Webinar: Modern Approaches to Hip Pain and Soft Tissue Problems

Hello and welcome everyone. Thank you very much for joining us this evening for our online talk on hip pain and soft tissue problems. I'm Katie, one of the members of the marketing team and I'm delighted to be joined by Mr Tofunmi Oni, one of our consultant orthopaedic surgeons here at The Horder Centre. Mr Oni specialises in hip and knee procedures including hip replacement, knee replacement, meniscus tear repair, knee arthroscopy and revision hip replacement alongside his expertise in knee injections. A reminder that this webinar is live and the recording will be emailed to you tomorrow. If you do have any questions for Mr Oni during his presentation, please type them into the Q and A box so we can address them during our segment later on. Once again, thank you all very much for joining us and please welcome Mr Oni. Good evening, all and all. So today I want to talk about something that's been inspired by a very common presentation that I see, common questions that I see about the hip from my patients and that's generally around where hip pain is and what it means when hip pain is in different places. So it's something that very much I've talked about recently which is why inspired me to mention this to the guys to give this talk. So we've tied to this sort of modern approaches to hip pain and soft tissue problems and so that's an ode to the fact that the hip joint itself is a bony construct but it's surrounded by soft tissue sort of elements. So tendons, ligaments and muscles which make the hip function. So just a quick talk about what we will cover. One is just hip pain as a symptom where typically it is and what that then points to. And then I wanted to look at some very specific causes of hip pain including osteoarthritis, bursitis, what that and what that means, tendon problems around the hip, when there's sort of typical and atypical presentations of the hip, and as well as treatments of the the these these various bits of pathology. So the first thing to say is where does it hurt? And this is a very simple, schematics or diagram, that I've sort of broken down into front side back. And the reason why I kind of did that was because often I see patients in clinic who tell me that their hip hurts and immediately point to a place that I don't consider to be the hip joint, but it's a place that a lot of people do. So very much so looking at the simple diagram Number two, I would say, is where a lot of people would say my hip joints are pointing to the side, but that's very much not where where the actual articulating part of the hip joint is. It's actually closer, to where number one is on that diagram that says front, or even number four, rather than number two. But as a very simple way of looking at things, that I will go into more detail after this, If it's the front of the hip, so that's number one or between number one and two, then that tends to be where you you get pain in hip arthritis, and certain types of tendinopathy and bursitis. Again, I'll go into this in more detail in a minute. The side tends to be where a lot of the most common type of bursitis is, and the back again is is, where you can get a lot of tendon sort of problems as well as other things that that can actually mimic hip pain. So where is the hip joint really? This I I love this diagram because really it it says everything about where it is. The hip joint is not on the side. It is closer to the groin. And often, I find this in fact, in in my clinic today, I had this conversation. Often, people feel like they've they've pulled a muscle in the groin or they have certain pains in and around the groin or inner thigh that didn't automatically register to them as something that might be wrong with their hip. But it certainly would if you spoke to a hip surgeon like me. So that diagram is really good to just keep in mind. Before we dive into those specific pathologies, this is a a slide just saying when the hip is not the problem. So common mimics because often we can have anatomical situations that's that help us spot certain patterns. So for instance, a lot of the time, patients with hip pain or hip pathology can present with knee pain, and that's because the nerves that pass the hip carry the pain sensation down. Sometimes it's from it's nerve pain from the back, and sometimes it's referred from sort of the butt buttock area where it can actually be more hamstring troubles. So there are a lot of sort of mimics, but the these are a little bit, we'll say, anatomically focused rather than things we see all the time, I would say. Now there's the do not miss, and and these are the rarer ones. But night pain has nothing to do with you sort of position, but I would worry if anyone had these sort of pains with unexplained weight loss or a history of cancer or sudden inability to weight bear, often it is more insidious, or painful hot swollen joint that made people unwell. These are what I would say need urgent review. But going back to the the pathologies that we mentioned, osteoarthritis of the hip, extremely common. On the right hand side is the is an X-ray of the pelvis of this individual. On the left hip, which is, as you're looking at it, the right, that shows severe osteoarthritis, which can be seen by looking at a complete loss of the space between the spool and the cup and the cup. And this gentleman has actually lost his sphericity of the cup as well, so clear osteoarthritis. So when a patient like that comes to see me in clinic, the typical presentation that I would expect is they have a deep sort of sense of groin pain or inner thigh pain, that's worse on weight bearing or activity, worse at the end of the day or at nighttime, which is extremely common because it's the culmination of the day's activities that build up to the night. Often, they have stiff morning stiffness or stiffness after long periods of immobility, a loss of movement, rotation especially, and the the the the most common, we'll say, activities of daily living that people struggle with is the bending over activities, putting shoes on, socks on, getting in and out of cars, and and they progressively get a limp as it as they, as the symptoms progress. So that's what I would consider to be typical symptoms. Now atypical symptoms would be the the the knees the the the pain solely felt in the knee, rather than anywhere higher up towards the groin or or indeed the buttock, or indeed a pain that sort of at the beginning of activity and then completely settles down over time, or younger patients after injury. That's a little bit more of an atypical presentation of this. Treatment options. We we we always we always talk about climbing the ladder when we talk when we are we're offering treatment options. The first line is all about conservative measures. So keeping mobile, weight management, physiotherapy to build up the muscles around the joint and all help to off offload the joint and and simple analgesia or sort of paracetamol or anti inflammatories. Then the next step on from that is things like walking aids and injection, which usually provides a temporary relief and more of an adjunct to physiotherapy rather than an actual treatment. And then the definitive, treatment is is replacement, surgery, like a total hip replacement. The next pathology I wanted to talk about was was a was bursitis. Now a bursa is an extra layer of tissue, and fluid that cushions any hard, surfaces of bone that are particularly close to articulating areas or close to the outside. So for instance, on on the side of the hip, there's a bursa there over that bone, which is called the trochanter. Even coming coming away from the hip completely, the elbow has a has a a bursa. Your heel bone has a a bursa. Anywhere where you might see, we'll say, lumpy bits, parts, You have extra layers of tissue that that and fluid that that cushion things. But when this is irritated, it becomes inflamed, and that's what bursitis is. So you talk about trochanteric bursitis, which is what that picture on the right hand side is, alluding to, which is where the, the muscles that are around the hip attach to that that large area of bone called the trochanter, there is a bursa of that point. But if these muscles become inflamed, they inflame the bursa in turn, and that is what trochanteric bursitis is. And that's the most common reason that patients I see get pain on the side of the hip. Then the next type of bursitis, we'd say, is iliopsoas. Now the iliopsoas is a type of tendon that runs over the front of the hip and has a corresponding bursa. And I think the next slide will actually show where this is. We'll find it in a moment. And the ischial bone, which is around the back of the bone of your of the buttock where individuals sit on, that also has a bursa. And wherever there is a bursa, which tends to be where tendons are attaching to, there is a a propensity to to be, prone to to inflammation of that point with the tendons and the burs around it and therefore bursitis. But the, the concepts of treatment are are the same regardless of where the bursitis is, which is you try and settle it down in the most benign way, I suppose, which is rest and potentially even icing it if if it's another structure that's that's deep. And and essentially physiotherapy to try and build up the muscles of the of the tendon it belongs to and short term sort of at courses of anti inflammatories. And when it doesn't settle, that's where injections come in to as an adjunct to physiotherapy or more novel things like shock wave therapy. And and surgery is really something that's that's not really done for this procedure at all, really. It's it really is a last resort. So going back to the iliopsoas tendon, it's just depicted in a picture on the right hand side. It's a combination of both the psoas and the iliacus forming a tendon that runs over the front of the hip joint, as you can see on the right hand side, and joining to just beyond it, and that area has a bursa. That tendon can become inflamed and lead to a bursitis. Now how it presents, it actually completely can mimic arthritis because you can also get pain at the front of the hip, which is, with arthritis, you can get You can get groin pain in the same way. The difference tends to be that when this tendon is in use is when it tends to be the most aggravated. And so generally lifting your knee up, especially against resistance, you might feel that that's when the pain is and other times it completely settles down. But this is where reviewing a surgeon to look at the nuances of this is imperative so that this isn't attributed to arthritis when it could be just a simple tendonitis or bursitis. And treatment, again, talked about physiotherapy to to build the muscles up around the the hip joint, targeted injections as an mainly as an adjunct to physiotherapy. And the last resort, that tendon can can actually be completely resected. And that sounds fairly drastic, but if the tendon's cut then it's no longer under tension and then it forms a scar tissue over a longer excursion which sometimes actually completely settles down the symptoms. So gluteal tendinopathy just means wherever the gluteal tendons attach to, which is the side of the hip, and we've talked about this, they attach to the trochanter, and that leads to a trochanteric bursitis. And so the notion of a trochanteric bursitis and gluteal tendinopathy is very much a blur, which is why these days we tend to use the broader term of greater trochanter syndrome rather than using a gluteal tendinopathy or bursitis, a trochanter of bursitis which are older terms. But in terms of how it presents, again we talked about pain on the outside and the treatment is much in the way of any other type bursitis or tendinitis. The one of the other things we talked about in terms of pathology was was a proximal hamstring tendon tendinopathy. So where your hamstring tendons start from is very much where that your sit bone is. And if you have a bursitis or tendonitis around that area, then you can have deep pain around around the sort of low buttock, especially when sitting down on hard seats or using your your hamstring tendon muscles. But, again, this can be can also mimic where hip pain can can come from. So it can mimic things like arthritis because some people atypically present with arthritic pain around towards the buttock. But, again, those being able to tease it out is all about when the pain is is worse and what activities that are that are being done when the pain comes on. And, the the the treatment, once again, very much a broken record is is pretty much the same. You ease the aggravating load, progressive strengthening with physiotherapy, targeted potential injections, and and surgery really is is is is a last resort again. So just a bit of an overview, which is gonna be pretty much my last slide. Just as a as a as a summary, I, you know, I I I wanted to talk about this because of, a lot of a misunderstanding about from my patients about where hip pain is coming from, and what can be involved, and what arthritic pain looks like. But I've just put I've just put it into this table to almost to simplify things to say location, what's most likely, what it's worth with, and what the first treatment is. So in in the front of the groin, most likely, either the arthritis, the in in terms of wearing away of the ball and socket joint, or the psoas tendon being irritated because that's the tendon that runs over the front of the hip. It's worse with weight bearing and use or lifting your your knee up, especially resistance in the in the case of the psoas. And first line, again, conservative measures, physiotherapy, all the way up to injections and replacement if it's arthritis. Second line is location, pain on the side of the hip. The most likely thing is gluteal tendons irritation and bursitis. In other words, the greater trochanter syndrome, and it's worse with pressure on it. So often people don't like lying on that side. It's also worse with sort of mobility, but the treatment, again, physiotherapy. If the pain is on the the sit bones or right in the buttock, then the most likely thing is hamstring origin. So that's where the tendon starts from, bursitis. It's also worse with with with certain types of mobility, explosive movements. And the treatment's the same really as as the great greater trochanter syndrome. And then pain in the knee or the thigh, it could may well be referred from either the hip or spine or indeed the knee itself. Let's not forget that the knee exists and can give problems. And it's it's it's worse with so put put on there varies with with the source. So very much depends on on the source as to what will make it worse, and those are the clues that you can get by, during during a consultation with with an individual. And, the key thing is examining, you know, the the hip as well as the back to try and form the full picture before diving in with treatment. So key takeaways, hip pain is a symptom. It is not a diagnosis in of itself. We have to match the site to the source. The the one of the things I want people to take away is pain on the on the outside of the hip is most likely a bursitis and not hip, joint, problems. Watch for the mimics in terms of knee pain and spine involvement. And most of the time, to treat things, we start simple load management, physiotherapy, and then build it on from there. Thank you very much. So I'm happy to take questions or I'll hand back over to Katie. Thank you, Mr Oni. I'm sorry for the slight delay there, and I'm sorry for a couple of you that have been experiencing difficulty seeing the slides. I'm just going to, I've got Marta here in the background trying to go through, she's sharing the slides her and Mr. Oni. So I'm wondering if they do start to move, which I'll see in a moment, I may ask you to just go over the top level. I'm so sorry, we've still got quite a lot of time. So maybe, no, she's confirming they don't move. Okay, that's fine. It's just some people have experienced difficulties tonight. It seems fine from our point of view, we'll just try and figure that one out. It has been recorded so you all will receive the recording of all of that information. So apologies to those who was experiencing difficulties. It does mean that we can go on to questions which some of you dropped in now and we had a couple come in in advance. So if I start with, after an injection for bursitis what is the next step as of yet the injection has not worked? So it varies slightly depending on where the bursitis is, but in terms of broader concepts, in the injection is not the treatment. Usually, injection is an adjunct to the treatment, which is progressive overload type of physiotherapy. So it's bursitis is it can be an extremely stubborn pathology often you know it lingers often it stays with people for long periods of time. There's a lot of back and forth between you know, patients and GPs and surgeons and things and and and things like that. And unfortunately, there's no there's no silver bullet. But the the key thing is the injection is is not designed to treat the problem. It's it's designed to help you. It's designed to facilitate the physiotherapy, which usually will more effectively treat the problem. So the unfortunate reality is the injections don't work in everyone and and in people where it doesn't. We have to, a, make sure that it's not another pathology involved, because like I said, there's there's lots of different, areas that that are overlapping. And so we wanna make sure that we are treating the right thing and therefore injecting the right thing. And that's a reason why injections can also be good because if it doesn't work at all, it may actually be telling you that's not where the problem is. It may be coming from somewhere else. And so it guides us into guides that diagnostic process to try and find where the problem is coming from. But I would suggest hanging on in there with keep going with the exercises and things really aren't improving, then it might be time to look look elsewhere. Okay. Fantastic. Next one says, how to release sharp groin pain that comes and goes? Yeah. So this is this is another it depends type question. Depends on what the what the cause of the of of the symptoms are. Now sharp pain that comes and goes suggests more, on the on the psoas tendon end of the spectrum. However, you can have hip joint, sort of sharp pain, either when, you know, bits of debris get caught in in the hip. You can have a similar sort of thing. It's all about building the larger picture, which comes with talking to a patient about all the other times when the pain is there and exactly where it it is and forming a full a fuller picture of when it might where where what might be causing it and therefore how we might solve it. So, unfortunately, it's not something I can sort of directly answer for sure without having a bit more information from, from the patient. But it also leads me into a a really sort of out of the box reason for groin pain, which is actually, which is nothing, orthopedic at all, nothing to do with anything I've said today. Another reason people get groin, pain type issues is hernias. And when we exhaust all of our sort of parameters of anything musculoskeletal that might be causing symptoms, our typical out of the box is, well do you need to be seeing an orthopaedic surgeon like me or do you need to be seeing a general surgeon to make sure you don't have a hernia which is mimicking the symptoms? So unfortunately I can't really answer that without a lot more information and someone in front of me to speak to and examine. Okay. Does an X-ray always show the extent and severity of hip arthritis? So there's a there's an age old adage that that whenever always used in anything, it usually usually means that's not the case. So the the the reality is an X-ray is a two d representation of a three d structure. And so for the most part, for severe cases of arthritis, absolutely, we will we will most of the time, it shows up in an X-ray, there's no need for any further imaging. But there are there are times when, the the location of the arthritis may be hidden by the fact it's a two d structure. So just in a in a very plain sort of explanation, if if we're looking at the front of my of of my fist and the arthritis is where the back of my fist is, then that's what an x-ray is. Whereas an MRI would be able to see the entirety of where things are. And so most of the time, severe arthritis, we can pick up on an x-ray, but more subtle sort of diagnosis, more subtle arthritis and different diagnosis of bursitis and tendinitis, we tend to rely more on MRI scans. Okay. One here that asks, how long after a hip replacement can the other hip be replaced? An extremely common question I get asked all the time, and the reality is there is no time limit. Often so I I I worked for for a lot of my my all my fellowship for for just under a year in Australia, very commonly, they did both sides at the same time. We tend to have a bit more of a sort of tandem approach to it, which means whenever we are happy, by we, I mean myself and the patient are happy with one side, then then we proceed to the next side, whether that's, two weeks because they're someone that recovers extremely quickly, or six weeks because they're pretty average and they're comfortable, or three months. It really doesn't, there there is no hard and fast rule about it. It really is just a matter of, feeling comfortable with your re rehabilitation. Usually, I would say that's around about six weeks is when I when I would discuss it with with the patient. If at six weeks people anyone's happy and we're happy, then we can list people for that. But no hard and fast rules, everyone's different in terms of their recovery. Okay, good to know. Apologies if you've covered this in the early slides, but could you just repeat, what causes bursitis? Yeah. So there is it's it's a tricky one because the reality is a lot of the time it it can be absolutely nothing at all. It can be nothing that certainly registers with the individual. In other times it can be surgery. So some of my patients after a hip replacement will will have bursitis that we have to treat as as well as their during their recovery. Sometimes it's trauma. So so, know, someone falls over and they hit the side of their hip, it's just just starts an inflammatory process that then starts the cycle. But sometimes it's it's seemingly no reason at all. And so there's a full spectrum of the reasons why we we, as individuals, as human beings, can can get bursitis, but the reality is that consistent ways that we treat it is is is similar no matter what the cause. Okay. I don't know if this is of the the the same sort of calibre that were talking about, apologies for my pronunciation of this, but advice for treatment of chronic trochanteric bursitis. I have been doing regular physio exercises and have had bilateral steroid injections, have helped for a short time. Is there anything else that needs with the pain? Yeah. So that's a very typical picture. The one thing I would I would say that is positive about that is the fact that if if the steroid injections help, even if it's for a short period of time, then that's a good thing. It's good from a diagnostic point of view rather than a treatment point of view because we know that that is where the pain is coming from. And so it's it's it's important not to focus on anything else. The important thing is during that period where it is better, that's when I would suggest really we marry up with fairly aggressive physiotherapy. It's something that I mention to a lot of people as to what type of physiotherapy and and what aggressive physiotherapy looks like or physiotherapy looks like at all, but I'm sure that that physios would agree with me. The physiotherapy is about ninety nine percent with the individual on their own, following the instructions that the physiotherapist has given them. There is no substitute for consistently doing the exercises, and that looks like multiple times a day, every day, for a few months. And the reality is that's what tends to break the cycle. Often I find that people engage with physiotherapists who are there as the ultimate guide to help to tweak the exercises and also sort of guide in in a in a very specific way. That's their sort of skill set. But often people feel that that is what that is only what physiotherapists or or physiotherapy is. But I but it's all about realigning to the fact that the majority of the physiotherapy is usually with an individual at home doing the work when no one is looking, and that's what's really difficult to do. It's certainly something that I've experienced myself having surgery. Sometimes I'd wake up and forget that I've done my physiotherapy for two or three days, I'm an oral speech surgeon who should know better. So it's extremely difficult, and often it takes routine. But but but that but that sort of routine is usually what breaks breaks the cycle. Absolutely. On to the next, which says, a slight ache in hip flexor when walking, but on waking in morning, no pain. Later in the day, I get bad groin spasms from sitting to standing or when legs are bent to straightening them. This only happens in the afternoon, then it goes overnight. Been doing various glute exercises as much as possible, and this is helping a bit, but do you know what this could be? So there there are different things it could be. So when when this is a classic case of you need we we need the individual to to to point to where on those depictions that people may or may not have seen, where the the the pain actually is because hip flexors, some people point to their groin, some people point to their mid thigh. But but if we're talking about hip flexor right or high up into close to the groin, then, again, that could be arthritis regardless of the timing, whether it comes on in the morning or the evening or or late late at night. It could be arthritis. It could be, tendonitis. There's always tendon across it. So it it we to to form a full picture of this, you know, this is where we need an an individual in front in front of me to to talk to about it, to examine their hip, which is something that we haven't gone through a lot of detail about today. But there are certain clues in in examination of a hip that you can get test to point you into into the right direction. So, unfortunately, can't I can't really answer that fully without actually having someone in front of me. Yeah. Of course. And this is a very sort of open ended question. I appreciate it. All it says is best pain relief. Presume that may be similar case of you'd have to identify where the pain is. Yeah. Well, yes and no. So often I get asked that question, and the reality is pain is the most subjective thing that that there is. And there are different combinations, and different, medications that work in some individuals and don't work in other individuals. And so when it comes to optimizing that, the reality is there there is a little bit of trial and error. Now there are broad concepts. We know that combinations of drugs tend to potentiate each other so that one plus one equals three for instance. We know that for inflammatory type tendinitis, tendinopathy, bursitis type presentations, inflammatory medication tends to work. But even within the same classes of of of analgesia medications, there are some anti inflammatory medications that work very well for some people and some don't work well for for others. And so really, it's about trying to find the right combination as part of that analgesic ladder and as part of the conservative end of the spectrum before obviously getting up to to to say, you know what? That hasn't worked, and let's go let's go for something a little bit more invasive like an injection. And that that can take a long period of time. It can be it can be weeks or even sometimes months to find the right sort of combination that works for an individual. But but it's it's it's worth seeking because sometimes it does. If it does, it saves a whole lot more that could be done on the potentially unnecessarily. Fantastic. I think you've actually probably just answered this next one, which does say, what other anti inflammatory drugs are there apart from ibuprofen as naproxen caused palpitations and had to be discontinued? Yeah. As you were saying. Yeah. So so I mean, there's a whole myriad of different different anti inflammatory medications, some which are, you know, combined with other other medications. Some don't go well if patients have certain conditions, heart conditions, lung conditions, sometimes asthma. And that's the reason why the best person to to to control all this is is is the GPs because they have a patient's full medical history. They have the full picture, as it were, to be able to be able to make the call and say, you know what? Actually, this anti inflammatory might not be good or this one might be. And, of course, you know, also protective elements as well because taking anti inflammatories can lead to potential issues with with the lining of of of the gut so the GP can look at sort of giving medication to to protect the gut whilst we're whilst we're sort of tinkering and trying to find the right combination. So all individual, very much run by the GP. Okay. Somebody had said, what is tendonitis? I have a strange feeling that something is crossing over a bone on the outer side of my hip. Is this tendonitis? So the mechanical feeling of something crossing over the bone on the outside of the hip very much sounds like what's called a snapping hip, where the the band of tissue that's on the outside of the hip actually just goes either side of the hip. That very much isn't tendonitis in of itself. But if that goes on for long enough, can certainly spark an inflammatory process which ends up in tendinitis. So in other words, some people can have that pathology without tendinitis. Some people have it with. So I think it's very it very much depends on what what the main symptom is. If it is if it is the mechanical element of, you know, that feeling of something moving back and forth, that's one thing. If between times, you know, people are getting this person's getting a lot of pain, then it may well be tendonitis. So there's a lot more to kind of tease out. Okay. Someone said, please recommend best physio who can work with active fit person to help groin pain. Obviously, we've got a whole host of physiotherapists here, but maybe if you could just explain, is it best to go through them first or speak to you in terms of consultation to identify the groin pain? How best to approach that? It depends on how we kind of look at it. The reality is I get all comers because often I see patients who come from the GP and the physio route and then to me or sometimes just just to me. I suppose the benefit of coming to me is is what I I attempt to do is hone down exactly what we think it is before sending it off to the physiotherapist because there are some broad things that physios can can do that certainly will help, any type of of of tendinitis around the hip, for instance. But, there there is benefit in, specifically targeting what that diagnosis is before then sending things to the physiotherapy to the physiotherapist. Sorry. So so, I mean, I I would suggest coming to see me, but then again, I'm very much biased in that in that regard. I know that there are some physiotherapists that are doing extremely good work. So certainly here at the Hoarder Centre, are host of physiotherapists that we work with. I know that a lot of patients I see come from far and wide and there are different physiotherapists that I work with closer to Tunbridge Wells as well, people on the West Kent side. But to be honest it's not too far from the from here at the Halda Centre which is a specialist orthopedic unit. I suggest coming coming to see me here or the physios here. Great. And this person has said, do you know anyone maybe just a quick explanation of what this is. Do you know anyone that offers platelet rich plasma therapy? Do I know of anyone? Yes. It it very that that therapy is very specific. Now I'm gonna assume that this individual means in and around the hip, because there are lots of different parts of the body that you can give, PRP injections into. They're they're they're a bit of a contentious type of injection because there are certain areas that that is very well evidence based that it improves symptoms. So generally around, tendinopathy of the Achilles tendon, for instance, some tendons around the hand. There's a lot of evidence that it definitely improves things. There is less evidence around the tendonitis around the hip, and there's even less so evidence of PRP injection into any joint. And so orthopedic surgeons, we tend to follow evidence based medicine to stop us essentially doing what we feel is right. And by evidence based medicine, it is the largest and most robust quality research and trials that's done that then answer the question, does this drug or does this system or does this thing work best in this situation? And right now, we can't say that about putting the PRP injection into joints. And that's why personally, don't do that. Now when it comes to in and around tendons, really the jury is out apart from Achilles tendon and some others where it certainly is proven. So it's not something that I routinely offer as part of my practice because the evidence isn't there. Okay. This may have triggered this question actually in terms of other options. Have you heard of cold laser therapy for hip bursitis? Again, yes. I've heard of it. It's not something that I I'm involved in or or or or use. The the notion of a lot of therapy like that, with lasers or shock wave or ultrasound or sometimes electricity, they all have a similar concept, which is aggravating the area so that the body almost is overstimulated into sending cells inflammatory cells to the area to then deal with the problem and then calm the inflammation down. So although I don't I I I it's not something I've I've personally used. It's something I've heard of, but the but the con the broader concepts are are the same, but, again, aren't as proven as as some of the other the other things we talked about, which is physiotherapy, which which is the most proven way of of dealing with with bursitis and tendinitis. It's also sometimes the hardest way because of the consistency that is necessary for it that I talked about before. Okay. Another one that's quite specific to their pain, potentially the same answer what you've given previously. What could pain that starts in the lower back, down the buttock, down the front of the thigh, and down to the ankle be? So whenever things radiate in that fashion and go beyond the knee into the ankle, the first thing that we we we would wanna rule out is is spine issues. Because the the when nerves in the back get aggravated, pinched, get unhappy in any way, they send the pain signals to where the nerve supplies. And there is nothing around the hip from a nerve point of view that that goes beyond the knee. And so very much I would suggest to this individual, we we'd have to work from the spine forward, if you see what I mean. Make sure that these symptoms are coming from the spine and then go and then go on from there. Okay. Fantastic. I think that's we've got through all of those questions. So thank you very much, to everybody who has submitted one this evening. And also thank you very much for your your time and thank you Mr Oni as well for sharing your expertise. Pleasure. If you did want to learn any more or arrange a consultation with Mr Oni, please contact our team using the details provided which is telephone 01892 600865 or via email, which is the letters pp@horder.co.uk. As I said earlier, apologies for those who didn't see the slides at the beginning of the presentation. You will receive the recording later in the week. And once again, thank you very much for your time and enjoy the rest of your evening. Bye. Thank you.