3 pain tests to help diagnose PHT (a 2012 paper)

: On today's episode, three pain tests to help diagnose proximal hamstring tendinopathy. Welcome to the podcast helping you overcome your proximal hamstring tendinopathy. This podcast is designed to help you understand this condition, learn the most effective evidence-based treatments, and of course, bust the widespread misconceptions. My name is Brodie Sharp. online physiotherapist, recreational athlete, creator of the Run Smarter series, and a chronic proximal hamstring tendinopathy battler. Whether you are an athlete or not, this podcast will educate and empower you in taking the right steps to overcome this horrible condition. So let's give you the right knowledge along with practical takeaways in today's lesson. Hey, we are doing another episode based on a research paper and it's going to be a quick one. I thought it might be interesting for you guys to know, especially when it comes to a diagnosis of PhD. I do have another one. There's a paper that's come out last year, which I'll delve into for the next, I guess, research episode that I do or the literature episode that I do. But this one was in 2012. And it was titled the reliability and validity of three pain provocation tests used for the diagnosis of chronic proximal hamstring tendinopathy. Angelo Caccio, I wanna say is, and colleagues were the ones who published this one. And they start off in the paper, I guess, like the intro, they say that the clinical assessment of chronic PHT, in athletes is a challenge to sports medicine. To be able to compare the results of research and treatments and methods used to diagnose and evaluate PHT must be clearly defined and reproducible. And when it comes to sort of tests, when it comes to being a physician or a health professional or a physiotherapist, we wanna try and find tests, clinical tests that we can do for someone. to help increase the odds or the likelihood of it being a certain condition or the odds of us ruling out a certain condition. And you'll probably notice if you've been to a health professional before, they'll ask a bunch of questions about your injury and about the nature of your injury, how you first got it, what the behavior of the pain's like, what the location of the pain's like. And then they'll do some tests. They'll either do some strength tests or try and produce the pain in a certain way. or just some really funny, awkward position type of test, just to help gather data, help gather information to point to a likely diagnosis, if a diagnosis is needed. And we wanna make sure the tests that we do accurate at interpreting or helping us predict whether this is the condition or not. So an example would be to say we have someone who we suspect has plantar fasciitis. And we asked them to one test that we could get them to do is like take their shoes off and hop on the spot. And if it's painful, uh, what's the likelihood of it being plantar fasciitis? Because I think, um, that most people who have an acute bout of plantar fasciitis, if they were to hop, then that would be extremely painful. And so we could say, yes, this amongst other tests, um, increase the likelihood of it being plantar fasciitis, but there's the other side of the equation that we need to consider, which is, um, does it might rule in a, um, plantar fasciitis, but does it also rule in other conditions? Um, an example being like a stress fracture. If someone has a stress fracture of the metatarsal of their foot, hopping would also be painful. And so this is why we have tests to either rule things out, rule things in, um, and we use the terminology of specificity and sensitivity and a test will have a certain score or a certain likelihood of it being specific or of it being sensitive, meaning that if something is specific, if the test is positive, what is the likelihood of that certain diagnosis being the case? And so if something is really specific, I would say the hop test, if I'm making things up on the spot. I'd say a hop test isn't specific at all because it can be positive, but it can be like that hopping test can be positive for a whole bunch of other conditions as well. Like you could get pain with, um, if you have a toe arthritis, if you hop on one side, so just coming up with that example on the spot, that'd be a very poor choice. But the sensitivity, if it's negative, if you do a test that's meant to produce pain and it doesn't produce the pain, what's the likelihood that we can rule out that condition. And so if we follow the example of plantar fasciitis, if you were to say, passively pull back on the big toe, like if the therapist like me is the physio, if I was to get the patient on the bed and I was to get their big toe and pull it back and kind of stretch the fascia, and someone was to say to me, no, it doesn't hurt at all. So that's a negative test, but what are the odds that now that is negative for the odds that they don't have plantar fasciitis. So that's where the sensitivity comes into it. So if that's gone over your head, that's okay. We'll continue with the paper, but I just thought I'd lay out that when it comes to the science and when it comes to health professionals, this is the, these are the terminologies and these are the tests that we use and it's very important that it does have a high specificity. or a high sensitivity to point towards a diagnosis. So the paper talks about, they say, typically the diagnosis for PhD, so what they've used in the past, has been based on a typical MRI finding combined with the exclusion of other conditions that may cause similar symptoms. And they use the examples of piriformis syndrome, which is more of your glute muscles. lumbar sciatic pain, so something that's referring from the back can refer down into that kind of hamstring region. Ischial stress fractures, so a stress fracture of the bone itself. Ischial gluteal bursitis, so it's going to be a bursar rather than the tendon. And a proximal hamstring strain injury, so the muscle being affected rather than the tendon. And so they say that typically in MRI... can be used to rule out a whole bunch of these. And if they have identified some pathology with the tendon, that's the accurate diagnosis. So that's kind of like the gold standard for diagnoses. The paper goes on to say that, however, no studies have yet assessed the association between pain provocation tests and the final diagnosis. The aim of this study was to describe three pain provocation tests. that are regularly used in combination with the MRI findings for the diagnosis of PHT to assess its reliability. We will also assess the validity and to assess its sensitivity and specificity using the MRI as a criterion measure. And so essentially what they do is they get a whole bunch of athletes, they put them through these three pain provocation tests, which I'll talk about in a second. patients do have PHT, some of them don't, and then we have a look at them afterwards to see how accurate those tests were at predicting PHT with an MRI. So later on they'll get scans and say, oh they did have PHT. Oh, how did they go with those assessments? So the three tests that they used, which I think I might include in the show notes, I think I might put in like a YouTube link. I'll try and describe the best I can what these tests are. but I might include the link in the show notes anyway, so that you can click on it and watch how this test is performed. So the first one is called a Purainen-Oriva test, which is, it's kind of a funny term. I haven't really, I hadn't heard of it when I was a physio. I thought of it as another name, but this is what they used in the paper, which I'll include in the show notes. But this test, let me see. So the article says that the test, Maybe I don't go off what the article says. Let me just describe it. So if you were to stand and you were to have like a couch or a bed in front of you, you just get that affected leg. You put it out in front, like you put the leg on the bed, keep it nice and straight and you just stretch forward. So it's almost like a very generic hamstring stretch. And what we're looking for is the, we're looking for pain provocation in that area that you're describing. in high up on that hamstring region. The leg needs to be straight and the foot needs to be supported. And then we're just bending forward. So classic hamstring stretch. The next one is the bent knee stretch test. Now you can't do this yourself. You need someone or a therapist to do this on you. So with this bent knee stretch test, the patient lies on their back. with their legs out straight. And then what the therapist does is they take the affected leg and they bring your knee to your chest. And then while your knee is to your chest, they slowly straighten out the leg. But they so they straighten out the leg, but they keep your knee to your chest. So it's almost like another hamstring stretch, but we call it passive because someone else is moving your leg. So that's the second one. And the third one is what we call which is the exact same procedure as what I just described above, but there is a bit more of a rapid extension. So the therapist brings the knee to your chest very slowly, but then when it comes to extending the leg and straightening out the leg with the knee close to your chest, it's a lot more quicker, it's a lot more forceful. And so that's the three tests that they described. And so the method, So 92 athletes with, I think, so they said 46 of them had PHT and 46 of them did not have PHT. They were examined by a physician and two physios who were trained at examining these techniques before the study. The examiner, all the examiners were blinded to the athletes and which ones did have PHT and which ones didn't have PHT. And then they did these three tests. compiled the studies. And so it's important that we do bias or no, it's important that we do blind these therapists, because we don't want any biases creeping in. And so they ask these athletes how they feel, whether there's the whether it's producing their symptoms, and then they make the accurate assessment or they try and make the assessment whether they do have PhD or not. And then little do they know that they've diagnosed them with PhD or not PhD through MRI, and then they see how they guessed, they see how they fare, and so that can determine the effectiveness of these tests. And so let's get into the results. This podcast episode is sponsored by the Ransmata Physiotherapy Clinic, which is my own physio clinic where I help treat a wide range of PhD sufferers, both locally in person. and all over the world with online physiotherapy packages. In the years I've been self-employed as a physio, close to 70% of my entire caseload has been helping people with proximal hamstring tendinopathy, which is why I decided to launch this podcast. So if you're building upon your own rehab knowledge through the podcast, but still require tailored assistance, I'd love to be on your rehab team. Whether you are a runner or not, head to runsmarter.online to see your available options for working together. If you're still unsure if physiotherapy is right for you, or if you need a rehab second opinion, you can always schedule a free 20 minute injury chat with me. Find the free injury chat button on my website or in the podcast show notes to be taken to my online calendar to book in a time. Okay so the results. The paper says that the values of all three tests revealed a high correlation for the and a high to very high correlation for the intra examiner reliability. And so this is how reproducible the test is when the same therapist does it to different patients, but also how reliable and repeatable this test is when different therapists do the same tests. And so it shows it's high and very high with both of those. All three tests displayed a moderate to high validity. with the highest degree of validity being yielded by the modified bent knee stretch test. So the one that's a little bit more rapid when you straighten out the leg. In conclusion, they say that all three pain provocation tests prove to be a potential value for assessing chronic PHT in athletes. However, they recommend that it's used in conjunction with other objective measures, such as an MRI. Do I think the MRI is necessary? Look, if you're an elite athlete and need to get checked out, need to get diagnosed, then if you have that available, it might be okay. But there are a couple of downsides, which I think if you've listened to a lot of these episodes, you probably know where I would go with this. But the MRI itself is, first of all, it's expensive. So it is a bit of a hit to the pocket. But also they can find a whole bunch of incidental findings that might spark a bit of anxiety or... if not interpreted correctly or if not explained to you in the proper sense, um, could lead to a lot of fear, a lot of worry, um, associated with it. And I know in the past I've had, say someone with PhD who does get an MRI and they MRI both sides and they show there's a lot more tendon degeneration, a lot more tendon fraying, a lot more tendon effects on the unaffected side. And so, um, that leaves a lot of puzzled people to be like, well, why is my unaffected side showing all this degeneration and showing all this pathology? Well, sometimes tendon degeneration is a normal finding. If you're in your 40s, if you're in your 50s, this is quite normal of a finding. But if it's not explained to you in the right sense, that can spark a lot of fear. And so if people MRI just only their affected side and the MRI shows this proximal hamstring tendon has a lot of fraying, a lot of degeneration, a lot of thickening, maybe a tear, it can spark a lot of fear, which it might be an incidental finding. And so there's a lot of downsides to getting the MRI because the way it's communicated, I know I've explained this several times, but when it comes to the radiographer and the clinician actually writing out the report, they don't know what you're like as an individual, they don't know the symptoms that you're going through, how severe it is, all they do is look at what's on the screen, they look at what's on the film, and then they write what they see. And there's no correlation between symptoms and what they find. And so when it's relayed back to you, sometimes the health professional and the GP just read out what's on the page and that can have a lot of downsides. So be careful with that. I thought I might add in also some tests that I use. I'm not sure what the literature supports with its validity and its accuracy, but I like to use the shoe off test when it comes to PHT. And simple in standing, just a lot of people would know without using your hands, standing up tall, how you can slide your shoe off. You sort of dig your heel into the front of your other foot and slide off your shoe and do that with the other side. And what that does is grab the hamstring when the... It's in a little bit of compression, engages that hamstring, that produces a lot of pain, starts to increase the likelihood of it being PHT. There's a couple of other tests I do, like a hip extension test. So if you're lying down on your stomach, keep your legs straight to try and lift your foot in the air, still lying on your stomach, that grabs or if that produces your symptoms, most likely increases the odds of it being PHT. But we also combine the whole bunch of the other tests. So you might do these stretch tests that I described. You might also in the subjective assessment, look at the behavior of symptoms, look at the onset of symptoms, like when it first happened, was there any training errors, where the pain location is, what the response is like to loading. So you might get them to do some deadlifts. or some lunges and see what symptoms are like. And just a combination of all these tests, all whittled together, you kind of sift through them, interpret them and as you compile them, come up with a proper diagnosis. And so that's kind of what I'd use. And yeah, I think after reading this paper, I'd probably do a lot more of these stretches as part of my repertoire in terms of the diagnosis. Um, so that's it for, um, for this episode. Like I said, it was a bit of a quick one. I will add all the links in the show notes. Um, coming up, I'll see what I've got in my to do list. Um, we'll talk about in the next couple of episodes, things to do with under training, um, as, uh, sorry, under recovering as well as over training, um, some things to do around your strength and conditioning and yeah, like I said, that other paper, um, The paper is around like expert physiotherapists and talking about diagnosis management and prevention of PhD. So in the next, um, research paper episode that I decided to do, I'm pretty sure it's going to be that one. All right, guys. Um, good luck with your rehab. Hopefully you're enjoying every episode. Um, I love seeing, uh, hearing from you guys on Facebook and reaching out on social media and saying how much of an impact it has had. Um, so yeah, I'm glad that you're enjoying and we'll catch you next episode. Thanks once again for listening and taking control of your rehab. If you are a runner and love learning through the podcast format, then go ahead and check out the Run Smarter podcast, hosted by me. I'll include the link along with all the other links mentioned today in the show notes. So open up your device, click on the show description, and all the links will be there waiting for you. Congratulations on paving your way forward towards an empowering, pain-free future, and remember, Knowledge is power.