Benoy is an advanced practice physio from the UK with a specialist Interest in Hip pain & Running Injuries. Today we talk about lateral hip pain in runners. Topics we cover: What is lateral hip pain? What factors cause hip pain in runners? Once painful, what should I avoid to manage pain? What are some early stage rehab exercises? Should I believe terms like 'your glutes aren't firing' & 'ITB tightness'. When can I return to running with hip pain. Follow Benoy on twitter by clicking here To learn more about the Masters Runner Symposium click on the link and enter code BENBRAD25OFF for 25% off. This course gives you 12-month access to 22 hours of Video, Audio, Free book and much more. If you would like to support the podcast and participate in future Q&As sign up for $5US per month at https://www.patreon.com/therunsmarterpodcast Check out our new website!! https://www.runsmarter.online To follow the podcast joint the facebook group Becoming a smarter runner click on the link: https://www.facebook.com/groups/833137020455347/?ref=group_header To find Brodie on instagram head to: https://www.instagram.com/brodie.sharpe/
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on today's episode, lateral hip pain and glute strengthening with Benoy Matthew. Welcome to the Run Smarter podcast. The podcast helping you overcome your current and future running injuries by educating and transforming you into a healthier, stronger, smarter runner. If you're like me, running is life, but more often than not, injuries disrupt this lifestyle. And once you are injured, you're looking for answers and met with bad advice and- conflicting messages circulating the running community. The world shouldn't be like this. You deserve to run injury free and have access to the right information. That's why I've made it my mission, to bring clarity and control to every runner. My name is Brodie Sharp. I am a physiotherapist, a former chronic injury sufferer, and your podcast host. I am excited that you have found this podcast and by default become the Run Smarter Scholar. So let's work together to overcome your injury, restore your confidence and start spreading the right information back into your running community. So let's begin today's lesson. Okay, welcome back to another episode. Today we have Benoit Matthewon. He is very active on Twitter. I've been following him for a long time. He is an advanced practice physio. He's a sonographer, shockwave specialist, and he has a particular interest in the hip and groin and also around running injuries. So a perfect man to have on to discuss today's topic. We didn't actually talk recording so I'll do it now. Lateral hip pain is our main topic of discussion and lateral hip pain is more described as pain on the outermost part of the hip. So if you do have hip pain that's more at the front or more in the back like the butt fold or the... the central kind of buttock area. That's not really what we're referring to or honing in on today's topic. We're more referring to that pain that sort of surrounds what we call the greater trochanter, which is that bony prominence on the outermost part of your hip. We're going to talk about what causes it, what causes it in runners, what we should avoid once it's irritated, what are some early and more advanced options for overcoming this injury. We delve into like strengthening, we delve into if stretching is of benefit, we talk about what it means when you're told your glutes aren't firing or you have ITV tightness, and then some good strengthening exercises later in rehab like some plyometrics and tips around that. Benoy has also got a, has just released a symposium. It's an online symposium called the Masters Athlete Symposium. It has tons of great guest speakers, which we delve into in the interview as well. So hear more about that. If you are interested, Benoy has been generous enough to give us a discount code for 25% off if you wanted to get all that content online. I've listened to it myself. I signed up while it was live and just amazing content. If you love this podcast and you love the content it delivers, you're going to love that symposium targeted around the Masters Athlete. And I'll discuss some of the guests that they do have on that online symposium in the interview itself because there are some past... guess that I've had on the podcast which feature in that online course. So I'll tell you the code now. Let me just pull up this email. It is Ben Brad 25 off and so you just complete that at checkout and you get 25% off the discount for the discount rate. It is 12 month access to 22 hours of video, audio and a free ebook. that kind of stuff and there's also more so benbrad25off I'll include that in the show notes I'll also include the link to the course and yeah just to scrub all those sign up and get 25% off so thanks Benoy for that. Before we dive into today's episode a bit of an update on me I know last episode I was going to talk about a bit more about my running journey and what I'm implementing right now to help with my running. And last time I mentioned I did get a little, I have been getting a little bit of heel pain and monitoring the morning stiffness. I'm not entirely sure what it is. It feels a little bit sharper and I have had plantar fasciitis in the past and it doesn't really feel like that but monitoring it and all of a sudden, it seems like the last three mornings or so, the pain levels are down to maybe a one out of ten and it probably lasts about five minutes and so I've spent the last three days, four days, trialing out some running. and last time we recorded I went for, I was just doing bike rides because I knew that would be totally fine on the heel but now implementing some 4k, 5k runs and just seeing if I gradually build up my mileage again, if it has any impact on the morning soreness and morning stiffness and as I've built up from 4k to 6k at the moment there's been no change it's still stated about a one out of 10 So those metrics is very important to know whether I'm tolerating what I'm putting my body through the day before. So just following our universal principles from season one of our podcast and just implementing those. I did also say that I'd start some gastrocnemius and soleus calf strengthening exercises, which I started about five days ago. I was doing calf raises, holding on to and keeping my knee slightly bent and going up and down single leg calf raises, I'm doing about three sets or four sets of ten and I seem to be losing a lot of power after ten so I think that's a pretty good range for me at the moment with single leg and the ten kilo weight. and I haven't really implemented a lot of calf work in the past. And so from what I know and what I've been learning on this podcast and interviewing a lot of experts, that seems to be what I need to implement. It seems to be my weak length because I have had a couple of calf stiffness, soreness, tightness, a couple of very mild strains in the past six months. So recognizing that and just implementing something and it's feeling really good. My calves actually feel a lot better now two attempts now, so all positive. Hopefully I can start building up that and building up the strength. Okay, enough about me. Let's move on to our interview with Benoit talking about all things lateral hip pain. Benoit, thanks for coming on. I've been following you on social media for a very long time now and had the chance to experience your online course which we'll discuss in a second, but let's get started. Thanks for coming onto the podcast. Thanks, Buri, for the kind invitation. I've been listening to your previous podcast and all the top speakers have brought in, so I've picked up a few things from a previous podcast and thanks for having me. You're very welcome, thank you very much. Let's start off with talking about your career and particularly your post-grad pursuits and why you decided to dive into the special interest of the hip and groin. Yeah, I'm, first you're based in London, so. got a bit of split role. So I work a few days in private practice in central London. I also do a few days in NHS National Health Service as an advanced practitioner as well working with orthopedic centenarians. I started into lower limb mainly hip and groin in the last 10 years. So one of my previous jobs where I started, we are getting a lot of recreational runners and obviously you deal with your straightforward injuries like your pet life and runners knee tendon. We had major difficulty with the hip and groin. So I found like that, you're talking about like 10 to 12 years ago, there was not much of literature and many of these conditions used to be stubborn. So that's what really got me involved. And what I found was conditions like hip impingement, hip tendons, although they are less common than knee injuries, they were more persistent. I looked at the literature, there was not much really going on. So I thought that was a... great area to get involved. And around that time, a couple of things also happened which made me interested. One of my best friends also had hip pain, which we in an office could pick it up and then he later developed avascular necrosis, which is sort of quite a serious condition and actually had a hip replacement. One of my colleagues also had quite other labral pathology. So this sort of... few instances happened at the same time, which made me think that it's a bit more complex than I thought. And there's not really much people to help me. So I thought this is a great area to get involved. And I was lucky, I had a few links with few surgeons who were in that specialty. So I spent some time with them, did a bit of work with them as well. And slowly, like with anything else, you start with a problem. And there was, I generally found, you know, there was a lot of excellent physios for low back pain, shoulders. knees, whereas the hip and groin was always considered to be like an enigma, like a black box. It's rightly called as the Bermuda Triangle in sports medicine. So I like that sort of challenge where obviously the first two, three years I was scratching my head, I really didn't know what I was doing. But then like slowly, slowly the puzzle, I wouldn't say I'm an expert, but I can say I'm a specialist in that area because I see purely, I see the numbers and you're always learning more and more. I would say it's as complex as the back or the shoulders. And it's sort of, and definitely we need more, more physios to be involved in that area because there's a lot as therapists we can do to help these patients. And most of the patients I see, they go around in circles, getting different diagnosis and then frustrated. So pretty much all my patients I see, I have at least seen two, three physios and they usually have symptoms more than a year. So I like that sort of, third opinion, fourth opinion, where they come to me and it's more like a detective work for me. So I like the complexities which come across to that and, um, gets me thinking. So, so yeah, so it was not an intentional thing, but I'm definitely enjoying it. And I'm doing it for 10 years plus. So clearly things are working in some way. Yeah. Fantastic. It's good to hear. And, um, with that said, hearing that there's no better person that I wanted to talk to about this topic, which. we're going to talk around lateral hip pain and glute strengthening, which I'm excited to dive into. And I guess the first question I have is, um, when it comes to runners getting lateral hip pain, uh, what might be the primary common cause for this sort of symptom developing? Yeah. So I think like, you know, when you're dealing with a complex area, like, you know, we all would agree that most of the reasons why we get running injuries, is multifactorial. It's just not as simple as saying like you're weak, you know, you've got the wrong shoes or you're running too much. Your body is a bit more complex than that. So, uh, it's fair to say that most running injuries are multifactorial. It's a combination of different things. So I just, I generally look at running injuries in like in this three sort of big areas, for example, like training errors, intrinsic factors and also some eccentric factors. So training errors by far is the most common 70 to 80% of most running injuries is because of training errors. So we all know that it's too much too soon, too much of speed work. Somebody who's running three days is now running five days or doing a lot of inclined work, making rapid change, or sometimes there's a change in lifestyle. The sleep is less, stress contribution. So I think it's very rare to see a runner getting a running injury without some form of training errors. So that is something we need. That's why a detailed history, and that's true for hip. knee or foot and ankles, the hip is no different. So I guess taking a detailed history on how much, how many days they are training. And also looking into non-running element as well, whether they made any rapid changes. So that's going to be the same specifically when you look into intrinsic factors. So what I mean by intrinsic does something which is related to the individual, for example, age. We know that the older we get, we are more likely to, we are talking about from 40, 45 plus. we are more likely to get tendon related injuries because I guess the aging affects your tendon health. And another factor is hormonal factors. We know that women, one of the biggest groups which get lateral hip pain is women, it's four is to one. And there is some evidence showing that hormonal effect like low estrogen, pre and perimenopausal women are more likely. So we know that estrogen is really important for tendon health. So those changes can be also be a factor. And also one of the biggest risk factors for any injury, running related injuries, previous injury, if they had a previous injury on that same side before. And there are some structural factors like, white pelvis, certain femoral neck shaft angle. So I don't really dwell too much on that because you can't really change those things. And then when you look into specific factors like strength deficits have been shown to be a factor as well, especially weakness of your hip abductors, external rotators, trunk stability. And there might be also be a role for your running mechanics. So commonly I find with this group who come with lateral hip pain, they might have what I call the medial collapse mechanics. So excessive hip adduction, the knees touching each other, crossover gait. So to make it quite simple, the typical profile I would see is a 40 to 45 plus female who's usually started running or started running more, who is normally done 10K, now is going for the first half marathon, pushing to march or trying to do more miles or more speed or more incline. And then usually they get a bit of a niggle. And, you know, runners usually come to me because, not because of pain, it's because when they can't do the mileage they want, or it's affecting their life. So one of the things I always ask my runners is, okay, you had it for eight months, what made you to come now rather than eight months ago? And usually they'll say is, uh, before I could run and it was a bit sore for five, six hours. Now I'm limping for two days, you know, or I can't do the mileage I want. Or another common reason is see when I lie on the side, I can't sleep. It's affecting my day to day life. I can't play with the kids. You know, I'm just sleeping like an old person. So this is sort of the reasons where people could, because they're not as very good at taking pain. It's part of being a good runner is you expect a bit of pain, especially around your glutes, but it's only when it starts affecting the training or the life, like sitting, lying on the side, walking, or they can't train, that's when they seek help. So that's sometimes a big major issues with runners is most of the time they come too late and obviously we need more rehab. So I always say to my runners, if your symptoms are going more than six weeks, obviously you don't have to come to us for every niggles, but If you're not improving in six weeks, then maybe it's a good idea to check with a healthcare professional for earlier because you might only need one or two sessions if you come back after, many of my patients come back after two years, three years, and it takes a long time to recover because a lot of things also develop. So I think six weeks is fair enough to sort of wait, but if you're not improving, it's always good to seek help. So obviously it's a lot of things involved here. But generally, a training errors, certain internal factors like your age, gender, uh, hormonal variation, and obviously some strength deficits or running a retraining. So it's, it's never, you may, in my experience, it's never because of one reason it's, it's not as simple as saying, Oh, you've got weak hips or your hamstring is tight. It's not as simple as that. It's always, always a combination of different things. Yeah. And I think if you have different population, but I like to say, It's usually triggered with training errors and what injury arises will depend on kind of your weakest link. And let's just say like an early, uh, let's just say young female runner. They might be able to tolerate some higher hip loads, but if they overdo their training, then their weakest link might be like the knee joint and they might develop knee pain, but sometimes maybe someone who, or maybe the same runner who has the same running style and they're 30 years older. might have the same training error, but their weakest point is now the hips due to maybe a loss in hip strength or maybe the hormones, maybe just age and just like the, how the tendons can tolerate up around the hip that all changes and then they experience the same training error, but develop hip pain instead. Is there... That's nicely put. I think I might add a few things there is this is, I think, you know, I've always... try to battle with my idea of the combination of factors which leads to injuries. So a hundred percent agree with you that the major, you know, that tipping point is the training errors. But in my experience, and I think the literature will also support me is there are four key factors which sort of will determine what injuries you're getting. I think number one is I would say the most important is previous injury. We know that from the literature, you know, if you had a hip problems before you're more likely to damage your hip again, if it's a knee. And the second is experience. So not all runners are the same. So if you're a 10K runner, half marathon, that's going to be different. And then the age and the gender. So those four factors, previous injuries, your experience in running, your age and gender, that four interacts with your training errors and then it produces that injury. So I think it's that combination of different. So like you and me, we could train, we could have training errors, but I will get a knee injury and you might get an achilles injury. Because for me, I already have knee pain. My weakness is my knee. I had four surgeries. So every time I do over training, it's always my knees which hurt. But as somebody else, it could be different. So it's knowing. So that's why the history of that sort of experience, what's the level they're doing, what's injuries they had, you can sort of predict what they're more likely to get. Yeah, true. Very well said is like, I kind of think similar to a proximal hamstring tendinopathy or like a plan of fasciitis, sometimes pain might get triggered by running. And it's caused by running, but then the aggravation and the irritation starts to affect everyday life, just generally sitting, getting up, moving around. Um, because I see that a lot with say hamstring tendinopathy is all of a sudden they're sitting becomes an issue or plantar fasciitis all of a sudden, like just standing still becomes an issue. Once someone does have lateral hip pain and let's just say it is triggered by those multitude of factors that you're explaining. Is there anything that we need to look at that we need to modify or avoid doing in our day to day life once it is irritated? Yeah, so I think the key thing is most of the time from my experience is they come to me because of three, four reasons. One is typical running is they can't do what they want because the mileage can't be done. They have to stop. So usually by the time they come to me, they'll stop doing the hills. They start doing the speed because they've realized that it's making them worse. So that is usually when they come to me. And they also come to me when it's affecting the sleep. So the sleep is getting affected and also, uh, it's starting affecting the daily life, like walking and limping. So I think at this stage, what we want to do is sort of, uh, they're already sensitized. So one, one thing, the first part of treatment is not making it worse. So we need to really desensitize the region. So what I find is sometimes people go on the internet and they look at, you know, YouTube and say like, okay, let's stretch the tendons. Let's do foam rolling around the greater trochanter. And we know that with tendons, you know, tendons, especially pathological tendinopathy, you know, the stretching and rubbing it, poking on the tendon is not, it's not a muscle. So that might feel good for that first half an hour or more, but a lot of times you feel like the patient inadvertently make it worse. So first thing I'll say is to stop all this poking business, you know, rubbing on the bone. If we, if you want to use foam roller, I'm totally fine as long as they use it on the muscles. You know, they can use it on the TFL. or hamstrings, you know, but directly rubbing on the tendon usually makes it worse. Second thing is stretching. So they sometimes they feel like they have to stretch it out and that'll be better. So they do a lot of, you know, gluteal stretches cross body stretches and things like that. So, and other things which I usually find, which I have to stop is, because they're not able to run so much. They, so they go to online classes and look at, you know, there are so many hit classes now, especially with lockdown. So they end up doing a lot of heat training. lot of plyometrics and jumping. And we know the plyometrics is excellent for building strength and bone health. But when you have tendon issues, especially in that painful stage that can irritate things as well. So, so main thing I stop is that sort of rubbing on the bone, you know, the foam rolling on the bone, stretching, hip training is a big one. And the other one important one, which I didn't really, I missed for about eight years, which I picked up in the last two years is you get this patients who will do everything you say. they won't get better at all. And I was hacking my head, like what's, what's wrong. One of the things I picked up is the gluteal tendons are very, very sensitive to your walking distance. So a lot of these patients I see in London, they walk the dogs for two, three hours and they do a lot of other stuff. So one of the things I've changed over my practice is with all my patients, I monitor how many steps they're doing in a, in a day. So a lot of my patients I find like, you know, one day they're doing like 8,000, the weekend they're doing like 28,000, 30,000. and then they flare up and they say to me, I've done, I've not done anything new. So that's something I've recently noted is monitoring how much we don't need to be perfect, but at least you need to have an eyeball bigger. So sometimes what I make with this patient is to reduce their walking with the dogs or the long hikes they do in the weekend. So I'll give them clear limit, like saying like do only under 12,000 or keep it under 15,000. Or if you walk in two hours, maybe keep it for 30 minutes. So I find that makes a big difference as well. So those are the three, four things is the stretching. the rubbing, all that sort of direct irritation, stopping the HIIT training. Although you might get this endorphins, which is a feel good factors when you do endorphin, but then later it just becomes more sore. And also having some idea to manage your total load going through the body, what else on that. So that's why having that close relationship with the therapist is really important. So you need to, for me, I don't treat the runner, I treat the person and the lifestyle. So I need to know exactly what they're doing, everything. So a lot of runners will tell you about running, but they won't tell you everything else they're doing. So I'm interested in what they're doing with the head classes. Are they doing the walks? Other stuff as well. So it's, we need to really dig in the whole lifestyle. Very good. And a lot of stuff to unpack there. You did mention sleeping can sometimes become irritable and sometimes people can lose sleep because of pain. And I know from my experience, sometimes sitting in certain scenarios can be quite irritating. Have you educated to your clients any ways to modify your sleeping or your sitting in order to reduce the level of irritation? Yeah, so I think the sleep is because as we know all healing happens, your growth hormone and all the hormones are released in deep sleep. So if you're one of the things I've noticed from my experience is you can give them the best rehab. But if your sleep is poor, you don't really get the best benefits. All the magic happens in the body when you sleep, especially in deep sleep. So I think the key thing is obviously avoiding the direct irritation on that. So avoid lying on the side. Sometimes I advise them to use a pillow to prevent that excessive adduction. One of the things I say while they're sitting is during the day is always keep the hips two inches higher than the knees. So I always ask my hip patients not to use low seats, low sofas, like you get some sports type cars and things like that. So... even when they're sitting in the office, sitting at home, simple rule is always keep the hips two inches higher than the knees. Take that effort, not to be curved up on that. And every 30 to 40 minutes, give a break, put something on your timer. So, and you just, you can stand up, do some calf raises or some mini squats or something just to get activation. So yeah, so really I'm interested the sitting posture during the day. We have to be careful not to say that we are damaging the tendons by sitting. The way I say to is we don't want to irritate and sensitize the tendons. So because once you get sensitized, then you don't get the full benefits of the exercise. So there's no point taking your pain to eight out of 10, then we can sort of make those changes. So the big changes I find is making the effect on the chairs while sleeping, putting like a cushion on the sides and also, you know, avoid lying on the side as well in very rare cases. So suppose a patient is waking up two, three times and they can't sleep. A short course of fight for seven days, taking some anti-inflammatory, I don't see any harm purely to bring it down. If somebody's waking up two, three times. So there's two types of pain I see. One is when they get pain when they lie on the side and they feel a bit sore, that's different than somebody who really wakes up. So somebody who really has to wake up and they can't go to bed. In those cases, a week or two of short term. anti-inflammatory, I can't see any harm just to break that sort of. And I want to, another thing which seems to work in that phase is getting them into hydro pool, you know, a little bit of water-based exercises, getting them into low impact exercise like cross trainer. So we, the fundamental thing is, you know, the more, when you start as a physio, you realize you think like exercise is going to fix everything, but then you realize the lifestyle factors is more important, like your recovery, your sleep, your psychosocial factors. So for me, I think. If you don't nail the sleep element, you're not going to get much outcomes with free with your rehab. So getting the sleep quality and also the pain levels has to be controlled in the initial stages. The exercise is the easy bit in my opinion. So if you could, if you go, if you go get those factors like controlling your pain, controlling your symptoms, getting the sleep, then your body will feel better that it's much easier to push into the next phase. Very well said. I should probably explain as well. So when it comes to modifying these activities, like you're saying, where we're trying to, um, in the short term, eliminate or reduce the level of compression. And when, when someone feels like the side of their hips and you get that, um, that bony kind of prominence that sticks out, what the, what the tendon does is wrap around that and very similar to like a hamstring tendon as it attaches up onto the sitting bone, it can be subject to compression. If your knee is in, or if your leg is in a certain position and sometimes when the tendon is already a little bit irritated, it won't like being compressed in that position for a long period of time. And so what we're trying to do in this irritated state is trying to offload it slightly so that it can tolerate things like sitting for long periods of time or sleeping in bed and make sure that in the long term, you're still allowed to compress the tendon. But in this current state of irritability, we want to try and modify things to offload and then slowly, I guess, train or strengthen the tendon to start tolerating more and more levels of compression. And that way we can go back to normal function without these modifications. Is that, would you want to add anything to that? Yeah, you know, that's nicely said, because the key thing is what we don't want to say is, see, tendons compression happens all the time. Like, you know, humans we're used to, you know, nobody's having the perfect gait. We go into adduction, you know, like coming from. my South Indian background, we squat, we cross the legs all the time, you know, that's sort of part of human, you know, repertoire of movement. So I think we have to be careful to say like, the body can't manage compression, that's part of the healthy tendon, but it's like, you know, when it's sort of decent, when it sensitized, the pain is high, it's not doing the thing. So it's quite simple way of looking at it is when you're in too much of pain, it's not doing the things to make it worse. And then eventually once it's strong. your body should be able to handle all the things, you know, compression, crossover, you know, direct pressure on the side. So it's not harmful, definitely in the long term, but initially it makes sense to reduce the things which irritate the symptoms. Because one of the things with tendons is it's a very slow thing to recover, but it's very easy to, so I say to my patients, what you build in two months, you can wreck it in one session. So for example, like you you have somebody with an Achilles tendon, you know, you're, you're making good progress. You know, rehabbing just one random session of running sprinting on sand will put you back by two months. So just one trigger. So that's the real important. They can be easily be triggered by, and you can easily undo months of training. So it's very slow to recover, but very quick to aggravate. So that's the annoying thing with tendencies is, uh, you know, you don't want to undo all the good work you've done just by bad. You know, you don't make a great body when one session, but you can really cause a lot of irritation by one bad session. So that's why, you know, sometimes I get patients who are doing so well and then they feel fantastic on one day and without checking with me, they just do one speech session on a hill uphill and then they're back by one month. So that's why, you know, uh, sometimes feeling you're a, how you're feeling is not a good indicator of whether you're ready. So that's why you need to be very honest with your therapist to know whether you're ready for that state. So, uh, and, you know, a very knowledgeable therapist will tell you the things not to do. So I think that's why you want to be very clear is the things not to do, which are more important than the things to do. So especially with tendons, I find the speed element is a big problem. And specifically with hip, one of the things which I will stop for a long, long time with hips is uphill, you know, hill running. Hill running is the biggest trigger for hips. It's a bit different from knees, whereas downhill running is more, whereas hip, hip uphill running is more. So generally, for a period of eight to 12 weeks, I'll stop all type of hill training. And then gradually when I feel it's ready. So it's, I think it's the trick of physiotherapy and rehab is not exercises in my opinion, is how to put it together, the package. That's the hard bit, you know, how to sort of sequence things together. And that's where, because I think, you know, to be honest, you can go on the internet and you can get all the best exercises. I don't have to tell you what's the best exercise, but is how to put it together, how to sequence it with the right advice. And that's where I think. a good professional comes in mind. You know, it's not really the people always ask me, what are the top 10 exercises? I don't have any problem. I can tell you the top 10 easily, but how do you put together? That's where the expertise comes in. Yeah. And I guess a runner might interpret that they're doing the wrong exercise if they're not putting all the pieces together and say, look, I'm doing this exercise. It's not working. Maybe I need to do something else when in fact, you are doing the right exercises and you are doing the right things, but you're just not combining like you said, all those pieces to the puzzle and putting it all together. Yeah, that's the fun bit with the runners is because there are at least a lot of variables which needs to come together. That's why you will never get bored tricking runners, you know, it's a combination of your training errors, your strength deficits, your gait analysis, your running pattern, your shoes, your recovery. So there's so many little facets which can really, and that's where, you know, when I started initially, I was just looking at the strength element. I didn't really care much about the training load. and then I focus on the training load, then I started looking at the recovery, then I started looking at the shoes. So there's a lot of little, little areas where we need to put it together. And then obviously as a therapist, you know, a bit this trial and error, but with experience, you know, what are the, what I call the big rocks, you know? So the big rocks is definitely your training errors and your recovery, which you have to address and getting those pain under control. And the strength condition in fact, in my opinion, it's fairly straightforward. once you address those and then you can build up the capacity from then on. I'm curious to know your thoughts. There's a few things like if someone has hip pain and they talk to me about it and they go through their experience with a previous health like a coach or another health professional, they usually say one of two things. One, they say their glutes aren't firing or they've been told that their glutes aren't firing and two, they've been told that they have ITB tightness. And I just wanted to pick your brain a little bit and ask sort of what do we currently know about these two terms? And we'll probably start with the glutes, not firing. So I hear that probably more often. Yeah, I think it's same here in London as well. I don't think I hear also my, my hip flexors are tight as well. You know, that's something I hear. And my hips are tight. Uh, I think the glutes are firing is something which I see actually, if you look at studies, um, specifically from the group from Stuart Meggle group, So they did a study where they looked at people with pain, with hip pathology. And what they found out was, which is quite surprising is, the people with pain with hip, actually the firing is more than people without pain. So in fact, when you have pain, your brain really gets aggravated by the pain and it starts firing left and right. In fact, you fire more. What is a fair statement would be is my glutes are weak, or I've got weakness, or I've got strength defects. That's a fair statement. When you say like my glutes are firing and people do, you know, like old paradigm, they they'll keep the hands on the glutes and the hamstring and say, Oh, your glutes are firing less than your hamstrings. It's a bit weak. So that's why one of the things, you know, if you're dealing with athletic population, you know, like runners and other hip patients, one of the things I feel like, you know, therapists, which makes a big difference is using a handle dynamometer. So that's something I've been using for the last five, six years. So one of the first things I do when a patient comes in is to assess their strength. So I'll sort of put them in a sideline, check their hip-up vector strength. And we got data to know what's the normal based on kilograms. So that's one of the things I find it useful is to give them the exact number and say, this is the number I expect. That's on your left side, which is your good side. You're about 20% weaker. And people like that sort of objective data. So that's one of the benefits of the face-to-face element is you can be a bit more precise. But... From a scientific point of view, there's no sort of evidence that shows that glutes are not firing really. A more accurate statement would be, I've got weakness in my glutes, which can be checked objectively. Another thing is the ITB tightness. So for a long time, including myself, we used the OBAT test for ITB tightness, which is the way to test the ITB. And in fact, a cadaveric studies have shown the tightness has nothing to do with the OBAT test. Like in fact, you know, it doesn't have any relevance with the tightness because it's a fascia and it's quite stronger than steel. So the element of ITB, if you look at, if the current thing of ITB is, it's more like a spring, like a tendon. So it sort of gets the energy recoiled and gets you back when you're running. So if you look at histological and anatomical studies, there is no direct evidence showing that your ITB tightness leads to that. So a lot of these things have historically been installed for a long time. And I don't think it really helps the runner or the therapist because one, we can't stretch the ITV. You can do all foam rolling, but you know, you can't really make any structural changes. And the second thing is the firing, you know, if you don't have EMG electrodes, you're not really going to do. So I think it's something, you know, I hear all the time. So the, the thing you know, which working with the runners is as therapists, we have to be very careful not to dismiss sort of these things because they've been told and they believe that. So I don't really spend ages trying to fight their thing. I try to change their narrative and say, okay, that's great, you've been told by somebody that's weak. Okay, let's check your strength. Or even if you're doing a telehealth, I'll ask them to, for example, go to the gym and do a cable machine on hip abduction and to see their 10 rep max or eight rep max on hip abduction. So for example, on the unaffected side, they can do like 10 kilos, on the affected side they can do only three kilos. So... I'm a big believer of objective data, even simple things like a leg press, checking the leg press, a 10 rep max on the affected side, a hip abduction or a machine. Those things are more useful. What you measure, you can change. It's always useful to think either like a handle dynamometer or a gym equipment. You don't need a handle dynamometer, but you need to have some data because then we can make those changes really. I don't dismiss those statements because... Sometimes they believe that and it'll lead to unnecessary argument, I don't want to be involved in a confrontation. But at a later stage, I will challenge them and say like, in fact, I might not do that on session one, but later I will say there's not really much evidence to show that it's nothing to the firing or the tighty flexes. And one of the things with the tighty flexes is, which I've known from patients, when you have chronic hip pain, a lot of patients have the subjective feeling of tightness. So that's something I've noticed. They feel like something has to be released, that something has to be released. So I find that's a common complaint is they feel like something is blocking them. And I find it's more a pain thing once that sort of the strength element and you see that in cough as well. People who have weak coughs who have that deficits feel they need to stretch it out. They need to do dry kneeling. I see a lot of patients getting mindless sessions of endless sessions of dry kneeling into the hips. And in fact, what they need is a good, you know, proper strength and conditioning program and their tightness disappears. So, so sometimes when you feel tight, in fact, that's when you need to strengthen it. And the body is telling you to make it stronger rather than doing stretch it and poking needles into it. Yeah, very good. I often think like the words we use as therapists can be very powerful and the whole glutes not firing is a very disempowering language because you can't really do much about it if they're not really firing. But like you were saying, if you can change that narrative and say the tendons actually just got strength deficits what we know about rehab and building up that capacity, what we're doing is trying to raise that tendons capacity to tolerate the load that we're putting it through. And that would be whatever running loads or loads throughout the day or the walking, you know, 30,000 steps, that kind of thing, and gives them something to work towards. And if, like you're saying, if you have those handheld dynamometers and you can see the strength deficits compared to the other side, well, that's a goal you can work on. It's empowering the the runner and it's giving them small steps to work on, which I really, really like. And like you said, with the ITB tightness, the actual fascia itself is way too rigid in order to create any sort of stretch. And in fact, if you were trying to stretch out your ITB, we're sort of compressing that tendon over the hip bone, which we've already discussed before, might not be as advantageous, but might just feel good in the moment, feel like you're kind of getting in that area, which is kind of human nature for people to do, like you said, with a calf or I see it a lot with other issues around the hip and around the knee or high hamstring stuff. People love to stretch their high hamstring tendinopathies because it kind of feels good in the moment. But yeah, I'm glad we can clear that up. It's very well put and very well set on your behalf. As we move on to like rehab. exercises? Do you have any particular go-to ones in the early phases of lateral hip pain? Well, I think when we do initial assessment based on the history and the severity of symptoms, I think that for me, a lot of times you hear, especially on social media, that you start with isometrics and then you go into isotonic. For me, the starting point is always fluid. it's entirely based on your presentation and your severity. I don't start everyone with the same, you know, exercises. So first is to find the starting point where you think based on the irritability, if you've got, if you get a runner who's already running 30, 40 minutes, then you get another runner who's stock running. Obviously, they'll be very different from you, very stock. So when we talk about generally with the gluteal tendripty, the, you've got a variety of options really. So For very sore patients, I might start with a simple isometric option with a simple band, either in supine or in sideline, trying to see their recruitment and how can they tolerate it. Definitely there'll be a bridge option. Start with your bilateral bridge, single leg bridge. And definitely we want to load your hip abductors and external rotators so you can start with a simple sideline hip abduction. You can add some ankle weights, then progress into standing, then progress them into band walks. which you see a lot of experts, if you look at experts like Alison Grimaldi and other things, what I find is the clam exercise, you know, I have nothing against the clam exercise, but for somebody who specializes in hips, for me, the clam is like a side lying favor. The favor is sort of a test we use for hip patients and it irritates. So there's nothing wrong with the clam, but what I find is with a lot of this patient, that irritates their hips more and more because of the position it is in. So that's one of the exercise which I don't really do with my hip patients. I use the clamp for other, suppose you get a runner with knee pain, I'll use the clamps, but all my hip patients who come to me, whether it's proximal or lateral hip or FIS syndrome, I generally don't use the clamps because it just the position irritates them. And then one of the things which you can progress with this hip patient is contralateral loading. So, and it's even a simple exercise like a split squat, putting a weight on the opposite side revs up your activation massively on your glutes. And then obviously you're going to progress them into more functional stuff like your gym stuff, you know, your leg press, your deadlift pattern. And one of the things which is commonly ignored in this group, I find is plyometrics. So we want to get that sort of ability to handle that speed element. So I'll start with a simple lateral hop. And the, what do you find is the patients I see usually come after one or two years, they usually will have some other deficits. So common deficits you see. in this group are especially if it's a female, it's trunk weakness, you know, lateral trunk. So I'll use a lot of lateral trunk stability work, you know, your side plank, your cable chops, your medicine ball throws, things like that. And another thing you'll see is either a core deficit or a calf deficit. So the key thing is obviously it's a hip problem, but we need to think beyond that. So a lot of patients will just have the hip, but most of them will also have either a trunk weakness. or a quad weakness or a calf weakness. So that's where your assessment is really important. So for me, it's addressing the whole package and then slowly getting them back into that running phase. Okay, fantastic. So you've mentioned as early kind of stage, we're looking at side lying band work or something to that effect, maybe some ankle weights, maybe putting that in there, some variation of a bridge exercise and I guess... If it is irritable, we're kind of doing an outer range. So we're avoiding compression until it's, you're able to tolerate it. And then we're progressing to things a bit more strong, maybe doing some band work in standing and doing some side steps in standing, and then eventually progressing to something that's a bit more plyometric and something that's incorporating the trunk stability. And we're looking at hopping, we're looking at deadlifts, we're looking at a lot more functional based movements. So I think the key thing with tendon rehab, this is hip is no different, is giving them a clear pain monitoring scale. So generally I'm more than happy for them to have four out of 10 pain while they're doing it. I'm more concerned with their 24 hour response, even if it goes to five out of 10, but 24 hours later, the next day, it's not too sore. That's the most important thing. So, you know, a lot of times patients expect it to be pain-free. In fact, a bit of pain is a good thing. So as long as we let them know that having a bit of pain while exercising is not likely to cause any damage. They feel empowered and maybe they feel that they heard it for the first time. So with tendons, a bit of pain. You know, some people they like the pain score, you know, I sort of keep it around three to five. Some people, you know, it's mild to moderate. The most important thing is they should not flare up 24 hours after. So as long as we give them a clear and even if they flare up, it doesn't mean they've damaged it. It means that what they've done was too much. So just need to back off a little bit. and then start again. So with the thing with therapy is it's part art, part science. So a lot of things, even with my experience, it's trial and error, you know, we don't get the answers right. Sometimes things flat up. So it's not to worry. We just back down and then restart again. So all experienced therapists, sometimes flat up patients. I do that every time. So as long as we, we inform people, it's normal. Getting a flat up is part of the recovery. I've not seen anyone. recover totally without a flare up. You know, you expect one or two flare ups on the way. As long as, and another big, you know, not advice, but sort of a key message I say to my patients with tendon, whether it's a proximal hamstring or lateral hippies, always expect improvement month by month. You're going to have some good weeks, you're going to have not so good weeks, but you know, October will be better than September. November will be better than October. So. you know, don't expect week by week improvement. Tendons are very, very slow to recover and have. So every month you will have some slight improvement. And if you look at the literature, you know, you're looking at least three to four months or five months for that sort of, to make a substantial improvement as well. So it's having the patience and expecting a few setbacks on the way. So this is something which we want to be very clear on day one, giving them a pain monitoring scale, you know, giving them an idea on the pain monitoring scale. Number two, explaining the... element of the longevity, how long it takes, you know, people expect it's going to be fixed in two weeks. It's not. So generally I say it's three to five months. And the third thing is expecting flare ups as part of recovery. It's never a linear progression. So those are the three key messages, which we want to be very clear on day one. I'm glad that you lay out those expectations for your patients as well, because sometimes that can often be missed with health professionals. And it's good for the runner to know as well. I did have, so I've kind of answered the, um, the strength exercise component really well. And I guess I've written down here any stretches that you did recommend. And I think we've discussed that a little bit before, but I thought I might ask a listener question, um, comes in from Mel and she says, is there any recommendations on how to stretch the glutes, uh, because she's getting knee pain and she said she'll do things like a pigeon stretch or other glute stretches where she doesn't feel stretching in the hip at all, but has pressure built up in the knee. Um, so Would you be, well, can you first explain what you think might be going on there? Yeah. So I think what you find is sometimes a lot of, you know, if you look at the fibers of the glutamate, this is the interesting thing is if you look at the orthopedic research, the glutamate tendon, GTPS is also known as the great mimicker. So if you look at the anterior fibers, sometimes they can radiate to the, to the groin and sometimes it can radiate to the buttock region as well, especially if you have posterior fibers. So even with your normal lateral hip, the lateral tendon, you can have a varied presentation. Some people are just on the side, in some people it just goes a little bit toward the groin and you might think it's a hip problem, but it's not really a hip joint, it's a ruffle pattern. And some people it goes towards the preformus deep gluteal region as well. So a lot of times you might have associated a little bit of the small rotatory muscles, the six muscles you might have associated issues with tissue length. So if you do feel tightness around that region, stretching that, I don't see any harm, as long as you're not bringing them into too much of hip adduction. You're not crossing over. And another group I find, especially men who develop this problem, if they are like 45, 50 plus, one of the things you see men lose as they get older, especially runners is a lack of hip extension. It seems to be something which happens with age, slightly more common in men. And getting that hip extension is really important for recruitment of your glutes. So sometimes I do incorporate some dynamic hip mobility exercises to... improve hip extension. And one of the things which we forget is eccentric exercises are really good to improve muscle length. So even if you have a tight hip flexes, I rather than stretching it, I give them like a bodyweight Bulgarian split squat. So like a slow six seconds down, three seconds up. So you're getting the benefit of strength and also flexibility. So we sometimes forget that eccentric strength exercises are also very good for improving muscle length. So a lot of my runners, I'll try to improve their hip extension, which we know is very fundamental for running. So if you want to improve that hip extension, try to reduce the pressure on the deep gluteal structure. I don't see any harm in including them, but the fundamental, you know, the, the bedrock of a gluteal tendon rehab should be strengthening. So this is everything is adjunctive, whether you're doing some hands-on treatment like dry needling or taping or stretching, as long as we realize that it's adjunct, but that's not the main, you know, treatment for this condition. And if there is knee pain going on during any of these stretches, is there any explanation for that? Is there anything we need to be worried about? Yeah, so sometimes you find the twisting, especially I find like in certain explicitly female, they might have a slight element of hypermobility where they might be twisting and creating a varus force. And what do you find is especially if they're having a crossover gait pattern or some alter, that sort of patient that I'll definitely be interested in looking at the gait analysis. So when they have like multiple joint issues. So sometimes I find when they have the crossover gait or a medial collapse mechanics, excessive hip aid deduction, they get this sort of pain combined with hip and they get a little bit of around the hip and groin, but also a bit on the medial aspect of the knee. So definitely I would examine the knee and also look at their gait analysis. Or even if you're doing telehealth, you can send them like a video, look at that. So common pattern which you see with this sort of patient with GTPS is what I call the medial collapse mechanics. So, you know, the knees, usually the runner will tell you like, after running they can feel like the knees touching a bit of, you know, the skin irritation, and also the crossover gait as well. So that's something you want to check at a later stage, because there is some link with some gait parameters with this pathology as well. So obviously the history, the training errors, the strength deficits, but definitely all runners, I will have their look at their gait mechanics at one stage. Might not be on session one. but something you want to look at a later stage. Okay, you've done an amazing job of like, answering a couple of my other questions that I have written down here. And one of them being like, how do we know it's okay to start running again? And when can we sort of trust our hip? And you did mention that we want to avoid hills in the early stages, we wanna avoid things like speed because that would just increase the demand through the hip so much. And you did also mention that we want to, as long as there's not like a significant flare up 24 hours after a run, is there any other things that you might consider or factor in when it comes to determining if a person with lateral hip pain can start running again? Yeah. So generally you have two types of patients who come to me. One patient group is already running, you know, for example, they can run 40, 50 minutes, but they're strolling the next day. So, As therapists who deal with runners, you always want to keep them running as much as you can. So let's imagine you've got a runner who is running five days a week, scenario one, who is running five days a week, running around 40 minutes and she gets pain the next day and she struggles, but she's keen to run. So in that patient, there'll be a few changes I'll make. For one, I use a simple rule called the rule of 25%. So it's pretty simple. I reduce the volume by 25% straight away. So. from five days, I'll get them to three days. And from 40 minutes of running, I'll get them to 20, 25 minutes. And then I'll totally stop the speed and the hills, and ask them to keep the pain around three out of 10 or four out of 10 when they run. And that might work in that group of patients where I don't want to stop, you know, ideally you don't want to totally stop running in many runners because a lot of runners use running as a psychological tool and for mental health. It's like, it's like the way I explained to, when I do my courses is like, to other physio's is if somebody's on antidepressant tablets, you want to ask them to stop totally just because you're doing some physiotherapy, you know, so the same thing with running, you want to ask them to stop total running just because you feel it's necessary. So I'm always wary of stopping running totally in a lot of patients because it's sort of, it's a very important for them in their lifestyle and mental health. So first, my first job is always try to modify the provocative activities that can be changed. Now we've got a patient B who comes to me. where she stopped running for three weeks because she's getting night pain. So there's only a few instances where I'll stop running. One is severe night pain and limping. So if somebody is limping and they can't sit for 20, 30 minutes, it's too irritable and they can't even walk for even, I explained to my runner, if you can't even walk for half an hour, should you be running? My opinion, not at that time. So if they're two, so they can't even walk for 20, 30 minutes. they're not sleeping, they're limping, then maybe running through it is not a good option. So obviously they might need a week or two or three where they sort of work on managing the pain, improving the strength. So when you get them back running, so generally I look at two, three elements. First is symptoms. First is the symptoms, okay, can they walk for at least 20, 30 minutes? Are they sleeping okay? They definitely should not be limping. So those are the things I want to achieve. Second thing is, basic ideals and basic sort of function like, you know, minimum is simple things like can they walk for 30 minutes? Can they do 20, 30 minutes on the bike or a cross trainer or swimming or some form of cardio. And then once they can achieve that, I'll always, always start the runner back on a graded work job program. So something like a six week program or eight week program, like an NHS, like a couch to five K program or something like that, getting them back slowly into that volume. And then my progression is always the same volume first. speed second and the hills the third. So I might give them like, I'll ask them to build up the volume for six weeks and then slowly increase some speed. One of the easiest way to get injury is to try to change more than one thing at the same time, you know, try to increase the volume and the speed at the same time. So my first job is to build up the volume. So for the first six, eight weeks, get the volume back 30 minutes, 45 minutes, whatever the distance they want, and then introduce some speed session, one or two sessions, see the response. And once the speed session is done, then get them back on the hills, as long as they're not doing hills with speed. So is that, is that careful monitoring of those three variables is volume, speeds and hills. So you don't want to be doing messing up with more than one at the same time. So it takes a bit of tinkering and obviously they need to be patient and it needs to be closely monitored by the therapist treating them so that we can see the feedback and go with them. So it's not, it's not like a, I've suddenly given them all clear and they can do anything they want. So it's sort of, it's guided gradually. And that process can take anywhere from one month to three months. Very well said and covers a lot there. And I think with, um, over the past couple of interviews, I've had Izzy Moore, Chris Bram and we're talking about gait retraining and like economy and all that kind of stuff, um, as simply as you can, would there be any, uh, gait retraining, any technique changes, anything that you might consider for some of these runners so that they can return to running more effectively? Yeah, I think definitely when they get back running, especially if they're a long injury, one of the common things I see is that excessive hip adduction, medial collapse mechanics. So one of the things I use, which has been influenced by the work of Rich Wiley is looking into mirror retraining. So the place I work, we've got a mirror in front. So you know, if the knees are touching together, I'll ask them to imagine they've got a golf ball or a tennis ball and not to touch that. So ask them not to touch where the knees are closing together. Or sometimes I may ask, don't let your knees kiss. So that sort of keeping the gap between the knees, that's important. And sometimes you might have a crossover gate and sometimes you might ask them to do track running in the field where you put a line and run on the side as well. So that's the common patterns you see. Obviously with every, you know, the big ones, which you always see in most runners, your cadence, your vertical oscillation, you know, those are the big ones. But specifically with the GDPs, I'll be looking into your sort of frontal plane, you know, your excessive hip adduction, excessive hip internal rotation, crossover gate. Those are the ones which are really relevant here. And there's definitely a role. I think people who work with gate analysis do understand the quality of evidence is not, we're not talking about massive level one evidence here. But for me, it's an important one. important adjunct as part of the progression. So I think if you look at the progression one, it's first is the load management and controlling your symptoms. Next is your strength and conditioning, addressing your deficits, then getting into the plyometric end stage. And the final sort of icing on the cake is the gait training. So a lot of people jump onto the gait training because it's hot, it's sexy, and you know, everybody wants to do that. But for me, it's sort of the final piece of the icing on the cake. It's not something I would rush into initial stages. If you don't get the fundamentals right, If we don't manage the load, address the deficits, educate them on managing the load, then I find the gate retraining doesn't really do much. Yeah, because we're not really addressing the weak links. If you have a hip or a tendon isn't tolerating a lot of compression or there is strength deficits, and all we do is gate retraining, we're not addressing those weak links. So what you're saying is we build a foundation, we manage those loads, we build up those loads, and then the... gait retraining, which would be like if your knees are rubbing together, then make sure we're running with a little bit wider knees or a little bit of a wider step width. And that's just the icing on the cake. Yeah. Awesome. Yeah, fantastic. We're going to finish up now, Banoi. Is there any other takeaways that we haven't really discussed that you think a runner would need to know around lateral hip pain? Yeah. I think one of the things to look at beyond bigger picture is. A lot of runners think, so I run five, six days, I'm really fit, I don't need anything more. And we know that as we get older, if you look at the stats, it's a bit depressing, we lose around 8% of muscle strength, muscle mass every year, especially it's more profound after 40, 45. And running and cardio is not really a good way of training to lose that, especially in bone health and muscle health. And that's where the strength element is really important. And especially it's more important to women because of the effect of sex hormones. and low estrogen. So I think you might be doing all the good load management. So one of the things I always insist with patients when they discharge is at least twice a week, they should be doing some global strength work to get that overall leg strength, working on big muscles, working on your fundamental movement patterns, your squat pattern, deadlift, your lunging, your step up. So investing that once or twice. And that's more important. to this sort of what I call the master athlete, that more and more men and women after 35, 40, they're picking up running, which is great because one of the best way to get fit. But we should not be under any illusion that running will prevent age-related atrophy. Unfortunately, running doesn't do that. The only way we can do that is by good, proper strength and conditioning. And you don't have to go to the gym five days or six days. If you're really, if you're starting at an obvious, just twice is enough. And during season maintenance just once is enough. It's all about quality and just giving it a good go. Another thing is also, you know, tendons and bones like that parametric load. So adding a little bit of jump training once in a while. We're talking about people without symptoms here, you know, once they're settled. So, you know, once a week, adding some skipping, some jump-based training is fantastic for your bone health and also for your, you know, tendon health as well. So... Sometimes as runners we need to think beyond running. Sometimes to be good at running, you have to do many things outside running. Like your strength stuff, bit of climatric stuff, and also most runners, if they're not doing an event, I will say to them every eight weeks, take one week off, do something else. Get on the bike, do some indoor climbing, go to a dance class, just give your body a break. If you want to be in the game of running for long, you have to think outside the box. A bit of strength, your body loves. variety, you know, it craves for variety. If you do the same thing again and again, it gets bored. You're more likely to get injured. So although runners like to run seven days, but if you want to keep running till your eighties and nineties, one of the best way to is variety. So mixing and maxing with different things is one of the best ways. So if you look at triathletes, they get less injuries than marathons purely because they cross-train. So mixing with other stuff is one of the best ways to get, uh, to prevent overuse injuries. So which sometimes the runners don't want to hear, because They want to do more and more of running, but that doesn't seem to work on the body. You know, your body loves variety. Yeah. And that's a really nice segue into talking about your master's athletes symposium as well. Do you want to just mention what that's about and what people can do if they want to sign up and start to learn more? Yeah. So we sort of linked up with some of the topics, but so if you look at, you know, you can definitely the largest growing segment is that 40 plus. runner, both men and women, and it's a great way to get fit. But we also know that there are some unique injuries which happens in that age group. And one of the things, as we all know, because I'm in that group, I can say that injuries take longer to recover. When you're younger, one of the big differences is it takes much easier to recover. So we got about 16 experts from all over the world, and we put them together in this forum, which is available. And We created a special code which I'll share with Brody so you hopefully can put on the show notes So you can put the links there So it's I think it's sort of it's mainly targeted for runners where they can look into the running element the cyclist element So we looked into all aspects of the master runner as well. So I think it was resounding success So we had many thousands of therapists attending when we had the free options and then you know, we do have that sort of online option which I'll be happy to share the link if you're interested in looking into that sort of masterclass. And so we got in total, I think about 26 hours of content. So a lot of content packed in, um, within that session. So I'm sure you'll find value from that. Yeah. And if I can add in as well, I've attended this symposium and love the content that you guys are delivering. Some of the guests we have, um, J F schoolie who was actually on my podcast back in episode 52 talking about, uh, what's the right and wrong shoe to wear. There was Rich Blaygrove, which I had on the podcast in episode 14, talking about strength training, Lizzie Marlow, who I will be having as a guest next week talking about Tidpost tendinopathies, obviously yourself talking about some great content, Brad Beer and Rich Willie, like these guys are just amazing. I love all their content. I listen to all their social media posts and content. So it's a really good collaborative. point where you can just put together a course and you know, everyone collaborates together and it comes together really nicely. So if you are interested, yes, I'll get a link or a code and add it to the show notes if anyone is interested. Any other social media links if people want to learn more about you? Yeah, I'm sort of quite, you know, most days I'm on Twitter, so LinkedIn. So, you know, it's quite easy to touch base with me. So if anyone has any queries, Please, you know, you can put the queries on Twitter, LinkedIn, so I'm available for any information. So as I said, I learn a lot from other colleagues, so it's a good way to sort of, because the thing with running is there's so many areas and so many facets. So, you know, I don't think a lifetime is enough to know the whole area. So, you know, it's a fascinating area and I still enjoy it even after 10, 12 years. So, you know, there's so much to go in depth in all those areas. Brilliant. Bunoi, thanks for coming on. Thanks for listening to another episode of the Run Smarter podcast. I hope you can see the impact this content has on your future running. If you appreciate the mission this podcast is creating, it would mean a lot to me if you submit a rating and review. 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