Answering Your PHT Questions

: On today's episode, I'm answering your PHT questions. Welcome to the podcast that gives you the most up to date, evidence based information on PHT rehab. My name is Brodie. I am an online physio, but I've also managed to overcome my own battle with PHT in the past. And now I've made it my mission to give you all the resources you need to overcome this condition yourself. So with that, let's dive into today's episode. Okay, apologies, because I am a bit unwell today. I have been for the last, I know, four or five days, and you might notice that this episode has come out a few hours, been released a few hours than it usually does, because I just wanted, usually I would record this, you know, two days before the episode's actually released, but I wanted to preserve my voice. I want to try and feel a bit better before recording this episode. But while I do feel... a ton better, like 90 to 100% better, I still sound quite poorly. So apologies for that, and apologies for getting this episode and releasing it a little bit later than usual. What I did put into the Facebook groups is asking for some questions, and so I thought it might be a nice episode to do. before I think next episode we might do another success story. I'm getting a lot of good feedback from the previous couple that we've done. So thanks for letting me know how things are going. I hear a lot of people say, I just found your podcast, found it really helpful. Love the success stories. So thanks for that feedback. Although now that I've asked these questions, I've put them into the Facebook group as of like two days ago and... you know, I get 42 comments all and the, had like maybe 20 people, 25 people asking questions and within those questions and multiple questions. And so apologies if I don't get to answering your question, please don't be offended. I'm trying to find the best questions. I'll try to answer all of them eventually. But for right now, while I'm trying to preserve my voice, uh, cause I do have a lot of client calls, that sort of stuff throughout the remainder of the day. Uh, I will be answering a few, um, I'll probably be doing another Q and A in a couple of weeks time and might get to your question then, but, uh, just bear with me. Apologies if I don't get to your question, just bear in mind, I get a flood of questions coming in. And so I'll try my best to get to yours, but, um, please don't be offended if I, if I don't, um, let's. move along and see how my voice goes. The first question came in from Jen, who unfortunately I'm gonna have to like, pass on the first part of her question. Jen asks, what is the effectiveness of red light therapy? I don't know, unfortunately, I haven't come across any studies yet, nor have I seen anything that proves or disproves it. Maybe there's some things that come out in the biohacking world, but I haven't, I'm not too up to date with that side of things. So apologies, I can't necessarily answer that, but Jen goes on to say, also, how soon to actually start doing more than body weight exercises? A lot of times I talk with clients, a lot of times I jump on injury chats with people with PhD, and a lot of times they're just doing body weight exercises. And so, If you have the same question of when we should actually move away from bodyweight exercises, I would say the time is right now. We shouldn't really be doing body exercises for too long, unless that is your adaptation sweet spot. What we want to try to do is challenge the tendon. We want to try to find what is the sweet spot between doing too much and not doing enough, and often that is beyond bodyweight straight away. And so... I like to consider bodyweight exercises in the same way I would consider like isometrics, which are just like, you know, your body weight bridges where you hold the position or any exercise where you just hold the position under light load and sort of maintain that. Cause a lot of people start with isometrics, but then eventually progress away. I have done previous podcast episodes on isometrics and when to do isometrics, how to do them, when to move away from them. and I'll consider body weight exercises in a similar vein. I consider them like taking pain medication. When there's a flare up, sure, we can do some isometrics or some body weight exercises to give the tendon, expose the tendon to some light load in the hope that you receive this analgesic effect, which is just a fancy word to know that there's like a temporary lull or decrease in pain, but it's only temporary. And so you could do that several times throughout the day just to get by the day in less pain. Similar to how you would take pain medication if you had a headache or something like that. But if you kept waking up, having a headache, day after day, all the time, and you just kept trying to mask that pain with pain medication, you'd get to a certain point where you're like, okay, enough's enough, I can't just keep taking this medication, I have to get to the source of this headache and try to get this headache resolved. can't just keep putting a bandaid over it every time. Let's do the same for the isometrics and the bodyweight exercises. Find out when the right time is to progress. Start gradual, go beyond the bodyweight stuff, try some, you know, even weighted bridges if you want to. They're not my favourite go-to ones. I usually start with some variation of a deadlift, some variation of a weighted step up, some variation of a hamstring curl, but... I'll say it again, I feel like those who've listened to multiple episodes is like, how long into the episode until Brody is gonna say it? Tendons love slow, heavy, progressive load. That's what they love, that's what they enjoy, that's how they adapt, that's how they get stronger, that's how you build your strength and function. And when we talk about all these things, there's heavy in that statement and there's progressive in that statement. So body weight exercises are not heavy and they're not progressive if you... continue doing bodyweight exercises. It's gotta be some point, to at some point where we do progress those exercises to get better. So, even if you've been doing isometrics and bodyweight exercises for four weeks and your pain isn't getting anywhere, just give it a try because I've seen several times the bodyweight exercises cause the same amount of discomfort. then as soon as they actually progress and start exposing their tendon to sustained heavy load, low time under tension, or I should say long time under tension. So like say for a deadlift, three seconds down, two seconds up is a five second time under tension, which is considered low when considering like three sets of six, something like that. That is now meeting the conditions that the tendons love and then they start feeling better. So I encourage you. Start now, start gradually, might just be adding a few pounds here and there, but treat it as an experiment. If you're doing body weight exercises and isometrics for several weeks and not seeing any change, what's the point of just continuing to do it? We don't wanna continue the same thing over and over and over again expecting something different. So let's try something different. Next question comes in from Jess who says, what is the role, types and timing that massages can play in post-op recovery? If you haven't had PHT or if you haven't had hamstring surgery, this answer is going to be still relevant to you because my answer is going to be the same. Whether you've had surgery or not, or if you just have chronic tendinopathy, PHT, like I said, my answer is going to be the same. It's there, that option is there for short term relief. to then hopefully make you feel better throughout the day, to hopefully then lead you to do, you know, more things functionally or help you progress your rehab along. Massage doesn't do much for releasing trigger points, making tendons longer, releasing scar tissue, I don't know, freeing up nerves for adhesions, that sort of stuff. Massage doesn't really do that. It makes things, makes people feel better. Well, most people feel better. Some people feel better, I'm not too sure. For a short period of time. And that might be 10 minutes, it might be two hours, it might be two days. But, doesn't really have any permanent effects. What does have permanent effects is your healing. If you are post-op, then your body does a good job of healing. And also, talking about permanent stuff is like your progressive training, like. building up your strength and function. That is the long-term path to getting better that we wanna head down. We don't wanna focus on too much of the short-term strategies. Sure, they have their time and place. That might be if you are really sore and you're struggling to walk around, but then after a massage, you feel great, you can move better. That has a purpose, but... it does like massage does not have a long term purpose. We don't want to continue going to the massage therapist three times a week for three months just to get that short term relief. We eventually, as you get better, want to decrease and eventually get rid of the short term solutions while slowly building up and eventually moving into only the long term solutions, which is your functional strength training, rehab, restoring that sort of stuff. because that restores strength and function. And so I will say that you do the massage stuff only if it's beneficial for you. Because I do know a lot of people will try a massage and they just feel indifferent. Don't worry about the massage person promising, you know, it's gonna have all these permanent effects and this is gonna help. What I would say is that if you find personal benefit, continue with it. Keeping in mind all of those things I said before, it is just for short term relief, and factor in how much does that cost? When we say cost, we mean like, you know, the price of the massage, but also time away, how practical is it to get there, like all that sort of stuff. We weigh up the pros and cons essentially, and then see the pros. Okay, if I do have a personal benefit, how much of a personal benefit do I have, and how long does it last? Because you can have it. you can be pain free, you could walk out and like feel absolutely incredible. But if it lasts for 10 minutes, maybe it's not worth it. You might feel a little bit better, but if that lasts for three days, that might also be worth it. So we need to weigh up all those sorts of things. In terms of the type of massage, again, it's just gonna fall back on where you find personal benefit. Cause like I said, there's gonna be no, like some people can do like deep friction massage, people can do like this effleurage massage or like, There's several different types out there. It's all just to try to see what you respond best to, whether that's a placebo, whether that's just, you know, bringing down or inhibiting pain signals or calming down the central nervous system, whatever effect that is having, but it doesn't have any physical effects on changing the structures and changing that sort of stuff. So, hope that answers your question, Jess. They're sort of my feelings. I did have a massage therapist on the Run Smarter podcast. Her name was Alice San Vito. If you wanted to Google her name and so the episode pops up. Um, she is very well versed on the research on what massage does for muscle length, increasing blood flow, trigger point release, uh, all that sort of stuff. And she's come to realize a lot of it is bogus when you dive into the actual research. She's still a massage therapist, but I found that as a very eye-opening conversation. Seems like my voice is still hanging in there. Let's get on to the next question. We have one from Chris who, very similar to what Jen was asking before, says, what can you do when isometrics aren't doing much, but trying anything more just aggravates it? So if we try progressing, like I was mentioning before, and then symptoms get ag... aggravated and then we just move back to general isometrics. We need to break out of that cycle. Cause like we said, it's just like taking pain medication. We eventually want to get to a long-term solution to restore strength and function, to get into the realm that tendons love. But yeah, if we try in Chris's case, if we try progressing and it just aggravates it, then what can we do? My advice would be, I bet there is something that we can find that is a progression. that doesn't flare you up. I am very confident, because this is what we do as physios. We make adjustments to training plans, to exercises, to rehab protocols. We're just constantly modifying and like just being a bit more creative with our options. So if I was talking to Chris, I'd really wanna delve deeper into what did you try that aggravated it? Can we have that, the number of sets and reps, can we reduce the weight? Again, it would be nice if I knew what actually was progress too, but some common adjustments would be the weight, the range of movement of the exercise, the tempo of the exercise, how often it is done, like the frequency of the exercise. So we don't want to do, like isometrics can be done four or five times a day if we want to, but when it comes to progressing your exercises, we might need to reduce that frequency. We can't all of a sudden do weighted bridges or deadlifts and do that five times a day. So we'd want to make the necessary adjustments. So weight, frequency, range of movement, the tempo of the exercise, so how fast you're moving through that exercise, whether it's single leg, whether it's double leg, we're just changing the exercise altogether. Maybe we just do, instead of doing hamstring curls, maybe we do... like just an eccentric portion when we do sliders, where we just slide out your legs instead, instead of doing an actual curl, like variations, it's constantly finding variations. Chris, keep getting creative. If you can't be creative enough to find that right sweet spot, then, you know, we'll, I'd say like, you know, book in with a therapist or, you know, jump in on a injury chat with me. We can discuss a few things. That would be my advice is there'd be something there. Okay, we have Katherine who asks, when can I start rehab? I am at two and a half weeks post-op and getting anxious to start. This one breaks my heart a little bit when I read questions like this because I do get a lot of very similar questions. And sorry, Katherine, I'm not gonna answer your question directly because I'm not entirely sure. what operation you've had, how serious it was, what it was like beforehand, how the surgery actually went, how you're feeling right now, I don't know. There's way too many factors to give out some accurate advice. And the last thing I wanna do is give out some advice and ends up making you worse. But I guess I put this question in here as a message to everyone listening. Like if you have a medical team, ask the right questions. All of this stuff of like, The fact that Catherine's had this operation and is two weeks post-op and doesn't know when to start rehab, like I say, it breaks my heart. That should be a part of the medical team. That should be the surgeon and the assistants and the nurses and the post-op care and all that sort of stuff should be guiding you on how you should be feeling, when you should be feeling it, when to start rehab. Here's when you go see a physical therapist. Here's when you do this. Then the physical. Physical therapists can reassure you, say these are the exercises to do based on how the surgery went, based on how much was done, based on, you know, all of these factors. And if the rehab team is unsure, then they're going to like, you know, start asking more questions about your unique scenario, how things are presenting and then just like move along. But as you said, Catherine, you're getting anxious to start, which no one should feel anxious after. Like. I guess, unsure, uncertain and anxious about when to start doing these exercises and that sort of thing. So I did talk to a few surgeons on the podcast several months ago. They talked through a little bit of post-op care for the general people. So you can go back to that episode if you wanted to. But I think it was Dr. Hardy and Dr. Lefebvre if you want to look at the title to try and find that. But yeah, like I say, when you are, if you are in the process of getting surgery, or if not, but you're still seeing a medical person, just ask some questions. Ask things that you are uncertain about. When to progress, how to progress, what should I do if I have a flare up? What should I do if things are feeling better? Get all those questions, get all those frustrations and get the roadmap. We want, we know that people respond well to a roadmap. not a rigid roadmap, it can be flexible, but just saying like week two, this is kind of what it might look like, week four, this is what it kind of might look like, month three, this is what it kind of might look like and helps reassure people, but also it's good to see a plan. And yeah, I would like Catherine for you to see your plan. So if you can get in touch with your surgeons or medical team and that sort of stuff about the right exercises at what time or with your physio or physical therapist. That's what we need to do. We need to get the right answers. We need to start asking the right questions. We need to keep asking those questions if what the therapist is telling you is a bit too complex or you feel like it wasn't simplified enough. Just keep asking, keep asking until you're clear with the roadmap ahead. Okay, the last one I wanna touch on today was from Sharon who asked a couple of things. Sharon says, two years post-op, MRI shows a high grade tear and tendinopathy. in both sides, both the surgical side and the non-surgical side. So the questions are one, I've read that NSAIDs, non-steroidal anti-inflammatory drugs, are not good for tendon healing. Let's start with that before I go into this part two. Okay, so first of all, I'm not a doctor, I can't be qualified enough to advise on medication use and that sort of stuff. This is a non-steroidal anti-inflammation drug. So it's meant to reduce inflammation with, it doesn't have a steroid component to it. So it's a non-steroid anti-inflamm. We know that for chronic tendinopathies, inflammation isn't the primary driver. It isn't the main source of pain. It doesn't increase, like there's not a lot of inflammation present. So therefore, like, is it that relevant? Is it that, is it required? I don't think it holds that much relevance. If things are inflamed, I don't know why, but if things are inflamed, let's say you roll your ankle or, you know, get a bruise or probably not a bruise, you know, you know what I mean. If we, if you've had an acute injury and things are inflamed, you'd probably take some anti-inflammation but maybe for two to three days. as prescribed on the packaging. So like long-term use, long-term NSAIDs use, like you shouldn't be doing that anyway. But yes, there has been some research to show that long-term steroid use or non-steroidal use can impact tendon strength and impact tendon function and impact tendon healing. So we do wanna shy away from it. Not only is it detrimental for tendons in long-term, but it doesn't seem that helpful for tendons, for tendon health or inflammation because there's not much inflammation present. So that'd be my general advice. Sure you can take it for two or three days and see things calm down, especially if there's a flare-up and you just want to see if it works. The risks would be relatively low if you just do that for a couple of days. But Sharad, second question, it seems very odd that I have tendinopathy on both sides. Prior to the hamstring evulsion, I had no connective tissue issues, no connective tissue issues. Now it feels it could be systemic, meaning like whole body type of stuff. Do you have any knowledge of a possibility of systemic connective tissue issues? Thanks for your question, Sharon. I, it doesn't say in your question whether you actually have pain on the other side. It says that your MRI just shows you have tendinopathy and a high-grade tear on both sides. But is there any pain coming from the non-surgical side? That would be my question. I wouldn't be surprised if there wasn't. But I wanted to jot down this question because yes, there are very much what we call incidental findings on scans. And we need to be very careful with when we send people for scans, how we interpret scans, what we find and how much is relevant and that sort of stuff because of incidental findings. Incidental findings are things that you find on scans that aren't relevant or don't fit the picture or just like complicate things that they're not actually presenting, that they're not actually symptomatic in any way. So we know from data, from research that if you scan the healthy population, So no one who's had any complaints of hamstring issues, perfectly fine, perfectly healthy, if you scan 100 of them, close to 18% of them will have bilateral proximal hamstring tendinopathy, 18% of the population. And that is the healthy population. This is what I mean by incidental findings. So if one of those healthy people end up developing a tendinopathy, and then they get scans, and then it shows that they have tendinopathy on both sides, that could be very puzzling for a lot of people. And so we see this with knee issues, meniscus, cartilage damage, we see this with a lot of stuff and so what we want to be very clear on is using scans only as one piece of the puzzle. It can be considered a piece of data that we factor in but it's a small piece of the puzzle that should be the same size as all the other pieces of the puzzle. Other pieces being like, you know, the signs and symptoms being some functional tests that we might do, the onset of symptoms, your past history and that sort of stuff. Because, you know, a lot of times my clients they send me scans and I look at those scans and I just, yeah, use it as a small piece of data. If you have no pain, or dysfunction on that non-surgical side, Sharon. I wouldn't be concerned. I would consider it just an incidental finding. And no doubt if I was to scan a whole bunch of tendons in my body, I would have some tendinopathies. I would have, not sure about high grade tears, I'm not too sure, but I'm sure there's some tears there. But functionally speaking, I am symptom-free and strong. I've got good strength, good function, and no pain. That's what I would consider. above everything else when it comes to, if I was to get scans, I wouldn't be too worried. An example, I would think about maybe three or four years ago now, I suspected a stress fracture in my foot. That's warranted for scans, so I went and got a scan. Luckily, it showed it didn't have a stress fracture, but it did say in the report, because I read it myself, I had moderate osteoarthritis in my big toe. I've never had pain in my big toe. But I could imagine a lot of people would then be worried about that finding and be like, oh, I need to take care of my big toe. I need to stop running. I need to limit the amount of running, maybe more stiffer shoes so that, you know, take some pressure off the big toe. But with my knowledge and understanding, I just tried my best to ignore it. I don't think about my big toe when I exercise. I don't think about my big toe when I run or anything like that, but just know it's an incidental finding. And... Those incidental findings can be quite worrying and troublesome for people who have them read their results. A doctor reads out the results and all these things that they find, it can be quite alarming. But let's go back to the basics. Let's go back to how strong the tendon is, what the function of that tendon is, what the pain levels are like, what the response is like, and move on from that. Sharon, you did ask about like a systemic kind of issue. If there is and there could be like the systemic things that I could think about is that yes, some people have a genetic predisposition to developing tendinopathies. I can't remember the exact genetic sequence or what the code is for that. I have that. I have the genetic predisposition to developing tendinopathies. And so if I was to be... If I was to miss... manage myself, the odds of me getting a tendinopathy is quite high. And that would be the case. Like I haven't had any Achilles issues, but I have had proximal hamstring tendinopathy. I've had long head of biceps tendinopathy. I think I've had patellar tendinopathy in the past. What other tendons have I gone through? Tibialis posterior tendon stuff. I think that's enough for today. That's so, you know. People might be quite alarmed if they do have this genetic predisposition, but hey, I'm strong. I know how to train, I know how to listen to my body, how to look after tendons. And so I think I might be a good example of just because you have this genetic predisposition, it doesn't mean that you're destined to get these tendon issues. It does mean that you just need to train sensibly. The other systemic sort of stuff, I guess, just like sensual nervous system sensitization would be a systemic way of... getting bilateral pain because what influences central nervous system sensitivity would be like hormones would be stress would be lack of sleep would be some maybe inflammatory diets food and that sort of thing could just stimulate the nervous system so much that like pain signals started rising in small little niggles here and there. So that might be a thing but hopefully that helps allay some of your fears and brings some awareness to that particular scenario that you find yourself in Sharon. So thanks to everyone. I'm probably gonna stop here, but I do have a list of like, I don't know, 10 other questions that people have wrote in, or probably more, because there's multiple questions within questions. But I'll try my best to get to them over the next couple of episodes. I will rest my voice. I'll go take a drink of water and have some lunch, and hopefully can preserve my voice for the remainder of my calls throughout the day. But thank you for. submitting your questions, even if you didn't, hopefully you found these answers beneficial and we'll catch you in the next episode. If you are looking for more PhD resources, then check out my website link in the show notes. There you will find my free PhD five day course, other online content and ways you can personally connect with me, including a free 20 minute injury chat to discuss your current rehab and any tweaks you might need to make. Well done for taking an active role in your rehab. listening to content like this and together we can start ticking off all of your rehab goals and finally overcome your PHT.