A 2023 Review of PHT Treatment

: On today's episode, a 2023 review of PHT treatment. 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. I'm an 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. First of all, a big thank you to Said for sharing this PhD paper that I'm about to discuss with you. Sorry, it took me so long to get to it. I just checked. It was February when you sent me this and I appreciate you Said. I appreciate everyone for reaching out because I've had a few people suggesting topics and sending me papers and those sorts of things. Really appreciate it. Just creates a good sense of. We're in this together, let's get the right information out there. And yeah, I hope you've been enjoying the content so far. Hopefully this has helped a lot with your rehab. Um, I decided to, uh, dive into this particular paper for this episode. The title was comparisons of conservative interventions for proximal hamstring tendinopathy, a systematic review and recommendations for rehabilitation. And so Let's break that down. Usually when it comes to these papers, the titles are quite lengthy and yeah, thought it'd be easier if we break it down. So it starts with a comparison of conservative interventions. So we're not look, usually we consider conservative as meaning not surgical. So if we're not operating, what else will be doing? That's usually conservative interventions. Um, it's a systematic review, which means they don't conduct the they don't find participants and have them go through the study themselves. Instead, the authors of the paper try to find a common aim or a common purpose and look at all the other papers that have already been published on that specific purpose, and then compile them all together to see if there is a strong correlation or a strong narrative or just evidence behind moving in a certain direction compared to another. And so when compiling all these things, the authors have developed recommendations for PHT rehab. Hope that made sense. So in the paper itself, the aim is to, while they said the aim is the purpose of this review is to provide insights into the efficacy of conservative therapeutic interventions for the management of PHT. Nothing new there. The design was Essentially what they do is they scan certain databases and they list all the databases, which isn't really that important for this episode. But they've gone and searched for those studies and they look for studies assessing the effectiveness of conservative interventions and compared that with a placebo or comparing them with other interventions. So other combined treatments and trying to see if they get better through function or reduction in pain or return to sport, looking at those sort of outcomes to know that they are getting better and which one is more superior. So the studies that performed conservative management, which was exercise therapy and or physical therapy, they did that in adults ranging between 18 years of age and 65 years anything, any age bracket or sample size outside of those parameters were excluded from the study. The studies that performed surgical interventions and those who had like a complete rupture or an evulsion of greater than two centimetres were also excluded from this study. So we're not looking at ruptures, we're not looking at surgical interventions, we're not looking at evulsions of those sorts. And avulsion is just when a bit of the bone also detaches away when there is trauma. So if there is a pull on the tendon rather than the tendon itself being, um, torn or having a tear, the bone that's attached to the tendon actually breaks off. So they would exclude those if that they were found in studies. And so they reach out, they see all these available papers, they pull them all in and by the end of their criteria, going through their criteria, they've ended up with 13 studies included. So five of those studies were exercise interventions, while eight of the studies looked at what they call multimodal approach. So that had exercise with shockwave therapy, it had exercise with other modalities, such as ultrasound, trigger point needling, or other. soft tissue mobilization techniques. And I dubbed a little bit deeper into the study, because there's not a lot there's not a lot of studies here, they only had five randomized controlled trials. So that's not a lot. They said they found 13 studies, but only five were high quality, you could say two of them, but case cohorts, and six of them are case reports. So they're not randomizing people, they're not really systematically going through a regimented system. They're just gathering people, putting them through an intervention and seeing what the effects are like. So we do need to be very careful with interpreting the findings with how good of a quality those findings are, which, you know, I'd say you could find a fair bit, but it's not like a massive. systematic review where they found 30 papers. And if you haven't really caught on to previous episodes and realised this, there's not a lot of research when it comes to PHT for whatever reason. There's, you know, more and more stuff emerging as it becomes more and more recognised. But if you go looking, you're not going to really find a lot. Let me pull up the paper because I want to go through the sort of specifics around the design. um, what people were included and all those sorts of things. And now that I've hit record, I have lost the paper in front of me. Okay. Now I have it. So, um, I had page five, let's zoom in. Okay. So the first thing I want to do, so I have a list of all the studies, those 13 studies that were included and I've got the age groups, I've got the genders. I've got the, um, activity level of people. So just as a general sense, because you know, it's good to know if 90% of these are male and 10% of female, you'd want to know that if they looked at weightlifters rather than runners, you'd want to know that. So just putting out there, I've got some studies here. It seems like there is a bit of a mix, an even mix between male and female. I have one study which had 41 females and 22 males. Then I have another study above that, which is kind of the flipped it, 27 male, 13 female. Bigger studies, 32 female, 68 male. So sometimes in these studies, they've heavily biased one particular population. This one, in terms of male, female, they've done pretty well. In terms of ages, I see ranging between one study 16 and 43 years old, 14 and 49 years old. Some older, one study looked at a 69 year old and a 71 year old, they were two males. So yeah, and then the activity level, I'll just go through the list. We have ultra marathon runners. Let me go through where the big studies were. So we looked at the sample size. here, there's about 63 people in this study and they're all runners. So that's good. 4050 people in this study. And there was a mixture of a whole bunch of people. Another big study just looked at track and field athletes. Some of the smaller studies had powerlifters and triathletes. We have recreational runners. So I would say mostly athletes that are around runners or ultra marathoners or track and field, and not so much to do with team sports, not so much to do with. gym goers, I have one power lifter, but that's one person in one study. So hopefully that gives you a bit of a sense of, you know, who we're actually studying and who we're looking at the effects of. And so yeah, let's go through the results. The results have a bit more of a visual element to it, but I'll try my best to describe what we're seeing. In terms of interventions. So every study, everything that they looked at needed to have strengthening as an intervention. Some just had strengthening and they're comparing different strengthening approaches. But then some include stretching, some include lumbopelvic stability, which is essentially like core strengthening. Some had other modalities such as shockwave and needling. Needless to say, everything that included things that weren't in strengthening, strengthening had to also be included. So strengthening was in every single one of these studies. Let's look at the, they've got a graph here of the top five strengthening exercises, and then also compare that to like the quality of evidence. And so I'm okay with this. There's, you'll see what I mean. So the five top exercises used when they pile all these together. One, a single leg RDL. Two, the Nordic curl. Three, the lunge. Four, a foot catch. And five is a leg curl. So I actually don't I was actually going to look this up before I actually hit record. Because I don't know what they mean by a foot catch exercise. a single leg catch or a foot catch. If I was to look up a foot catch, essentially what someone's doing is lying on their stomach, both feet are, both knees are at 90 degrees. So you're in kind of like a, there's no weights or bands or anything included. You've just on your stomach, knees are both bent at 90 degrees. And then you just let one leg drop. And just before it hits the ground, you sort of stop it. So you're catching that leg. And I guess that's just causing a big um, affect like a big contraction of that muscle and I don't know, building up strength that way. That seems like a bit of a weird one, but, um, nonetheless, that's one of the five major most common exercises that they did when it came to, um, the lumbopelvic exercises. So they have four, the top four lumbopelvic exercises. They included the plank, they included the side plank. They included a Swiss ball. curl which I'm assuming is in a bridge position. So almost like a hamstring but also a you know core exercise anyway and then they had a single leg stance as a core lumbopelvic stability exercise. So keep those in mind when it comes to the results. Those are the main things I want to go through. And then they talked about the grade of recommendations. So very important that when the authors write what these studies show, they also need to kind of correlate it with how good the quality is with those studies that they're talking about. Cause there's five RCTs in here, which in most cases are quite good quality cause they're randomized and lower risk of bias. Whereas there's other case studies in here, which are usually what we consider lower quality. So if our findings come from those lower quality papers, it needs to be known. So they look at grade of recommendations and they say, interventions that included progressive loading with a minimum of five out of 10 RPE. So I guess your effort to do that exercise, if it had a minimum of five out of 10, at increasing while increasing the muscle length during that exercise. So they're talking about simultaneously flexing the hip or extending the knee. That sort of looks like a deadlift and lumbopelvic stabilization performed at least five times a week with gradual plyometric exercises as that sort of mimicking return to sport demonstrated a B grade, which is moderate strength. of recommendation. This is based on high quality randomised control trials with findings demonstrating the highest reduction in pain and the fastest recovery to return to sport. Now we're going to break these down in a second. They continue. Loading regimes should be sustained for a minimum of eight weeks with shockwave performed as an adjunct treatment to a multimodal approach rather than a standalone treatment, which demonstrates a grade C, which is a weak strength of recommendation. So essentially with the quality of papers that have come from this, we couldn't really get to grade A recommendation. There's not like a really strong correlation based on the quality that they're retrieving. So just bear that in mind, we're going to break these down into different outcomes, which I really like what this paper conducted. So let's start with pain, because someone can get better. And because they have a reduction in pain, but someone also can get better when having the same amount of pain, but their function increases. And, you know, someone can have a two out of 10 pain the entire day, but can only run for five minutes and only sit for 20 minutes before symptoms increase. But someone can have still the same amount of two out of 10 per day, but can tolerate 60 minutes of sitting and 30 minutes of running. So as symptoms improve or as the condition improves, pain staying the same but function is increasing. So they start with breaking down just the pain element. So let's talk about just improving pain. They say moderate to high quality evidence supports progressive intensity of exercise interventions using a multimodal approach, which may optimize the reduction in, how they call the VAS, the visual analog scale, or just another way of saying pain. They looked at the studies that did show the greatest improvement in pain, and they said, similarities across studies include increasing progressive intensity, with exercise interventions and all consisted of multimodal approaches of strengthening, lumbopelvic stability and endurance training. So let's break that down. Increasing progressive intensity, so making sure that the effort of that exercise is progressed in areas that include strengthening, so you're looking at your gym exercises. Lumbopelvic stability, so those core exercises. and endurance training. So that's probably going to be running in most of these cases, cause most of the population sizes were runners or ultra marathoners and those and the like of those. So they continue. A differentiating component of the slider paper, this is slider et al 2013. They're just referring to one of the papers, which was a high quality RCT. The difference between this paper and a few other papers that is consistent with the current tendinopathy management was the use of increasing effort hamstring isometrics. So they seem to find that the study that had the highest degree of isometrics, so an isometric is more of a activate and hold. So most people are familiar with a bridge. I like to use a long lever bridge. So instead of moving up and down in that bridge, you are just holding that bridge in place so that the hamstrings are working, the hamstrings are activating, but you're not moving anyway, you're just holding it in place, that is an isometric. And it seems like this paper had their people involved, improve their pain. Their pain improved more than other particular studies. And this isometric was progressed. So you might look at progressing it in the way of doing a bridge and doing it with longer, a longer lever. You might put some weights on your hips, you might move to single leg, then you might move to single leg long lever with weights, you know, in that fashion. And they say isometrics have been substantiated to be beneficial due to the activation of endogenous opioid system. which has been associated with changes in pain sensitivity, improvements in neural adaptations, and increasing in force output. Essentially saying that isometrics do have quite a nice analgesic effect. If you hold and activate that tendon and the muscles for a desired period of time, sometimes people feel better and you can actually use it as pain medication in some cases. We've talked about this in previous episodes, but. know, if someone is going through a flare-up or if someone has pain, a low level of pain throughout the day, sometimes they can do some isometrics throughout the day and they actually have less pain. So you can use it in a substitute almost like you would as a pain medication. And so that seems to carry over in the studies when they found one paper that did more isometrics than others and found a better improvement in pain. Recent RCTs found no superior effect with the high load magnitude compared to that of moderate load on clinical outcomes, tendon structure and function when performed at a slow 313 concentric and eccentric tempo. Therefore, clinically it is important to choose the exercise intensity that matches the patient's tendon load tolerance performed at a slow tempo. Let me break that down. Based on these RCTs, there's no superior effect, there's no difference when looking at high load magnitude, so really heavy, heavy stuff, compared to that of moderate stuff. And they said that the moderate load was 55% of your one rep max. So if I can deadlift, if my one RM was say 120 kilograms, which I reckon that's... pretty close, then this, what they deem moderate load would be my like one would be maybe 60 kilograms. So still pretty heavy. And all of these are done at a slow tempo. So they said 313, which I'm assuming is three seconds down, hold for one second, three seconds up. type of tempo for say a deadlift and said that, you know, something of that moderate compared to something higher than that seems to have no, seems to have no superior effect in things like tendon structure, tendon function, and so on. But I would argue and say, I rarely find people deadlifting that heavy anyway. And so time to, you know, progress those weights anyway. And yeah, keep a slow tempo, still keep progressing those sorts of things. Moreover, progressive heavy slow resistance has been shown to have greater tendon collagen turnover than submaximal eccentric training. So tendon or collagen turnover, they call it, is essentially the tendon getting stronger. It is the tendon adapting to a load stimulus. So if you load it up, then you leave some recovery time afterwards, the tendon's going to get stronger. It goes through that collagen synthesis, collagen turnover is what the paper called it. But they say that progressive heavy slow resistance has been shown to be superior when compared to submaximal eccentric loading such as I'd say probably a Nordic drop would be or maybe a Swiss ball rollout or, you know, something along those lines. They continue, the progressive intensity of exercise interventions in the above mentioned studies with the highest observed reductions in pain also underscores that the key to preventing further matrix destruction is through appropriate progressive loads to the tendon to promote remodeling and reduce hype big words here, by reducing the tenoside expression and vascular endothelial growth factor. That is a ton of scientific mumbo jumbo. Essentially saying that progressive strengthening exercises does reduce pain, but also helps with, I guess, preventing the tendon matrix or the makeup of the tendon getting worse. what happens with chronic tendons is they undergo remodeling. They, I called it hypervascularization before, meaning the tendon itself gets little blood vessels and the tendon, if the tendon wants to perform optimally, we don't want all those little things in there. We want just the tendons, we want the tendon sheath, we want the little tendon fibers, we want them all nice and aligned, but with chronic mismanagement and chronic pain and dysfunction, they get disorganized. So the heavy, slow, progressive exercises helps prevent those sorts of things. All right, hopefully you're on the same page with me here. Hopefully I'm doing an okay job of making sense of all this, because like I say, there's a lot of mumbo jumbo in here. That was all looking at pain, improvements in pain. And it seems like slow, heavy load is good and If you do have, if pain is considerable, a considerable factor for you, maybe some isometrics performed, progressing your isometrics can maybe help in terms of improve it. Yeah, have a superior outcome. That was pain. I want to look at disability now and mention a few things in disability, which is kind of like function in my before example. They say, Moderate to high quality evidence supports programs that allow a maximum of three out of 10 pain with combined exercise, lumbopelvic stability and progressive endurance components. So, there's moderate to high quality evidence that when you do these things, when you do strength training or core exercises or progressive endurance components like cycling or running, those sorts of things, you can allow up to three out of 10 pain. That kind of falls in line with what I've been talking about on the podcast. I usually say less than a four. This says up to three out of 10, which is exactly the same thing. I would say that for some people, based on the individuals, I change that. I sometimes say less for some, more for some, just depending on how they respond. I've mentioned on the podcast before. For me, if I am managing tendon pain, I like to go higher. For someone who's really weak and irritable, I like to go less. So it all depends on the irritability and how much risk you're wanting to take on. Because I like to take on a bit more risk for me because I've taken on that risk in the past and it's been successful with me in the past. And so continue to head down that direction. Okay, still on with disability. So two studies that demonstrated the greatest improvement in disability were, and then they reference this Cushman et al, which had 60% improvement and J.S.Leen et al 2014. Those two papers showed the greatest improvements and they said the similarities across both of these studies included a dosage of three sets of five repetitions performed daily. with a focus on strengthening, core strengthening, and progressive endurance training. So those three things that we mentioned before when it comes to pain, those same things were included in improving function. Strength training, core strength, which is lumbopelvic stability, and progressive endurance training. The significant improvement in functional outcomes observed by these two papers suggests clinicians may be potentially underloading patients. should they encourage only pain-free loading? How often do we see this? How often do we see people, clinicians and patients, not wanting to progress their exercises because they're scared of poking into pain and they just wanna stay pain-free and they stay doing their glute bridges for years. So glad the paper sort of highlights this. We want to, we can, we have permission to poke into a three out of 10 pain. I like to add in that returns back to baseline in less than 24 hours, 12 hours probably better but yeah just thought I'd put my little caveat in there as well. So summarizing the function again might be repeating myself here a little bit but we're looking at strength training, core, stabilization, slow return back to exercise, maximum three out of ten pain during those. Now conclusions. So this paper had a conclusion and said that this systematic review found few high quality randomized control trials and a predominant number of case studies that supports recommendations for progressive loading at a minimum of 5 out of 10 RPE while increasing muscle length, The effort needs to be about a five or minimum five out of 10. Okay. And we need to do those five days a week. We need to do that for eight weeks. That's what this paper shows based on current evidence, a gradual plyometric progression should guide clinical practice in most clinical situations. So I would say this depends on the person, whether we need to get the tendon to adapt to plyometric stuff. So plyometric will be power-based. stuff, so jumping, skipping, box jumps, power stuff like sled pushes and things that you need your body to return to. If you are a sprinter, you need to focus on plyometric activities. If you just want to cycle, you're probably less so. Based on the lack of high quality evidence, shockwave should be used as an adjunct to treatment. as an adjunct treatment to multimodal approach rather than a standalone treatment. So they're saying if you choose to do shockwave, make sure you don't do it as a standalone treatment, make sure it is also accompanied by high quality, what they call a multimodal approach, which needs to have exercise in it. Although universal sports demand, although universal sport demands exist, on an individual level, several intrinsic and extrinsic factors further necessitate a comprehensive multimodal and individualized approach for PhD management, essentially saying, based on the individual, like their specific muscle involvement, what deficits they have, do they have calf deficits, do they have range of movement, deficits, all those sorts of things, we need to factor that into someone's management plan, and should be factored in. And you know, essentially saying it's not a recipe, we want to make sure that we're tailoring to people as well. So that's what the paper has shown. And I guess my key takeaways was probably the importance of the lumbopelvic stabilization, which was, you know, your planks, your side planks and those sorts of things. I don't really include that in a lot of people's reports. I mainly focus isolated on the tendon, but maybe I do need to include some core stuff. And that's something that I was quite, you know, surprised with in the, in this, these findings. Um, I know that in the past evidence has shown, or maybe experts have advised that glute strengthening does help assist in hamstring rehab. So I do give some people, um, glute exercises, glute, meat exercises. I do crab walks. Um, people are already doing dead lifts and step ups and lunges. I get them to do them in their rehab, which is glute strengthening anyway. Um, but you know, maybe for you, for your own rehab, maybe you do want to include some planks and side planks. Um, it wouldn't be harmful to the tendon and might have some benefits. So, um, hopefully that's a good takeaway for you as well. Hopefully you enjoyed this. I do know that looking at the research is really important, especially this is this come out this year, 2023. So, um, very recent and. even though it might not have too many insights or something revolutionary of we all need to shift the way we're thinking and do this instead. Sometimes it's nice for confirmation to know that we are on the right track and the studies are showing it. And if there's more papers that come out in the future, I'll review those. Like I say, can get a bit dry, but very important. And I know people do appreciate that this is kind of evidence based and research centered. And so when these papers come out, if you are enjoying it and you appreciate them, then I'll keep delivering. So good luck with your rehab this week. Thanks again, Saeed for bringing this paper to my attention and we'll catch you next time. 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.