All right, hip pain in young adults,
it's one of those problems that can linger
for years.
Patients balance between providers.
Imaging looks confusing.
Symptoms don't quite match what the
textbooks actually say.
And sometimes what looks like a simple
orthopedic issue turns out to be something
much more complex,
a structural problem in the hip that was
never recognized in the first place.
Our guest today has been studying exactly
that.
She's a physical therapist, researcher,
and educator who's been digging into
whether the things we measure every day,
strength, range of motion,
even hypermobility scores,
might help clinicians spot hidden hip
instability earlier.
Because when hip dysplasia goes
undetected,
patients can spend years in pain before
they finally get the right diagnosis and
then treatment.
She presented this research at CSM.
Her goal was simple,
give clinicians better clues to recognize
the problem sooner.
Our guest today, Libby Burton.
Libby, welcome to the show.
Thanks, Jimmy.
I really appreciate that introduction.
That was awesome.
Big fancy intro.
That's the peak.
I do nothing well for the rest of
the show.
It's all on me, so no pressure.
So you're spreading hip dysplasia and
instability in young adults.
A diagnosis that I said in the intro
often gets missed.
So we'll just go with it.
Let's do the value for a million-dollar
question first.
Why does this happen so frequently?
Why are we bad at this?
What happens?
Gosh.
That's such a complex question.
And I think your summary in the first
minute of introducing this topic, I mean,
if everyone just knew what you said in
the minute, I'd be stoked, right?
That's a starting point.
I mean,
I think our knowledge about what hip
dysplasia is, is so far behind the times.
You know, when I went to PT school,
I'm going to do one of those that
dates me.
When I went to PT school over twenty
years ago now,
I was told that the hip can't be
unstable.
It's just impossible.
It cannot have a hypermobility there.
And that just didn't make sense to me.
And so I think a few things.
One,
there's a misunderstanding about hip
dysplasia and instability,
and that's that dysplasia only occurs
between birth and age two.
And so we think about this as something
we learned in pediatrics.
We think about a screen for the hip,
but that's just not true.
As we're starting to really learn about
growth and development and growth plates,
it turns out that dysplasia,
when it occurs in adolescents and adults,
particularly athletes,
It does not mean that it was necessarily
missed at birth.
It actually is something that can develop
as a result of loading in the way
the growth plates are loaded during growth
and development.
And that's kind of why we've changed the
terminology in hip dysplasia to
developmental dysplasia of the hips.
So this is not just a condition that
occurs between zero and two,
but it can develop at any time in
the growth span of human development.
So as long as that skeleton is open,
someone can develop hip dysplasia.
Understood.
Okay.
So we've gotten the million dollar
question out of the way.
Let's get some other ones.
Your specific research looks at whether
standardized clinical tests,
I mentioned this in the intro too,
range of motion, strength,
hypermobility scores might actually help
predict hip dysplasia.
So what early signs should clinicians
start paying closer attention to?
Where should they be looking?
What is the canary in the coal mine?
Yeah, I think, first of all, history.
You know,
if you've got someone with unexplained hip
pain and they come from a sporting
background with kind of more of a
hypermobile bias.
So our ballet dancers,
we know in performing arts,
particularly ballet,
the incidence of hip dysplasia is
somewhere between eighty and ninety
percent.
And so if you have an athlete that's
kind of living on that hypermobile
spectrum with unexplained hip dysfunction,
you can probably bet there's some hip
instability and possibly dysplasia there.
That'd be similar even with running,
breaststroke and swimming.
And so sports that were done at a
high level.
So I'm not talking about occasional
performance,
but these high level athletes that are
exposed to many,
many hours of loading in these end range
positions during adolescence are
definitely more at risk.
We know women as predominantly females
more than males.
And then, you know,
generally as a clinician,
what I see so often is just there's
increased motion.
So I think our target and what I
hope to see eventually,
and we're starting to see in the research
that I'm working on,
is that when we look at the arc
of rotation, particularly in hip flexion,
so in hip flexion,
when we look from external to internal
rotation, seeing just a global increase,
you know,
greater than what you would expect.
Yeah,
I've got someone in the clinic right now,
and he's in his seventies,
has had multiple back surgeries.
And the guy's got somewhere between eighty
and ninety degrees of external rotation of
his hip.
And you got to look at that in
an otherwise kind of stiff,
not super mobile guy and say, you know,
that doesn't add up.
That's more than I would expect.
So, you know,
hopefully someday we're going to be able
to say, well,
beyond this range of motion cutoff,
if we look at an extreme of external
to internal range of motion in the hip,
that maybe there's something along this
instability or dysplasia spectrum
occurring.
Great, as a former breaststroker,
I am very in tuned with this.
And yes, I understand a lot of this.
Me too.
Yeah, that's how I got into this research,
likewise.
I bet, right?
I mean,
that's how we get our research interest a
lot of times, is personal experience.
It was the only stroke I could do
where my mediocrity was an advantage.
Nobody wanted to do breaststroke.
Yeah, and actually, for me,
I couldn't do breaststroke.
And so my parents doubled down and said,
well, if you can't do it,
we're going to get you extra lessons.
So I went through special lessons to be
able to do that motion.
that guess what my hip couldn't do and
then i wound up being almost a collegiate
breaststroker doing a breaststroke was my
specialty so you can imagine what that
caused in a hip that couldn't do that
motion over the years so yeah yeah so
you've trained pts across an entire health
system to use a standardized measurement
protocol what would that look like talk us
through that and why was that important
for your your research
Yeah, yeah.
So I'm very fortunate to work with a
phenomenal hip preservation specialist.
These surgeons can be difficult to find
and there's a small network of them.
I work with Dr.
Joel Wells in the Dallas metro area.
He is a phenomenal human being and an
exceptional surgeon.
So when you look at trying to find
clinical measures,
so if we're going to look at,
you know,
what do PTs look at and how do
we start to develop a screen or any
sort of clinical utility of tests that we
do?
What we really wanted to do was create
a pragmatic trial where we're able to kind
of look at tests that PTs do every
day.
And thankfully,
like a lot of hip preservation
specialists,
he'd already kind of had a system of
data collection and he had PTs that he
referred to.
And so we just had to ask the
question of how can we standardize how
these measurements are done,
get some decent reliability data,
and so that we can use this information
that's basically passing by every day and
start to capture it.
so that was kind of the overall goal
is you know initially we trained over
fifty clinicians across a hundred clinics
and then for the study we had to
kind of pare it down with the ones
that were really interested in continuing
on in this work and so um it
took a few trials um in looking at
reliability we have some of our
measurements were a little more
problematic than others but you know we
came up with a good mix between something
that's more research based and something
that's more pragmatic that clinicians do
every day so we can get good information
and data
again on things that pts would measure
every day anyways right and that's the
sweet spot right you don't want to make
it so specific that someone couldn't do it
quickly consistently clearly and you don't
want to make it so loose and so
easy it doesn't give you any good data
you sort of have to have that that
sweet spot between clinician and
researcher that understands what the
constraints are for both absolutely yeah
now do i have this right you just
presented at csm right as we record in
march correct i did i did i just
had a poster
Perfect.
So your poster presentation at CSM,
what trends are starting to show up in
the data?
Like give us the movie trailer version of
the poster,
which I think is how we should look
at posters in terms of movie trailers,
because who doesn't love a movie trailer?
Yeah, I love that.
It's a good synopsis of what we're
starting to see.
We've screened over a hundred and fifty
people.
We have about sixty that we included.
At the time that I published the poster,
we only had about twenty five that had
dysplasia.
We only had nine with FAI.
And so with this study,
we're really looking at those hips that
are not arthritic.
And we're seeing that when we catch FAI,
they tend to be people that are already
arthritic.
And so we're having a harder time
capturing those FAI hips.
But with that early data where we had
about twenty to thirty dysplasia cases and
about nine FAI cases,
we actually did find some cool things.
And the take home is that there's two
things that are starting to show up as
predictors.
One,
generally range of motion being greater in
acetabular dysplasia group.
Because of the type of prediction modeling
that we were doing,
we weren't able to really come down to
which one just yet,
but it's already starting to pop up that
we think that there's going to be one
or more of these range of motion
measurements that is showing some
relationship to what we see on imaging
studies.
And again,
it is kind of probably that flexion
rotation arc of motion.
And as we get more numbers,
we'll be able to now really kind of
dive in and figure out which motion
measurement is the one that's triggering
the significance.
The second thing that we noticed is that
adduction strength.
And so patients with hip dysplasia had
significantly weaker hip adduction,
and that was actually able to predict what
we see on imaging studies.
So the two of those things together.
So a little surprising,
not the Baten hypermobility score did not
pop up,
but increased range of motion and
decreased adductor strength.
And it makes sense, right?
Go ahead.
Yeah, keep going.
It makes sense, right?
Because the adductors and the rotators are
really what's helping to create
compression of the femoral head into the
socket, right?
So those patients who have dysplasia,
and remember,
these patients are symptomatic,
they went to see a surgeon.
And so we think that maybe once the
adductors get weak enough with dysplasia,
so say you have an athlete,
they're performing at a high level,
they go to college or they become an
adult, they become less active.
And now all of a sudden we have
this situation where the adductors get
weaker and we have more sloppiness and
instability and they have symptoms.
That makes sense.
For there to be a good story or
reason for people to change,
there needs to be tension in the story
to go along with our movie trailer and
movie analogy.
If PTs can identify possible hip dysplasia
earlier, what changes for the patient?
Why are we doing all this?
Tell me the outcome.
If we can do this, what happens?
This is the key point.
As someone and anyone who's listening to
this,
who treats patients that have this can
testify, these patients suffer for many,
many years with chronic unexplained pain.
Their pain isn't always in the hip.
It can be back pain.
They oftentimes have a history of multiple
surgeries.
The average time right now for a patient
with hip dysplasia from symptom onset or
entering into the medical system to
diagnosis is over seven years.
They see an average of three to five
years.
Seven years.
I was not expecting that.
Yep.
Now that study is older.
That's a twenty eleven study.
But we're actually looking at those things
in the current study and we're seeing
something similar.
It's about five to seven years before
someone gets an accurate diagnosis.
Wow.
That like took the wind out of my
sails there.
Imagine the suffering, not understanding.
Yeah.
Unnecessary.
Yeah.
And there's surgical implications for
that.
So when you're younger and you have a
lower BMI,
there's surgeries that can help.
You know,
when we're older and we gain more weight
and we have more arthritis on board,
you really don't have as many options.
And so there's surgical options that
change when you know earlier.
And to be honest,
a lot of people will not opt because
those surgeries are they're pretty
invasive.
So even if you opt not to have
surgery,
the power of understanding what is wrong
with you is life changing, you know,
and then you have the power to decide
what you want to do about it.
Wow.
Was not expecting that answer.
Wow.
Yeah.
That's very clear now.
Wow.
So your work really sits at the
intersection of research, performance,
science, clinical care.
How do we make sure research like this
actually reaches everyday clinicians
besides being on a podcast like this?
Yeah.
That's a million dollar question.
As we know,
the publishing environment is challenging.
And as a newly minted PhD and researcher,
obviously,
I have to work to get this to
the quality level that it needs to to
get out in publications.
But yeah,
I hope in the common or current media
environment, things like podcasts,
social media, understanding, you know,
really helps to grow the understanding
about what's happening in hip dysplasia.
I think the people that treat hips,
there tends to be kind of a small
circle of us that are really passionate
about this stuff.
And yeah, it's a good question.
How do we start to disseminate this
information?
You know, it starts with good data, right?
Some of this stuff is at the very
beginnings of understanding.
And so when we don't have great data
just yet, like my posters,
only twenty or thirty people, right?
It's important and it's a start,
but we need to keep going with this
study.
So for us,
we're trying to get almost a thousand
people through this study.
And that hopefully in that a thousand
people, we'll have about four hundred.
And then we can have at least maybe
it's looking like we'll get lucky if we
get two or three hundred with dysplasia
and a hundred with FAI.
And that'll give us enough power to really
understand with better numbers and better
data and better confidence that we have
these clinical measures that can predict
this hip dysplasia.
And then you have to go on a
roadshow.
You got to go on tour.
I'll do it.
I would love to.
They call it the poster child for a
reason because we've got a problem.
We didn't put a face with it.
Now that face needs to sort of be
everywhere.
We have a segment on the show at
the end called Words of Wisdom.
I'll ask you this for our last question.
If a physical therapist is evaluating a
young adult with chronic hip pain,
just hammer it into them.
What are the one or two signs that
should make them pause and think this
might be dysplasia instead of something
else?
Hmm.
Signs or symptoms.
My mind is going crazy.
So young female athlete stopped sport has
chronic unexplained pain in and around the
hip, low back, down the leg,
mechanical symptoms.
And they've probably seen multiple
providers and they're struggling and
they're upset about their pain because
it's very limiting.
Yeah.
Well said.
If someone wants to reach out and find
out more and connect with you, Libby,
what's the one spot you want to send
them?
Sure.
Our private practice is Performance
Science and Rehab.
So if you go to
performancesciencerehab.com,
you can find our clinical practice here in
St.
Augustine, Florida.
It's a very well done website.
I went there earlier.
So I want to give you kudos for
that because I think your science is
great,
but people have to want to engage with
it.
And you have a very engaging website.
Well done for whoever did that.
Thank you.
It was not me.
Well, Libby,
thanks for doing this work and thanks for
sharing it with us here on AMT.
Thank you so much,
I really appreciate your time Jimmy.