One of the more challenging conditions for doctors to diagnose whether pain is originating in the hip or back. In this episode of Back Talk Doc, host Dr. Sanjiv Lakhia and his guest, Dr. Puneet Aggarwal, MD, troubleshoot different patient symptoms and explore how they would treat them.

Dr. Aggarwal is the director of Atrium Health Musculoskeletal Institute of Sports Medicine, where he specializes in non-surgical treatments for the spine and interventional pain medicine. 

Dr. Lakhia and Dr. Aggarwal discuss multiple scenarios and treatment methods for a patient presenting hip and back pain. They run through different ways of identifying the root cause of the pain, how they would go about treating it, and the multiple options for patients who need more help. 

And for patients dealing with ongoing pain, Dr. Aggarwal stresses the importance of stretching and strengthening to maintain flexibility in your joints and muscles. 

From tight IT bands to testing pain on the stairs to SI joint pain and steroid injections, the two doctors cover the full gambit of hip and back pain. They provide tips for physicians to diagnose pain issues, and also help patients assess their own pain. 

💡 Featured Expert 💡

Name: Puneet Aggarwal, MD

What he does: As the director of Atrium Health Musculoskeletal Institute of Sports Medicine and division chief of Physical Medicine and Rehabilitation, Dr. Aggarwal specializes in non-surgical spinal treatments and interventional pain medicine.

Company: Spine First - Atrium Health

Words of wisdom: “I think maintaining strength, but also maintaining flexibility at the same time is the key.” 

Connect: Website

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Back Talk Doc is brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. To learn more about Dr. Lakhia and treatment options for back and spine issues, go to backtalkdoc.com. To schedule an appointment with Carolina Neurosurgery & Spine Associates, you can call us at 1-800-344-6716 or visit our website at CNSA.com.

Welcome. You're listening to Back Talk Doc, where you'll find answers to some of the most common questions about back pain and spine health, brought to you by Carolina Neurosurgery and Spine Associates, where cutting edge nationally recognized care is delivered through a compassionate approach. This podcast is for informational purposes only and not intended to be used as personalized medical advice. And now, it's time to understand the cause of back pain and learn about options to get you back on track. Here's your back talk doc, Dr. Sanjiv Lakhia.

One of the more challenging conditions that I often encounter in the office is that of hip versus back pain. People often will come in with pain either in the front of their hip or in the back of the hip, and it's our job as physiatrists to sort out where the pain is coming from. I'm delighted today to have my friend and colleague Dr. Puneet Aggarwal on the show to help me do just that. Puneet, welcome to the show.

Thank you, Sanjiv. It's a pleasure being here.

Awesome. Let me introduce you to the listeners. Puneet is a practicing physiatrist. How long have you been working in the Charlotte area?

16 years now. It's been a long time.

Yeah, 16 years. Long time. He's board certified in physical medicine and rehabilitation, pain medicine, and sports medicine. He specializes in nonsurgical treatments for the spine and interventional pain medicine with a focus on spine and joint injections. Puneet is motivated to help each patient achieve relief from their symptoms so they can return to their normal activities. Dr. Aggarwal is the Director of Atrium Health Musculoskeletal Institute of Sports Medicine and Medical Director of Physical Medicine and Rehabilitation. He has been named one of the best doctors in America, best physician in Charlotte by the Charlotte Business Journal, and a top doctor by the Charlotte Magazine for multiple years.

He enjoys research in the topic of regenerative medicine, and he did receive his medical degree at the Medical College of Virginia, did his residency at Baylor College of Medicine, and a fellowship at the Medical College of Virginia Commonwealth University. And more important than all that, he is a very close friend and someone at highly respect. Again, thanks for taking time to sort through this issue.

It's a pleasure, Sanjiv. Thank you for having me.

Yes. Before we started, we chuckled at the idea of patients coming in with hip pain, buttock pain and what to make of it. I kind of put it in the same category as trying to determine neck versus shoulder pain. It's one of the areas that as physiatrists I think we are probably really well positioned to help answer just given our background in orthopedic spine and neurology. I thought we'd touch base. Let's set the stage first with a case presentation, and then we'll deconstruct it.

For example, and tell me if this is one you often see, is let's say 57-year-old female who has been dealing with a fair amount of pain at times where the pant pocket would be, but also in the front as well. They get pain with standing and walking, but also sitting and sometimes can have some relief with lying down. Some difficulty with stairs. Is this something that you come across on a routine basis?

Definitely. We see that all the time in the office, and it's always tricky to figure out whether it's the hip, whether it's the back, or possibly even both.

Yeah, exactly. For the listener's sake, as I told you before, I have a combination of people who are just looking to improve their health and also medical professionals who listen to the podcast. We'll try and keep this understandable for all you guys listening, but let's break that down. Talk a little bit about the anatomy of the area of the hip. I learned through my own challenges with my hip over the last year, there's like 17 different muscles and ligaments across the hip joint. Starting in the front, when someone comes to you and they have pain let's say in the groin, what are you thinking about considering anatomically?

Well, you're certainly thinking about the hip. The hip is a ball and socket joint. It's formed by the socket, which is the acetabulum of the pelvis, and the ball, which is the top part of the thigh bone that moves in that socket. It is responsible for a wide range of movement and stability in the lower body. Abnormal movement of the hip can lead to different areas of pain in that pant pocket, but then refer into the groin area.

Yeah, exactly. We'll jump to imaging a little bit, but oftentimes we'll check x-rays and right away start to look at the ball and socket. One of the things that comes up quite often that I'll have patients ask me about is the health of their labrum. Can you tell people what the labrum is in the hip and its significance?

The labrum is the outer cartilage that lines the hip socket. It's the cushioning of the hip joint. It's like a rubber seal or a gasket that holds the hip ball and the socket. If there's a tear in the labrum, patients may hear like a pop or a click when moving their hip. Even a large tear can cause the hip joint to lock up. They may have pain when they move their hip outward or turn their hip out or even extend their hip, and that's a sign of a possible tear in the labrum.

Right. I like to think about it, and I think you know as well with your sports medicine background, that these labral tears almost similar to disc degeneration, there's a component of this where it's just an aging response versus there are patients who come in, I think particularly younger patients, who have the symptoms that you just described. You can think about that more as actually relevant and significant. Sometimes that can be a little tricky to determine to chase that or not.

Absolutely. Sometimes they have a labral tear and it may not be the source of their pain. Especially in a young person, they might have a small tear and that could just be there. It's tricky for us to determine whether that's really causing their pain or is there something else going on.

One of the ways we do that would be with physical examination. What are you looking for when you're examining someone's hip?

You're looking for pain with movement of the hip joint. They often have positive FABER sign, which is where they flex the hip, move the hip out, and turn the hip joint out, or they may also have an opposite positive FADIR sign, which is where they move the leg in and then turn the hip in. Both of those typically reproduce pain. Sometimes you can even feel a little bit of instability as you move the hip joint and that's a sign of a labral tear.

Right. Those are two exam findings that I definitely depend upon as well. Although I don't know how you feel, but I've found over my career that I get all sorts of responses when I do those tests from back pain to knee pain and other things. I'd have to look up again how specific they are for the finding, but that's a good way to start. Essentially if you're at home and you're wondering could your hip joint be a problem, one of the things that I'll ask from a history perspective would be, do you have pain when you go up steps or get your leg in and out of a car, because some of those movements can reproduce what you just talked about.

Yes, that's correct. Pain going up the stairs, getting out of the car, pain with walking uphill. That often will cause pain as well.

Yeah, I think those are definitely standbys. One thing that I'll look for is just observing how someone will tie their shoe. A lot of people will just put their ankle on top of the other knee to tie their shoe. My experience has been if you truly have a hip joint problem, that can be quite difficult for you.

Yes. The other thing I often see is a patient presents holding their hip with like a C, so their fingers are in front of the hip joint and their thumb is behind the joint and they're just kind of holding their hip like they're trying to hold it in place. Typically, if they'll walk holding their hip like that with a C around their hip joint, that's a sign that the pain is probably coming from the hip joint itself and not from elsewhere.

That's a great tip that I haven't stumbled upon or read about in the literature, so maybe we can claim that as the Aggarwal sign.

I think I did read about it somewhere, so I don't think I can claim that. I don't want to get in trouble. I definitely see it sometimes when we see patients walking around and just walking with a C.

Now, shifting gears to pain in the buttock area, that back pocket so to speak, that almost is more common to me than the pain in the front. When someone complains of pain in their hip, they say, "My hip hurts," I always say, "Can you point to what you're talking about?" I would say probably three-fourths of the time they're actually pointing to the buttock area, the gluteal area. Share some of your thoughts on what's going through your head both from an anatomical basis and maybe a history exam basis when someone has buttock pain.

Well, when someone has buttock pain, I think of the most common cause is likely the back, usually the spine. Usually the lower lumbar spine area can refer into that gluteal area and cause pain. I ask them if they're having pain sitting or standing. If they're having more pain walking around, then that could be the hip because there's weight bearing on the hip. But if they have pain more sitting, then I think it's probably more likely coming from the spine because the hip isn't really supporting you at that point.

There's not a lot of weight bearing on the hip. Just the typical history can tell you a lot about where the pain is coming from. Certainly on exam, having them bend forward, bend backwards, having them move around and see how they can move their spine or their hip can tell you a lot about where the pain is coming from.

Right, I agree with that totally. Now, I don't think it's 100%. In fact, one of our former colleagues I believe published a paper where they looked at doing some diagnostic injections in the hip joint and looking at referral pain patterns, and they found up to 20% of the time buttock pain and even a small percentage of the cases they had pain going down the leg mimicking a sciatic nerve distribution. Certainly medicine is not black and white. But in general, if it's in the back, so to speak, the back of the hip, I think spine. If it's in the front, I think joint. What are some of the let's say key muscles in that area that also you think could contribute to pain in the buttock?

Well, certainly the gluteus muscles contribute a lot of pain in the buttock. We often have weak glute muscles. Our trunk muscles aren't often very strong because a lot of us spend a lot of time sitting and that can lead to weak gluteal muscles and that can refer pain into the area. Some of the other muscles like the hip flexors may refer pain in the front, but sometimes they can refer pain into the back as well.

I agree with that. Now, the other one that I'd say joint wise would be the sacroiliac joint. Not to go back and look at my catalog, but I talked about this a little bit. If you're listening and you haven't heard, it was one of my first episodes where I talk about top causes of non-disc related back pain, but the sacroiliac joint is definitely a big culprit for a lot of people for just the reasons you mentioned, people sitting, weak glute muscles. Particularly in women, just the wider dimensions of the pelvis can put more stress and strain on the SI joint, which is basically what I tell people is where the tailbone meets the hip bone in the back.

The SI joint is a tricky joint. As you mentioned, it's where the spine meets the pelvis. It doesn't move very much. But if it moves little or moves too much, that can lead to the pain. I often find these patients have pain when they get out of the chair and try to move around, especially the first few steps are often difficult, but it's not an easy area to diagnose. There's many different tests and none of them are very specific to making the diagnosis. We oftentimes have to rule out other possible causes of pain when we're diagnosing the SI joint as the possible cause.

Right. I agree with that. The best way to determine if it is the cause is to inject it with some steroid and anesthetic and see if someone gets better, which on the scale of risk, that is a very low risk procedure for most people and can provide some fairly immediate feedback. I do a fair amount of those. One of the things when you're talking about hip pain that can be tricky, and I want to get your thoughts on it, is the idea of pain in the knee. Do you ever see the hip joint refer pain into the knee?

Yes, often, particularly the outer part of the knee. The iliotibial band or the IT band runs from those glute muscles on the outside of the hip joint down to the side of the leg and down into the side of the knee. Oftentimes patients may have a tight IT band and then that causes pain not necessarily in the hip, but actually down in the outer part of the knee. That pain usually can occur when walking, running, that can actually make it worse, and a lot of times just doing the right type of stretching can help that.

Just to illustrate for you guys listening, what he just said, how challenging it can be to sort this out. When you come in, if you've got pain in your hip and knee, it could be coming from the joint, it could be an irritation referral pain from the muscles going down the side of the leg, but there's also the lumbar nerve roots, the L2 nerve root, the L3 nerve root, SI joint. It can be a very complex issue. If you've been struggling with this type of pain, don't give up hope. You need someone who can really help tease it out and sort it out.

As he just said, there's muscular sources of pain that are quite often. Now, you mentioned the IT band. I would kind of put an asterisk or caveat on that. This is not the same thing though as IT band syndrome that runners get, correct?

Correct. This is more IT band tightness, but not necessarily the syndrome.

Correct. All right, so that's pretty good. You broke down for us the groin pain, the glute pain, the referral pain pattern. Let's say you've made a diagnosis and you feel like this patient that came in earlier is truly a hip joint problem. Let's move into some of our specialty here, which are the rehab principles. What are you thinking about if you're writing a PT or physical therapy prescription, what are some of the things you've seen be helpful for people?

Well, most patients with either hip or back pain present with tight muscles. Doing some stretching and strengthening of the glute muscles, the gluteus medius, minimus, maximus, those are three muscles of the buttocks, can really be helpful. Also, stretching out our hamstrings can be helpful as well. Many of us sit for work and we have as a result tight hamstrings because they stay constantly contracted and that often leads to back and hip pain.

Stretching those muscles out and try to strengthen them at the same time can be helpful. The hip flexor itself also plays a role in hip pain. The iliopsoas muscle, which is our primary hip flexor, allows us to mover leg forward, can be a source of pain and making sure that that muscle's loose and flexible is important to limiting both hip and back pain.

Yeah, that's terrific. I think you checked all the boxes there on what goes through my mind. I think from an exercise perspective, like actually what helps people, if we're talking about I think pelvic or glute bridges, monster walk side steps, all this resisted band work. My physical therapist in our Rock Hill office, Tanner, he turned me onto a program called Crossover Symmetry, and we'll link to them in the show notes. They have a real nice, very comfortable exercise band, resistance band that you can put around your ankles or around your upper legs and they walk you through some of these exercises.

You can download it on a video. Of course, there's no substitute for getting personalized care by a physical therapist. But you're correct. I think inhibited glute muscles plays a huge role in dysfunctional hip joint movements. If you're having pain in the front of your hip, you likely have weakness in the back of it, so getting that strong, as well as the hamstring and psoas work. It just really is important to have a good physical therapist who can look at you, see what your muscle imbalances are, and have a very customized exercise prescription.

Absolutely. We're all built a little differently, and seeing a physical therapist and assessing where your weakness is, where your muscles are tight, and then coming up with a good exercise program can be really beneficial. Going back to the glute strengthening, I also am a big fan of wall squats or even just air squats and strengthen the glute muscles that way. Even if you can't go all the way down, just going down a little bit can be beneficial.

Some of my patients who may be a little bit older and aren't able to do squats, I tell them try to just sit down on the couch and just go as far as you can and then stand back up. If you go too far, you're going to sit on the couch anyway, so you're not going to get hurt, but that way you can work your glute muscles without putting a lot of stress on your glutes and you do it in a safe environment.

Puneet, that's an excellent tip. I really like that. It speaks to the idea that we don't all have to perform the exercise to the same level. If you're doing a squat with a chair behind you or a couch behind you, you're not going to get as deep, but it'll still be very effective and you can preserve your knees and your ankles. And then what you're referring to with the wall squat, I'll recommend that as well because you can basically do what's called an isometric contraction. This is where you're contracting your quads and your glutes, but they're not changing their length, so you can use the wall for support.

Although I would say if you're going to do that, do not do that with socks on on a slippery floor because you can end up slipping or falling. But the there's really all sorts of modifications that can be made. If you're struggling with it, don't be discouraged by exercise causing discomfort. Just get with someone who knows what they're doing and there's so many different variations of things. One muscle, I don't know if we touched on that, also can be quite important to some of this is the piriformis muscle. The piriformis muscle is a deep external rotator and it abducts the hip or moves it out and oftentimes can be a source of pain. Do you have experience with piriformis syndrome in your practice?

Absolutely. I see a lot of patients with piriformis syndrome. It's, again, a very difficult area to diagnose because it refers pain from the buttock into the back of the leg. Sometimes we may think it's coming from the spine, but sometimes pain is just coming from the piriformis muscle itself. Personally, it's a hard muscle to stretch out. It's not very easy. It's a small muscle, but it causes a lot of discomfort and it's not easy to stretch.

I would agree with that. Tight piriformis, very, very common, I think it's because of some of the factors that you elaborated on earlier, which is sitting a lot driving, desk, computer workstations, et cetera. It can be something that you have to stay on consistently. Every now and then, I'll do a requested piriformis block where I'll inject it under ultrasound. I try not to put too much steroid in a muscle, but the ultrasound guided injection can give us some diagnostic information. I do feel like piriformis syndrome is a bit more common in women and, again, probably due to the dimensions of the pelvis, but it's not exclusive.

I think it's just part of a comprehensive rehab program if that's something that we feel like you're suffering from. One asterisk to that diagnosis though, and I'll get your thoughts on it, you mentioned the piriformis when it's irritated or inflamed can refer pain down the back of the leg. I feel like for every 10 patients that maybe a physical therapist sends to me for treatment of piriformis syndrome, five to seven of them actually have an S1 radiculopathy or an L5-S1 disc issue irritating their S1 nerve root, which goes down the back of the leg. Do you feel like you'll pick up that sometimes as the piriformis diagnosis could be not complete?

Absolutely. I think that's what makes diagnosis in piriformis difficult is sometimes we label everything in the buttock piriformis and it's hard to figure out what's truly piriformis and then what's actually an S1 radiculopathy or an L5 radiculopathy. Usually when it's going down the back of the leg, I would agree with you, most likely it is radiculopathy, but occasionally it can be the piriformis. More times than not, it would be radiculopathy. I would agree with your numbers about five to six out of 10 is probably more likely radiculopathy.

All right. Circling back to our case, let's say she's come in, you thought it was hip joint. You set up some PT. She comes back to you. She's made some progress, but still having some discomfort. You're ready to do some diagnostic workups, some imaging. What are your thoughts on what's available to help us figure these things out?

If you're thinking of a hip issue, usually you can get an x-ray. If you're thinking osteoarthritis, a weightbearing X-ray can help you determine if there's arthritis in the hip joint. But if you're looking for something more involved like a labral tear, you probably need an MR arthrogram, where they inject contrast in the hip joint and then shoot an MRI. Nowadays, though, there's 3T MRIs that often can show a labral tear without having to inject contrast in the hips.

That's a newer thing that makes it easier to get an MRI, because you don't have to inject contrast in the hip joint and worry about those issues. If you're thinking of a muscular issue, then ultrasound can often be helpful to look for a possible tear or even tendonitis on an ultrasound.

Yeah, I agree. In the Charlotte area, I think we have fabulous radiology services, that 3 tesla, 3T MRI. Patients love it. Avoids the injection of contrast in the hip. And then there's a good point there about the diagnostic ultrasound. There are some other clinical entities like snapping tendons in the hip and diagnoses that can be made only on movement-based imaging, and that's where musculoskeletal ultrasound can be quite phenomenal in helping find a diagnosis.

The key take home there is there are a fair number of imaging options to look at the hip joint, but most of them, I would say in general, aren't needed beyond the x-ray. If you're in the older age bracket, we're really looking just for degenerative problems. Let's say you got an x-ray on this patient that came to you and it looks like there is some degenerative issues in the hip joint. What are some of the injection options that you offer?

Usually we do a guided injection into the hip joint itself, intra-articular hip joint injection. Typically, I myself perform it under x-ray, but also can be done under ultrasound as well.

You're talking about cortisone mixed with some anesthetic, right?

Yes. I'm talking about a steroid injection into the hip joint.

What would be a reasonable expectation for someone who gets one of those?

Well, steroid injections aren't going to take all the pain away, but I think a reasonable expectation would be about 50 to 75% relief in their pain. And then with all steroid injections, the key is once the pain is better to focus on exercises and even physical therapy to help treat the underlying cause and then have long-term pain relief.

That's absolutely key. I'm glad you said that. If all you do is come in requesting an injection, you've put out the fire temporarily, but the biomechanical factors that Dr. Aggarwal just discussed for us in great detail, if those aren't addressed, you're just going to end up probably in the same spot you were in about three months. Now, you and I both know all the rage in the last maybe five years and gaining steam in the last two years has been the idea of biologic injections into the joint.

Everyone wants stem cells. You cannot listen to the radio without a commercial for some practice advertising regenerative injections. I know we could probably spend an hour on this topic, but give us your just initial instincts and thoughts on the evolving field of biologic options, regenerative options for, let's just keep it simple, for mild to moderate hip arthritis.

That's a tricky field. Like you mentioned, it's evolving and what we know now may change in a couple years as we get more research about regenerative medicine. Currently, there's no great data to show that stem cells into the hip joint would regenerate the hip joint. But there's case studies where patients have had mild or moderate arthritis in their hip joint and they've had either PRP, which is plasma-rich therapy, where platelets are injected into the hip or stem cells and gotten some benefit. But these were very small studies and we still need large studies to really see if this is something that can be used widespread.

I think I share a similar view. For the hip joint, hip arthritis, I've done a handful of PRP injections. I've done a handful a few years ago of some amniotic fluid injections, and my results I think have been unimpressive for that diagnosis. Where I've seen the PRP in particular be quite effective are with the muscle tendon issues around the hip. Very common, partial tears of the gluteus tendons at the trochan or the side of the hip, the bone that you can feel on the side of the hip, I see ultrasound guided injections for that to be really effective. After about three months, people seem to have a fair amount of relief.

To me, that's a really good application of regenerative medicine where we don't really have good other options. Nobody wants a hip replacement. But if you're in your fifties, sixties, seventies and you're having a lot of pain, you have moderate to severe hip arthritis, the hip replacement has become I think so effective for a lot of people, and the rehab times are far shorter than when you and I were in training.

Absolutely. I think the surgery itself has been refined so well, and there's been so many surgeries. I think they do a really good job of knowing what to do both before the hip replacement, so prehab, strengthen the area, the surgery itself, and then the therapy that's needed after. There's good results from hip replacement. I think if you really have severe arthritis, I don't think a stem cell injection or PRP is going to help you. But as you mentioned, if you have more like a muscle tear or tendonitis, that's where some of those biologics or regener medicine can be effective.

I think that's a responsible approach to it. One thing that just occurred to me that I definitely want to touch on, be remiss if I don't, is the role of EMG and electrodiagnostics in trying to evaluate patients coming in with buttock pain and hip pain. Can you share with the listeners just at a high level what an EMG actually is and then how it can be helpful in this process of figuring things out?

EMG or electromyography is testing the nerves as they leave the spine. In this case, we're looking for whether it's a pinched nerve in the back, or whether there's an issue with the local nerves in the area. The test is performed by performing little bits of electrical stimuli in the nerve and seeing how the signal is carried along the nerve. If there's a breakdown along the nerve, then we're going to see abnormality on the test. Patients who come in with hip pain or groin pain or buttock pain, the test will really help us determine if there's a nerve ideology that's causing their pain, whether it's a pinched nerve in the back or a local nerve in the area.

Yeah, exactly. Let's just be honest, it is uncomfortable, but it's tolerable. Hey, that's probably the number one question I get from people is, does it hurt? I think it's a little bit uncomfortable, but it's very tolerable. The nice thing about EMG is we interpret that in real time. We have results right then and there that we can share with people.

Exactly. I agree. It's a little uncomfortable, but it's definitely tolerable having had it on myself. You get the results right away, and it gives you an idea of what's going on with a nerve as well. Not just that there's a nerve issue, but is it in the healing stage, is it still in the injury stage, or is it a little bit of healing and recovery stage.

Well, I hope this gives y'all out there with hip issues a little bit of food for thought. I think Puneet has done an amazing job breaking down everything from the anatomy of the hip joint, how it can present in many different manners, some of the diagnostic imaging that we consider for people, and just even some of the treatment and rehab options. Now, as we close the interview today, before I let you go, I know you're an avid runner. I see you running around the neighborhood, putting me to shame every weekend. What are your thoughts about the hip joint and running in general? If someone has a little bit of arthritis, are you pro or con slowing that running down?

I had this debate with my father all the time who keeps telling me that I should stop running because my joints are going to wear out. My response to him is that if I did nothing, my joints would probably weaken and that would be actually worse. I think maintaining strength, but also maintaining flexibility at the same time is the key. I like to run, but I do spend a lot of time stretching as well.

Usually in the evenings after we put the kids to bed, my wife and I watch a show for an hour and I'm on the floor the entire time doing stretches. I think you want to stay active and keep your muscles strong. Sometimes learning the right stretches and the right exercises are key, but I think that's much better than just sitting around and the muscles weaken and you actually have more issues.

Yeah, I agree with that. In Cincinnati, I had a partner who would run those races that were 50 miles or even 100 mile races. Just crazy, crazy distances. He looked amazing. He's in his late fifties, early sixties, Bobby Whitten, just amazing physiatrist, amazing person. I decided to look up a little bit the research on running and joint degradation. Surprisingly, there's very little published evidence and data to suggest is problematic long-term. I think for acute injuries, it certainly makes sense for a load-bearing joint like the hip to involve some degree of rest.

But in terms of people who run versus those who don't long-term how do the joints turn out, I don't think there's convincing data either way to have an answer. As you said, you've got to move your body. You've got to maintain strength and flexibility. I also know for you there's probably, I'm going to guess, a significant mind-body component to being able to go out for an hour or two run, time to yourself, endorphin release and stress relief.

Absolutely. I really enjoy running. In every run, the first mile or so, I'm like, "I want to stop. This isn't going to happen today." And then after that mile or two miles, it feels great. You feel on top of the world. You're running. It's just you and the road and you just get to relax. For non-runners, that sounds strange, but it's a great endorphin release and it's a lot of fun.

That's awesome. All right, well, thank you so much for your time. We're going to link to your practice in the show notes. I know you have a couple offices in the Charlotte area, and we'll put your contact info in for any people listening that feel like they want to come in and get an evaluation by you and they certainly can connect with you. I appreciate your time and I really enjoyed it, Puneet.

Thank you, Sanjiv. Thank you for having me. This is an amazing podcast. I'm sure a lot of people find it helpful, but I appreciate you having me today.

Thank you.

Thank you for listening to this episode of Back Talk Doc, brought to you by Carolina Neurosurgery and Spine Associates, with offices in North and South Carolina. If you'd like to learn more about Dr. Lakhia and treatment options for back issues, go to backtalkdoc.com. We look forward to having you join us for more insights about back pain and spine health on the next episode of Back Talk Doc. Additional information is also available at carolinaneurosurgery.com.