mental health of these individuals. But I think it provided insight into the impact on their mental health as well as their physical health of this condition.
Dr, Charlotte Ganderton:
So I'm convinced that pain sensitization at its most basic level is present in this cohort. I think what also we have to think about is that this condition, yes, it can affect postpartum women, people with knee osteoarthritis, all sorts people that are, you know, on the wait list for renal transplants is another one where we see the prevalence go up. But the greatest prevalence is in post-menopausal women during that time. We have a huge reduction of estrogen. We've got hot flushes, we've got change of life, we've probably got kids that are moving out of home. We've got heaps of social factors that go on there. You know, marriage breakdowns, all sorts of social impacts that occur at the same time as physiological or or hormonal changes in the body. In addition to the fact that we know that as we get older, we get muscle atrophy, we get increased fatty infiltration.
Dr, Charlotte Ganderton:
So I think it's just this culmination of life issues that sort of hit at one point, and particularly in that post-menopausal phase of, of a, of a female's life or a biological sex, female's life, that would probably compound the mental health of these individuals clinically I screen for it. I mean, not necessarily formally, occasionally I'll use a das to, to assess the, the possibility of depression, anxiety, and stress, but I certainly will discuss mental health and question individuals about the mental health at the time and then refer accordingly. So I think it's a really interesting point you made. I absolutely think it is a problem in this population, but I don't, to my knowledge, I don't think we've done enough research in the area.
Dr. Jared Powell:
Do I remember that Rebecca Mellor did a follow up, a mediation analysis to her lead trial and found that self-efficacy was one mediating variable predicting response to the exercise. Is that right?
Dr, Charlotte Ganderton:
Yeah, she did do a mediation study and, and I have absolutely no idea how to do mediation analysis. It, it's extraordinarily complex, but yeah, absolutely. It's a, it's a great paper to, for listeners to refer to, to get an idea of what does mediate or what our mediators in this population.
Dr. Jared Powell:
Yeah, it's super important when we think about, you know, how our treatments work, not just do they work. I think she found that hip strength didn't change, which was curious. It wasn't, was found not to be a mediating factor, which is the same sort of thing that we see in the shoulder as well, where changes in self-efficacy may be a mediator of outcomes, but changes in biomechanical variables such as the ability to produce force doesn't need to change. So it's really quite interesting when we start to look at how these treatments work.
Dr, Charlotte Ganderton:
Definitely. Yeah.
Dr. Jared Powell:
Love it. Okay, so treatment, what do we do? Somebody comes in the door, let's say 55-year-old woman for argument's sake, who this condition tends to primarily affect. Doesn't only affect, I've had gluteal tendinopathy and I'm I got it in my late, early thirties after doing box jumps for the first time after a long period of time and then followed them up with single leg squats after a long period of time that'll do it. And I, it was raging, it was the worst thing I've ever had and I couldn't sleep on my side for it felt like a couple of years and certainly crossing my legs was painful. So I can attest to the significant disability associated this condition. Anyway, that's, that's just a side point. So 50 55-year-old person comes in, you've done your tests, you're 99% sure they've got gluteal tendinopathy presentation because they're positive to all three of those tests has mapped out in the kinsella paper. What do we do? So let's start with education and advice. What do we inform about, you know, the prognosis and the natural history of this condition? What do we explain is going on in terms of pain generating structures in the hip, et cetera, et cetera? Yeah,
Dr, Charlotte Ganderton:
So number one, I always explain from a physiological perspective exactly what's going on in their tendon because they often don't understand tendinopathy what it is. And I think by giving them an indication of what's happening with, you know, a for example, increased cellular activity, you know, increase in proteins, draw in drawing of water, separation of collagen, the fact that that reactive process is reversible or you can reduce the reactivity, I think is really empowering for the individual to go, actually I can do something about this. So that's number one. I read as much as sometimes perhaps we give patients too much information, information is actually power for them. So particularly those that are very analytical with their thinking, I like to really explain this is what is going on in your tendon at the moment? You have a really unhappy tendon, we have to settle that tendon down and make it happy.
Dr, Charlotte Ganderton:
Most basic level, sometimes individuals walk away from the first consult with sort of a confirmation of yes, this is the likely diagnosis. They walk away with an understanding of what that is. They walk away with knowing what is abusive load on the tendon in the short term. And I always make sure that I tell 'em, this is not forever, you don't have to avoid this activity forever, but it's short term so that we can get on top of your clinical symptoms and get you back to enjoying life a bit more. So I talk to them about, specifically I focus on the car. A lot of cars these days, particularly if you have clients from higher socioeconomic areas, they often have those really low seats where the bottom is lower than the, than the knees. You know, your Maserati style for those people and for really any person who drives a car, they tend to be tilted back a bit and most people commute in some way, shape or form.
Dr, Charlotte Ganderton:
So I always talk about commuting and sitting, whether it be sitting at their desk tilting the base of their chair, I always target the car, they're often driving to work and this is all time where the hip doesn't have to be in a position of compression. And we know that increased flexion of the hip increases the compression around the greater trita. So address that. And then the biggest one I address in addition to sitting is sleeping. Sleeping is fundamental and I don't know enough about sleep, but all I know is my kids aren't sleeping. I'm sleep deprived, I can't think, feel like my cognition is close to zero and I'm frustrated and angry. And I feel like, well, if someone's not sleeping day in, day out, not only are they not sleeping, they've got pain as well, their life is not gonna be very enjoyable.
Dr, Charlotte Ganderton:
So let's target sleep, let's get them in a position that is offloading their hip, whether it be a pillow between their legs, whether it be pillow under their knees. If they're a back sleeper, the most important thing is we reduce the compression of the top hip balling across into adduction. And then for the underneath hip, you know, there are circumstances where these people have bilateral pain, if they cannot sleep anywhere else but on their side, put something nice and soft and cushion like underneath, whether it be an old school eggshell mattress, whether it be a double folded over douna, just something to increase how plush it is under their underneath hip. So target both the upper hip and the lower one. So if you've addressed their sitting and you've addressed their laying down position, then you can potentially talk to them about walking gait if needed.
Dr, Charlotte Ganderton:
If they're a walker, you know, you might reduce their stride or they lay long how far they're walking and just go within what is they're able to tolerate rather than pushing that walking. And then from there, sometimes I don't give them any hip exercises, and I might start sound a bit peculiar, but sometimes the education, as we know in a randomized control trial that I undertook, we know that education works and we also know that the calf is 60% of the propulsion of the lower limb. So, and these people generally have shocking calf strength. So send them home with a double leg calf, raise a really good double leg calf race, single leg they probably won't tolerate depending on their presentation. Send them home with that, send them home perhaps with a wall squat, get their cords going and send them on their merry way for a few weeks.
Dr, Charlotte Ganderton:
They might do that for two to four weeks before they come back before I consider isometric loading. That's not how we did the trial. Obviously trials are slightly different to the clinical setting and I think I've learned a lot more since 2017 of, of how patients respond. But oftentimes I just go with little bit of kinetic chain, little bit of education or a lot of education, and then I start loading the glutes. Now I generally use isometric initially the thought process behind that is the small amount of literature we have that isometrics reduce pain. However, , there was a study done by Christopher Clifford in 2019 and he, he compared isometric exercises to isotonic exercises and found no difference. So it made me question as to do I actually need to give this individual isometric exercises? And clinically, I think some people respond beautifully and other people's like other people get sore.
Dr, Charlotte Ganderton:
So that's where I've kind of changed the way that I do things and gone with a bit of kinetic chain and education first. And then I'll play around with, okay, are we going, are you gonna be someone who likes isometrics? And I'll go through three hip pitches, say for example, three hip pitches. We'll do sort of 15 to 22nd holds, see what they tolerate, see what their response is immediately. And then I ask them to think about how they feel the next day just to see whether we've got any latent responses. If they've got reducing pain during that exercise, boom, that's great and I'll send them away with an isometric plan. But if they, if they do it and they're like, I just don't like this exercise, or Oh, I'm not really, you know, feeling like it's reducing my pain, then I might opt for a sideline hip abduction out of compression.
Dr, Charlotte Ganderton:
I think we do load the hip, we need to load the hip, we need to make sure that it's can tolerate both lateral pelvic stability, but also really important that we address femoral rotational control as well. And that's something that you, you can move into. But I think we should forget about the deep external rotators of the hip, you know, the rotator cuff of the hip, so to speak. These people still need good control. They still need to be able to stand on one leg. It's not something we focused on in the randomized control trial, but it's something that I certainly add to my clinical practice. And then just slowly building the loads that you're putting into those exercises, both with your kinetic change strengthening and you keep strength exercises. Yeah,
Dr. Jared Powell:
Yeah, a hundred percent. That made too much sense, Charlotte. Yeah. So yeah, that's
Dr, Charlotte Ganderton:
Good.
Dr. Jared Powell:
You're doing it wrong. It made too much sense. Advice, education, load management, progressive exercise.
Dr, Charlotte Ganderton:
Absolutely.
Dr. Jared Powell:
Physio in a nutshell, isn't it? And I think that's really well explained. I like your deliberation about isometrics there versus isotonics then it's a, I think you, you hit the nail on the head. You, you don't have to start at isometrics, you know, typically we were taught that they were a really good entry point for loading, but maybe not. Maybe if you can find an isotonic exercise that's tolerable at the start, that's fine as well. That's typically what I do with the shoulder. If I can find an isotonic exercise to start with, I'll start there. If I can't, then I'll regress to an isometric exercise. It's all just load, it's all just movement. Like there's nothing intrinsically good or bad about any of this stuff. And I don't think it needs to be an algorithm. I think you have some creative control, you can experiment.
Dr. Jared Powell:
That's part of the beauty of being a physio. I think you can experiment with movement, you can experiment with lever arms, with, with intensities of exercise and you can find something that fi fits that person because it's very likely the next person will respond very differently. So you have to be able to, your toes and your recipes won't always work. Conscious of your time here, Charlotte, you've been very generous and you've gone through almost the entirety of your paper, so I really appreciate it. Is there anything else you want to add before I let you go? I
Dr, Charlotte Ganderton:
Don't think so. It'd be interesting to see where the literature goes, particularly with respect to mental health, I think and pain sensitization in these individuals. It's not something that I'm currently working on. I've sort of moved much as I love my gluteal tendons, I've moved a little bit more into research or or hip related pain , we'll call it. So I, I guess an exciting study coming up where we've looked at the impact of a hip rehab, comprehensive hip rehabilitation program in individuals that have hip related pain. Most of which had developmental disclosure of hip and also in a circus population. But I think, you know, circus is elite sport, isn't it? So call 'em young athletes. And so that'll probably be my next paper to roll out and hopefully that'll be really clinically applicable for listeners as well to apply to a, probably a younger population as opposed to gluteal tendinopathy, which MO mostly is more mature adult.
Dr. Jared Powell:
Yeah, remember I had it as well. So , thanks for
Dr, Charlotte Ganderton:
The occasional young
Dr. Jared Powell:
Yeah, the occasional young strapping lat. Awesome. And are you on socials? Can people find you anywhere? Do you hang out on X or Twitter or Instagram? What do you do? I
Dr, Charlotte Ganderton:
Have to say I am not that great on social media. Occasionally I'll, I'll have a little bit of a presence, but no, mainly I'm an RMIT, so you can certainly track publications through RMIT or Google Scholar, and it's probably the best way of seeing where I'm at and following the research I'm doing.
Dr. Jared Powell:
Dr. Charlotte Ganderton, thank you very much.
Dr, Charlotte Ganderton:
You're welcome. Thanks Jared. See you later.
Dr. Jared Powell:
Thank you for listening to this episode of the Shoulder Physio podcast with Dr. Charlotte Ganderton. If you want more information about today's episode, check out our show [email protected]. If you like what you heard today, don't forget to follow and subscribe on your podcast player of choice and leave a rating or review. It really helps the show reach more people. Thanks for listening. I'll chat to you soon. The Shoulder Physio Podcast would like to acknowledge that this episode was recorded from the lands of the Ter Lang people. I also acknowledge the traditional custodians of the lands on which each of you are living, learning, and working from every day. I pay my respects to elders past, present, and emerging, and celebrate the diversity of Aboriginal and Torres Strait Islander peoples and their ongoing cultures and connections to the lands and waters of Australia.
