Brodie discussing PHT on the Fit Cookie Nutrition Podcast

: On today's episode, my interview about PHT on the Fit Cookie Nutrition Podcast. 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. Doing something a bit different today. Um, the host of the fit cookie nutrition podcast is Holly and she reached out to me to, uh, and wondered if I wanted to jump on to be a guest on her podcast. And she wants to talk about PhD and we jumped on the episode. Um, the title was trading runner proximal hamstring tendinopathy with Brody sharp. And it was released, uh, early March this year. And. After the interview, everything went really well and I asked if I could use this episode, use the audio and create my own episode to put on the PHT podcast. And I was thankful that Holly agreed. And if you want to check out her podcast, it's excellent. At the moment after me, there were episodes about what is a dietitian, your protein questions answered, CBD for runners with Erin Henney. And running and pelvic health with best Matheson. So a ton of stuff. It covers like nutritional knowledge covers like anything to do with sports endurance, preventing injury and like say burnout and Holly does a great job of interviewing her guests and has a top range of guests. So fit cookie nutrition podcast. Uh, I'd love to plug that since I was also featured on that podcast. And we're just diving into the interview today. So I hope you enjoy. Hi Brody and welcome to the fit cooking nutrition podcast. I am so excited to have you on today. Holly. It's a pleasure to be on. Thanks for having me. I'm excited to delve into the topic of today. All right. So you can tell everyone who you are, what you do and where you live. So my name is Brody sharp. I'm a physiotherapist, which is similar to a physical therapist, um, from Melbourne, Australia. And I am on a mission to educate runners as best I can so they can sort of navigate between the misconceptions of the world and what's helpful, what's unhelpful, because it's extremely confusing, especially if you're trying to reduce your risk of injury or if you are injured, trying to negotiate that injuries as much as possible. So I think that's, I see the confusion that's out there and I'm on the mission to make it the easiest way possible for them to get. the clarity and make it as clear as possible in terms of what they have to do. Yeah, absolutely. And you do such a good job and I know you have your own practice and your own podcast. So yeah, tell everyone about that as well, because I think that's a really great resource in case they're like, wait, I need, you know, this physio who specializes in running, cause I think that's a very specific niche where you lie. Yeah, exactly. And it, it was off the back of like. me being a generic physio, just, uh, developing like just becoming a recreational runner and seeing all these runners come in injured and seeing all of these, um, the questions that they have all seem to be the same questions, the same puzzling kind of confusions. And so I thought I'd develop this podcast as a way to help, I guess, point them as a resource and trying to educate them as best I can. So the run smarter podcast is what I've started. Um, uh, I sort of came off the first 10 episodes of that podcast being 10 universal principles that I believe will help reduce the risk of injury as much as possible. So I constantly direct runners to that resource and then it's just stemmed off to 200 plus episodes now where, where I interview other health professionals or some solo episodes, me just talking about ways that you can overcome injury, reduce risk of injury, increase running performance safely. And I am. And in person, but also an online physio where I just treat runners all over the world, if they do require that tailored assistance, but I always, I always direct them to the podcast first so they can develop their own wisdom and trying to build on their running IQ themselves, and then hopefully can negotiate the injury on their own without my assistance, but then if it becomes a bit too stubborn, or if people are just looking for that tailored guidance, that's where I can step in for one-on-one physiotherapy. Yeah. And it's, it's super helpful. I really appreciate what you do on your podcast. And I actually point a lot of people in that direction too, because I think, um, when we enter like the running community, um, you know, as like timid, innocent people, and then we start to accumulate this like baggage over the course of our running careers. I think a lot of runners at first are like, Oh my gosh, something hurts. You know, I'm doomed, but it doesn't have to be that way. And it's just, you know, kind of a part of the sport is getting stronger. Um, so I mean, in terms of like how you got started with running, tell us a little bit about like your own athletic background. Yeah. So I actually grew up playing basketball as my main sport. And I played that all the way till my early to mid twenties and started playing quite competitively at the later, later stages of that career. And then once I gave that up, my sister was training for a half marathon at that stage and she wasn't much of a runner either. And I had. fitness behind me, but just wasn't equipped to slow long distance running. So had to take a long time to adjust to that and a few injuries along the way. But that's where it took me. I sort of as an accountability sake for my sister, I decided to agree to train for this half marathon. And then that led into a marathon that led into several other half marathons and trial events and triathlons as well. And so that sort of jumpstarted my endurance career, which, um, was a fun process. I love every moment of it now. I absolutely love running. And these days don't take myself too seriously. I'm just recreationally running around and doing some triathlons and events here and there, but yeah, loving every moment. Yeah, absolutely. I love how you described it too. Like, yeah, I kind of got into running and then like now I have this podcast and I help runners. That's like how I started my business too. I'm like, where, how did I get here? Yeah, exactly. I think in your intro to your podcast, you say running is life. And I'm like, ah, I can relate to that. Absolutely. Um, well, I'm excited to talk with you today. I know we could talk about a lot of different injuries and runners, but I definitely wanted to bring you on to talk about hamstring issues and particular proximal hamstring tendinopathy. Um, so actually first, could you kind of different differentiate for us, like some of the different common hamstring issues you see in runners, because I know they all present a little bit differently. Yeah, I think we can finish off with the proximal hamstring tendinopathy and start with maybe an acute hamstring strain, uh, not as common with runners unless they're doing some sprinting or some like high intensity efforts or hill sprints or something that demands like a lot of speed. And so the, usually when that is presented, it's usually quite an acute onset. Usually it comes on. during the run, if there's like an intense effort, it will require like a huge bout and then all of a sudden there, you notice a ping or you notice some sort of sensation in the belly of the hamstring that usually tends to get worse as you cool down and as things go on, but, uh, that management is completely different to a tendonopathy, which is the pathology of the tendon itself. So muscles. require tendons as like an anchor point onto the bone. That's how they attach onto bone and move around the skeleton. And what happens with the hamstring, high up in the hamstring, close to the hips and around the glutes, is that it attaches onto the sitting bone. And so the sitting bone, as the tendon attaches onto that, that tendon itself can become quite irritated if it's overused. So if the demand is quite high, sometimes fast running, sometimes Hill running, or sometimes it's increasing your overall load to abruptly might, might cause that, uh, that might've caused that tendon to start developing symptoms. And so that's when it develops into a tendon opathy, which can become quite problematic for a lot of runners, triathletes and endurance, uh, yeah, endurance athletes. Yeah, thank you for kind of like going into the difference for us because I think, um, yeah, a lot of runners might experience like that initial like hamstring, like, no, like feels like it's pulled or tweaked and then, um, maybe don't do the right thing or don't address it. And then it can, I know, turn into like more of a nagging problem. Like why, like why in particular does, um, like the tendon issue, I know tendon issues in general, but in particular this one, why does it tend to just like linger in, in your experience? Sometimes it's misdiagnosed. And I think the awareness around proximal hamstring tendinopathy is more mainstream these days, 10 years ago, it wasn't really talked about too much. And because it's so high up on the hamstring as it attaches so close to that sitting bone, it tends to feel like glute muscle pain and people stretch it and they try and do some glute strengthening exercises. Sometimes it might get assessed and it's misdiagnosed as a glute issue. And so they're given these stretches and these glute exercises, which can sort of settle down the pain momentarily, but long-term just doesn't do anything about it. So that can be one potential reason. The other reason is if it is misdiagnosed, then you can continue doing something that has irritated it in the past and then just continue furthering to irritate it. So like I said, he'll work. any sort of sprint work, if you're a triathlete and you're doing hard sessions on the bike and then you get off the bike and go for a run, that's enormous. Demand for those hamstring tendons. But then if it is irritated, one other particular reason why it does carry on is because the irritation can carry over into everyday life. So sitting can be very problematic for people with this high hamstring tendinopathy. So because it attaches onto the sitting bone. if it is irritated, then sitting, particularly on hard surfaces, particularly in low chairs, particularly if you cross your legs, that further compresses and irritates that tendon. And so it carries over into the everyday necessities that we need, bending over, squatting, picking things up off the floor, that can become an irritant as well. And so it becomes more difficult to settle because it's not just as simple as decreasing your running loads or doing some strength exercises. Because if you are having to sit for eight hours a day, if you are an office worker and it's constantly being more irritated, it's extremely hard to negotiate very hard to overcome. That's why you see these prolonged recoveries. Yeah, absolutely. And I'm like nodding my head along. This is like also a selfish podcast. This is something I've of course dealt with. Um, for a long time and kind of addressed and fixed. But yeah, I mean, like sitting is like the worst. And it's something that, you know, if you're just like an average human doing your job or driving a car, like it does carry into your everyday life. So I could see where that would be. Just like not helping you get ahead when you're not running. Yeah. I could put my hand up as well. When I was running marathons, I was fine with my hamstrings and then decided to commit to triathlons, which, or sprint distance triathlons, which required a lot more faster running. And. harder efforts on the bike, which then you get off the bike and they have to do some fast sprinting, like I said, huge demands for the hamstring tendon. And my, um, over the last couple of years, I've dealt with the bouts of proximal hamstring tendinopathy as well. Mm-hmm. Yeah, absolutely. And I even tried like, you know, I was trying to figure out, all right, like I want to add in like cross-training to my routine. Like I'm doing pretty good in general. And I tried sitting on the bike and that was just like a trigger, just like sitting on the seat. And I was like, all right, well, maybe we'll think about this differently. Um, so yeah, sprinting off of the bike. I like cringe when you said that I was like, Oh, that sounds tough. Um, and like you said, this injury, um, and hamstring stuff, you know, in general can present when we're running faster, um, when we're doing hills, when we've maybe done too much too soon. So if someone's like, Ooh, like this seems like it's kind of common. Like I want to learn how to prevent that in general. Do you have any just like general preventative recommendations? The recommendations would be. First of all, like the global recommendations to reduce all injuries and that is to reduce abrupt changes in your training loads. So yes, you can do hill work. Yes, you can do speed work. Yes, you can train for sprint distance triathlons. However, you do need to make sure that training is gradual and you do need to make sure that you foster your training within your own adaptation zone and make sure there's just not that huge abrupt shift in training. If you want to focus on the proximal hamstring itself in regards to reducing risk of injury, it's just trying to make sure that is a really strong link in your, in your body. You don't, you want to make sure that your hamstrings are strong so they can tolerate higher amounts so that you do have a little bit more wiggle room or a little bit more leeway when it comes to introducing hill work, speed work, higher volumes. And so you can do that with strength training. You can do that with incorporating say. most people are familiar with the gym machine that you lie down your stomach and you curl a set of weights behind your ankles towards your hips, deadlifts, especially single leg deadlifts, kettlebell swings. Once you're all, once you've adapted to those exercises and you're progressively getting stronger with those exercises, that creates a higher capacity for your tendon, for the hamstring tendon and for the hamstring muscle belly. And so it's Uh, have an abrupt change in training and overuse that particular tendon. I love that recommendation. And also too, um, this could probably be a whole podcast episode on its own, but like, I just noticed, like you didn't say anything about like aggressive flexibility drills or anything like that for the hamstrings. So for someone thinking, oh, like I need to stretch, stretch my hamstrings to keep them healthy. Like, is there research on that going one way or the other, any recommendation behind that? Uh, flexible tendons and do not reduce your risk of developing a tendinopathy. What we care about is capacity because your, um, tendons are a structure that have to produce and absorb a large amount of force. And so it's all about training loads and training loads, uh, independent of how stiff or how tight or how flexible your tendons are. In fact, when it comes to the tendon itself, we actually want the tendon to be rigid because it's more efficient and can absorb and produce energy more efficiently. If it is rigid, um, if we're on the topic of stretching, particularly with the proximal hamstring tendon, a lot of people, uh, if they've, if they've found the right health professional, that's fine. But sometimes if you do have an irritated hamstring tendon, And you go to a professional, sometimes they say that stretching can help. And which is fine because if you stretch that area, if you do a hamstring stretch, people tend to feel a slight tightness, a slight pain, a slight pulling in that area, and it kind of feels nice. And like, Ooh, this feels good. I'm finally hitting the right area, but similar to sitting, if you overdo that, it can just cause further irritation. And so when people are suggested and five, 10 years ago, this was a very common practice, if they had this. proximal hamstring tendinopathy, it's stretch your glutes, stretch your hamstrings, um, stretch, uh, or just exercise or strengthen your glutes and see how you go. And people are just constantly stretching their hamstrings. They're just further irritating that tendon. So don't prioritize when it comes to your rehab, don't prioritize the stretching. You need to prioritize the strength and capacity and building up that overall endurance, overall strength of that tendon. Oh, that's so helpful. Yeah. I'm also thinking to myself, I'm like, Oh yeah, I did that wrong the first time. I remember why that one lasted for such a long time. Yeah, absolutely. So like if someone is starting to experience like you kind of mentioned, they may feel like tightness when they first cause an issue with their hamstring. I guess like what would you recommend they do? Because I think the like intuitive thing that people want to do when they feel that sensation of tightness. is to stretch. And that's not always what they should be doing. Yeah. It seems human nature that when something's injured and you can stretch and reproduce a little bit of that pain, then it kind of feels nice. And you just gravitate towards that particular thing. And then all of a sudden you're stretching all day. Achilles or calf issues, people are stretching their calves all day. If you have a sore shoulder, then you're trying to stretch your shoulder out. It's just human nature to do. If you do it in mild dosages, then it won't further, it won't cause further irritation, but just understand that it might feel good in the moment, but it only lasts that relief and sensation only lasts about 30 to 60 seconds. And it's back to, you know, how you had prior to stretching initial treatments, if you are starting to notice that it is a bit sore, uh, particularly the next morning, usually tendons they're okay when they're warmed up, usually during a run or during a. a ride once you're warmed up, getting to the flow of things, pain tends to really settle or completely alleviate. And does, if you have overdone things in that session, it'll tend to carry over the next morning. So you wake up, you have a feeling you may be sit or you may be. Bend down to put your socks on and then you start to notice tightness there. If that is carrying over beyond a few days, it's worth taking action and being quite proactive with. negotiating this, these symptoms. And what you need to do is identify, okay, in the past week, two weeks, what has there been any change in my training? Cause you really want to identify that because if you continue with that training error presence, then it'll continue to further flare up that, that tendon. So the first thing you want to do is identify any abrupt changes. Have I done more speed work? Have I done more intense sessions? Have I. adjusted my bike so that the seat's higher or my handlebars are lower and putting more stretch on my hamstrings. Have I been doing more yoga classes, which, uh, you know, sort of stirs up a lot of stretching for the hamstrings. Have I, uh, done more fitness classes that requires a lot more deadlifts or a lot more squats or a lot more lunges. Have I overloaded myself in the gym somewhere? And once you identify that, if it's there, um, then you'll have to adjust that. You'll have to dial back. the intensity is dialed back the dosages or the weights or something so that the tendon has time to recover. That's the first thing you can do. The next thing you can do with being proactive is identifying, okay, now that it's stiff and sore, where's my new adaptation zone? What can I currently tolerate and how can I build a backup to where I want it to be? So it might be just backing off the intensities, backing off the overall mileage of running or cycling or gym exercises. And seeing how the tendon behaves and if day by day, if the tendon starts, uh, settling down, then you can slowly build back up. And it seems simple. It seems like it's, um, does very like broad general sense, but if you catch a tendon, if you're proactive early enough, that's all that needs to happen. You just need to make a slight adjustment. Then it gets better. And then you haven't lost any fitness and then you can just continue on your merry way. But it's. you know, weeks or months, or what I sometimes see years of people having a particular tendinopathy, that's when you need to be a lot more proactive with particular, um, strength exercises, particular rehab stuff, particular, um, assigning certain dosages and then seeing how that tendon responds to that dosage and then just adjusting the dials that way. But if you catch it early enough, it's the intervention is very minimalist at a provider that you. interpret the symptoms appropriately and you adjust those dials appropriately as well. Yeah. And I think one of the things that you just said that I think stands out a lot from a runner brain perspective is you didn't say you need to stop running for weeks, right? You don't need to take this huge chunk of rest. Can you just talk a little bit about that maybe misconception? Because I think a lot of runners, when they feel something hurt, they freak out. They're like, oh no, if I go see a physio or if I go Google myself, it's going to tell me I need to stop running. And that's not necessarily true because like you said, with attendance, sometimes it actually, it does improve with movement. You see runners sometimes take two, one of two approaches. If they start developing an injury, sometimes they pull all the way back and completely rest and say, I don't want this to get any worse. I've had an injury in the past and it's really disrupted my training for weeks and months. I don't want that to happen again. So let me just completely have seven days of complete rest. We'll give my body time to heal. Cause that's what the body does. And then we just resume in seven days time. Um, so that's one approach. The other approach is the runner that just ignores it and then just continues and says, Oh, I just need to push through. It's just a niggle. Um, I'll be fine. Uh, I'll just, you know, and they, they do the other side of things and just totally just do way too much and that just gets irritated, gets aggravated. And it's not until the injury is severe enough that it hinders their training. That's when they start like looking for answers and. trying to change certain ways. And by that stage, it's really sore. It's really irritating. You know, you need to, there's a lot more damage control that needs to be had. And the answer lies somewhere in between the two, because when the complete rest, what actually happens, if you do have a tendon that flares up and that you address that in its particular sensitive state, it's actually a little bit weaker. It can no longer tolerate the demands that it once could. And so in this momentary kind of short-term state, when it is quite irritated, it actually becomes weaker. And if you take seven days off and say, all right, it's only a little niggle. It's only a mild sort of soreness, but let me just have seven days off and let me heal that seven days of complete rest actually triggers or fosters further weakness. And so when they get back to those seven days and they start running again at their pre injury dosage, you're then. overloading it again, because it's now weaker and that further flares things up. And you think to yourself with your, your rational mind thinks, it's just not healed yet. Let me just take more time off. Let me take two weeks off and then continues that weakness again. And then they're left with a particular, um, what I call the pain, rest, weakness downward spiral. I say this a lot in my podcast and I, like, I've got a whole episode dedicated to this particular concept because the, um, this how you should negotiate this particular scenario is while it's sensitive and while it's sore, you still have a certain adaptation zone. It's not where it was. It's a little bit weaker, but let's try and find where that weak new adaptation zone is that doesn't flare up symptoms, but you can still stay active. So that might be some strength exercises that might be just dialing back your running mileage or dialing back the intensity and doing less speed work or heel work and still continue. slow running, it all just depends. And you'll have to decide with either a trained health professional to guide you along that way or accurately interpret your symptoms. And so paying attention to symptoms over 24 hours. And if everything's fine with that certain dosage and there's no flare up of symptoms, you can say, okay, maybe I've negotiated that dosage and then just slowly build up from there. So yes, in most cases. foremost running related injuries, you can still run provided that you accurately interpret how symptoms are behaving and seeing where that dosage currently is. There are exceptions to the rule. Stress fractures are usually the main exception. If you do have mild pain with that, it's complete rest. But for the most part, provided, like I said, that you're interpreting those symptoms properly, then you can still maintain some sort of running. Yeah, and I think that's really important. And with the examples that you gave, this could be maybe you were supposed to do on your training schedule a tempo run at half marathon pace, something like that. And maybe that means you do the same time on feet, but you do it at an easy effort, or you do less mileage. And I think that's just an interesting example to give. Because I think, like you said, there's those two camps of people who are like, I must rest for a week. And then the opposite end of the spectrum is like, well, let me just test it with a track workout and see if it's really injured and kind of do themselves in further. So I like that analogy. And with hamstring too, like we talked a bit about like the trading mistakes that people can make that can cause some of these like weaknesses and balances and then injury. Are there any like biomechanical things that you also see with this type of injury, like even just with running itself or with someone's particular stride or you know are there any other like muscles that get involved like the adductors or glutes or anything surrounding? The, the evidence and the research hasn't necessarily pointed to anything. Uh, we do know that people with PHT do have weaker glutes. They do have weaker hip structures. So usually when you rehab this particular condition, it's also nice to accompany the strengthening exercises with hip strengthening exercises as well. So you're doing both hamstring and both hip. So that can be quite nice. Theoretically. Um, a low cadence or running with an overstride can put a particular pressure on the hamstring. So, uh, usually when we talk about overstride, we mentioned the very first point of contact when your foot makes contact with the ground, how it far in front of the body that is. Um, because usually if you are contacting really far in front of the body, then it is putting more stretch on that tendon and it is. creating a little bit more of what we call a breaking force. And so it's less efficient as a running stride. So if someone is eliciting a really low cadence, which is how many steps they take per minute, and we're also witnessing quite an over-stride pattern, which the two usually go hand in hand, it would be recommended that they increase their cadence and that will naturally bring their foot at initial contact more underneath their body. doesn't necessarily matter whether they're a heel striker, mid-foot, four-foot striker, that doesn't matter. What does is like how far in front of their body they're making contact. So that can be something, but it's only just like a one percenter, because usually what the big rocks, the big rocks in the problem are, are just speed work and heels, because that will spike the demand so much more than what an overstride would. But theoretically, if you bring that foot, more underneath your body, it puts less of a stretch and then less of demand on that tendon. That's good to know. And like when someone is experiencing this too, like at what point, I guess in their symptomology or how long it's taking, if they're maybe trying some things on their own and it's not working, like at what point would you recommend they seek professional help if they don't maybe already like have a go-to person, like a physical therapist, physio, someone like that. Yeah, good question. I, I do like runners to educate themselves and then try and negotiate or try and manage the injury themselves. But some can be a little bit stubborn and like go way too long without the, the injury really resolving. And so what I'd like to suggest, if someone's had this for say, up to a couple of months, try building on your knowledge and try managing or, uh, changing your management plan some way, however you want to do that might be, you know, modifying your sitting, increasing your strength, uh, doing something in the gym, rehab exercises, monitoring your training loads. And you should be seeing a gradual improvement week by week. That's usually my recommendation. If you are noticing the symptoms, if you're noticing, you know, pain for the first five minutes of exercise, what sitting pain is like, what your morning pain is like. And you're seeing a slow but gradual improvement week by week, then just continue doing that thing. Just continue if, if something is working, then do more of it. If you've started doing deadlifts and it's helpful, then just slowly progress those deadlifts and then continue to notice if it's an improvement week by week. However, if you notice a plateau, which I see very often people try these strength exercises and for the first couple of weeks, they realize or notice some success. but then it plateaus out and stays plateaued for three, four, six months. It's definitely harder to get rid of. Once they go to a health professional and say, I've had this for 12 months instead of if they would have come in at the six month mark. So that's why I always say that if there is a gradual improvement week by week and be honest with yourself, if there is that, um, improvement week by week, then just continue what you're doing. But if there's a plateau or if there's constant flare ups, or if there's constant hiccups in that week by week, um, trend, then you need to seek help because the odds are if you haven't identified something or there's maybe some tweaks that you're unaware of that could help proceed the right direction, um, and you haven't picked it up yourself, then it's going to be the odds of you continuing in that flat up state and having those future hiccups or having that plateau stay at a plateaued state. The odds are quite high. So that's when I usually recommend seek professional guidance, um, and change up your management plan. Cause if it's not working, what you've previously been doing, then don't continue doing it, which is a really big tip that I have for PhD clients, cause I talk with them all the time. Like my caseload currently is about 70% of my entire caseload is PhD. So I'm very familiar with their particular, um, how they've tried to treat the, it themselves. And a lot of them have been doing body weight exercises, body weight bridges, single leg bridges, body weight, maybe say clam shells or theraband clam shells or glute work. And it's very minimalistic, but sees initial success because strength work is good for PhD, but they only just continue with that body weight exercise for six months. And they do see that initial success and it just plateaus out. And... because they've seen that initial success, they start doing more of it. They start doing more reps or, um, they start maybe applying a little bit of weight, but this stays really light stays really body weight, just higher reps. And they just, um, have created a ceiling for themselves rehab wise. And it's not until they start progressing those exercises and doing heavier stuff and fostering that tendon to adapt to heavier stuff, which is where they see better, or they see a bit of a kickstart in their rehab trajectory. This podcast is sponsored by the Run Smarter series. If you wanna take your knowledge building to the next level, I have built out a proximal hamstring tendinopathy video course, which complements the podcast perfectly. Sometimes it's tough delivering concepts and exercises through an audio format, so the course brings a visual component full of rehab exercise examples, graphs, and visual displays to enhance your understanding. Even if you sign up now, you'll have access to all current and future modules that I create. Sign up through my link in the show notes, then download the Run Smarter app, and you'll instantly have unlimited access to all the course resources on any device. And to say thanks for being a podcast listener, I want to give you a VIP offer. There will be a link in the show notes in every episode that will provide you 50% off the course price. Just click on the link and it will automatically apply your 50% discount. With making that transition where someone is doing those exercises, they've been seeing some success, they're comfortable with it, it's body weight, they're not intimidated by it probably, do you see one of the barriers to adding more weight being unsure of what levels of pain are normal because they're not used to strength training in general? And how would you help someone navigate doing that in a safe way that's productive? There are definitely ways you can be safe and have a very gradual step. And a lot of people are very fearful of doing squats and deadlifts because sometimes that's what's flared them up in the past. Sometimes they've read or listened to information said deadlifts are really good for the recovery of proximal hamstring tendinopathy. And then they do deadlifts and it's way too much. And then they just flared up for seven days. And then they're scared to return back to it because they think that's not good for me. But it does need to be in their program, no matter how gradual it is, sometimes I start with people doing dead lifts and they do maybe 10 pounds and maybe like for the most severe cases, cause sometimes I see people with this for four or five years just because they've mismanaged it for that long, that period of time. But as soon as they start managing and doing the right things, they start getting better. So if someone is really weak, really irritated, like the worst case scenario, I start them with 10, 15 pound. Deadlifts. And all they do is a quarter range. That's all they do. They only just bring the dumbbells just above their knees. And maybe they'd hold that. Maybe they hold it for five seconds and then come back up. And then maybe they do that 10 times and that's a start. And we pay attention to symptoms along the way. Pain during the exercise is totally fine. As long as it's around, if it's under four out of 10 pain and how we subject to that is a bit of another story. But, Recently speaking under four hour, 10 pain that doesn't carry over and flare things up afterwards and pain returns to baseline within 24 hours, that's usually fine. In fact, if you aim for pain-free exercises during the exercise, if you aim for pain-free, your progress is going to be very slow and it's going to be so hard to make those adjustments where in fact, I prefer if the pain level is a zero or a one during that exercise. It's worth increasing the way it's increasing the range of movement to try and hone in around that two or three out of 10 pain, because we know that's, you're going to be more productive and we know it's not harmful for the tendon. You're not making the tendon worse. And yeah, the, the progress is a lot easier, a lot swifter and a lot quicker when you are allowed those pain rules. Cause we know that we know that tendons, um, can progress very well and they adapt very well to slow, heavy load. Um, even if those pain guidelines are placed in there. I'm really glad you mentioned that because I think that is like, uh, it's intimidating, like if someone is going to add, you know, more complexity to their program and then they're like, Oh, that really, you know, I, I feel something, you know, in the hamstring and I'm kind of afraid to keep going with that. So I think that too is probably where working with a professional and having that guidance to say, no, like this is actually okay, um, is really like encouraging. Yeah, I totally agree. And I understand the fear that people have. I understand that if they've had a flare up from a certain exercise in the past, or they think that if they really load up their tendon with heavy stuff, that it's going to make the attendant worse, it's going to create more of a tear. It's going to just further contribute to the pathology. I understand all those apprehensions that are in there, but if you're educated correctly on the right pain levels and the guidance and all that sort of thing, then actually a little bit of pain during exercise should be encouraged, should be fostered. So yeah, it does take a little bit of education, just reassuring a lot of people. Yeah. And with, with the proximal hamstring tendinopathy, do you find that like, I guess where, like if someone's coming to you in particular, like let's go with someone where it's a bit more complicated, maybe they've had it for several months or even years. Um, and maybe they have tried certain things in the past, like where would you typically start someone like that? Um, in like the actual like strength program and how would you progress them? Like how quickly do you typically like add weight and at like what intervals and range of motion to what you mentioned? Yeah, it's going to depend. Cause you might have a 55 year old frail lady who's never done strength work before and just loves running, but hasn't run for six months because of this. and hasn't done any gym work, that's going to be different from someone who's had it for the same amount of time, but is still running and is doing a little bit of gym work that does flare them up here and there, but still they've got very different starting points. And so it's my job as a therapist to try and to find out what factors I can gather to find a starting point. And so you ask them about what their exercise has been like the past few weeks or the past few months, what their... experiences like with heavy lifting or with gym stuff and, um, what their sitting tolerance is like, what it's feel, what it feels like to bend forward, like all these sorts of things, just gather a little bit of data for us to justify. I think this is a starting point and that's just a guess based on the data and based on my experience. And we just have that starting point to see how you respond. And what I do with my online runners is have them document and comment on day by day when it comes to certain exercises. I felt a two out of 10 pain during these dead lifts afterwards. It was a bit achy for maybe two hours, uh, by the next day, return to baseline symptoms. And then we can say, fantastic. That's a success. Let's see if we can get away with a little bit more. And then we're slowly just dialing it up a little bit more to see, and just seeing how things respond. So it's very tailored, um, how they progress. If someone. was to do a deadlift of the same dosage and say, oh, my pain was like a three or a four, unsure what it was and lingered around for a few hours. And the next morning it was slightly irritated than it was the morning before. Then you're sort of thinking, okay, it's not alarming. We definitely won't progress. Maybe we keep at that dosage for a week and see if those symptoms calm down. And if they don't calm down, maybe it's worth backing up a little bit and regressing slightly. Um, but usually I like to see how we go starting with lightweight and then getting a full range of movement. So start with a quarter range, then go to a half, then go to three quarters of range. Um, once they're at three quarters of range, then we could probably start to add in, um, some heavier weight. But if they're not agreeing to every attendance difference, so if they're not agreeing from that quarter range to that half range, if that little jump always flares them up. then let's just go heavier and stay at that quarter range because we do want the tendons to be triggered by slow heavy movement because the slow heavy stuff is really nice for the tendons provided it's the right adaptation zone. They get people recover so much quicker. And so it's nice to include the heavy stuff really early on. Even in fact, a lot of people say that they're scared to add weight because their body weight exercises produce a five out of 10 pain and they're thinking, you know, adding weight will actually increase that pain in some circumstances. You have people that actually add the weights and they start feeling better compared to the body weight exercises. So it defies all logic in someone who doesn't know how tendons behave. Cause I say that on my podcast all time, tendons love slow, heavy load. And if you can foster a dosage that doesn't create a flare up afterwards, then you're on the right track and then you need to start being progressive with that. I think that's really helpful. And I think it's helpful to define like, okay, at what point, um, you know, wasn't, not that it wasn't like success, so to speak, but at what point was the soreness after the morning after, or like what sensations were kind of a flag to say, okay, we're not going to go further, but What I think is helpful is if we're going to stay here, we're going to cause this again, potentially, but it's for the greater good. I think it's helpful to have that professional guidance because to the average person, they're like, heck no, I'm not doing that again. It caused pain, right? So I think that's really interesting to know. And with just the different types of exercises that you work on with people for hamstring, can you just go over the different types of movements that you would do from a basic standpoint? the hinge, you know, and different ways to load the hamstring and what you tend to find is a bit more triggering to flare ups. Definitely things that involve tendon compression do have a likelihood to flare things up compared to things that don't have compression. So if you do a prone hamstring curl, like if you lie on your stomach, on the floor, and you have a thera band or resistance band around your ankle and attached to something close to your feet. And then you curl that. and put tension on that band close and bring it towards your hips. That's a prone hamstring curl that isn't compressing the tendon. It's kind of like opening up and not stretching the tendon around that sitting bone. That's less likely to flare people up compared to say a deadlift, which creates tension and creates this eccentric lengthening of the tendon and the muscle under compression. So when the hips bend, the tendon kind of presses into the hip, uh, the sitting bone a little bit more forcefully, which is encouraged. We want the tendons to start tolerating compression, but initially, if that particular exercise fleshings up, then it's best to do things outside of compression and slowly work into compression as the, the tendon adapts. So yes. In the very, very early stages, you can do some hamstring curls. So prone hamstring curls with a band or at the gym with some light weights, you can do bridges because bridges, um, tend to be out of compression, tend to strengthen the hamstrings, particularly if your feet are walked a little bit further away from your hips. So what we call a long lever bridge. That can be quite helpful. Sometimes when you do a bridge with your feet up on a step, up on a bench or up on a ball or something. that tends to activate the hamstring tendons a little bit more. So we're strengthening the hamstring muscle itself, but as quickly as possible, usually from day one, usually we can skip a lot of those first initial exercises and go straight into compression. So my favorites are deadlifts. And that's with whatever variation possible that might be quarter range isometric. So you're holding rather than moving in and out of that movement. Um, but if you can tolerate it, that's going in there day one straight away. Uh, weighted step-ups can be a nice one as well. So you're holding onto some dumbbells each side and then you're stepping up onto a box or a bench or a step or something and doing repeats of that. That tends to be some of my favorites as well. Um, sometimes just lunges, if they can tolerate sometimes lunges flares people up, if they can tolerate it, then we're putting it in there and then just some glute stuff, like I said, um, people with hamstring tendinopathies tend to be a little bit more successful if you concurrently add in, um, some hip exercises. So crab walks, um, or like TheraBand side to side walking, uh, hip hikes or hip hinges are a really nice one and just trying to incorporate a few of those. But then it could just be very generic after that. So those base foundation exercises were then progressing. If you just do deadlifts and you get really good at deadlifts, you're going to do it very well for your. a hamstring tendon. And then after that, like the next stage is just trying to tailor to your specific demands. So if you are a triathlete, or if you are trying to do a fast 5k, then we want to try and introduce some speed. We want to try and introduce something that's a little bit more fast. So kettlebell swings or single leg deadlifts or box jumps or plyo lunges, all these sorts of things that just try to mimic the demands of the tendon that we want to call upon it in the, in your future goals and future demands that you want and future capacities and, uh, all those sorts of things. This podcast is sponsored by the run smarter series. If you want to take your knowledge building to the next level, I have built out a proximal hands-on tendinopathy video course, which complements the podcast perfectly. Sometimes it's tough delivering concepts and exercises through an audio format. So the course brings a visual component. full of rehab exercise examples, graphs, and visual displays to enhance your understanding. Even if you sign up now, you'll have access to all current and future modules that I create. Sign up through my link in the show notes, then download the Run Smarter app, and you'll instantly have unlimited access to all the course resources on any device. And to say thanks for being a podcast listener, I want to give you a VIP offer. There will be a link in the show notes in every episode. that will provide you 50% off the course price. Just click on the link and it will automatically apply your 50% discount. And that's great. I think it's important that you mentioned, and I've heard you say this on your podcast before, part of the physical therapy routine should be introducing the speed work, the actual running components. So I guess what are some common mistakes you see in runners when they're like... been strength training a lot. My hamstring feels great. I'm doing awesome. And I want to go get back into speed work. Like what, what are some mistakes that you may maybe see runners make and what, like, again, it probably depends on the person, but like, where do you typically start when it comes to adding in some of those triggering things in the actual sport, like speed work hills, or like getting off the bike and doing a brick run. And again, it's like, gathering as much data as I can to come up with an answer similar to, okay, what, what strength exercises can we start with? Well, let's gather data of how strong they are in the past and their capacities. The same thing is with when we need to introduce running or introduce speed work. It's like, okay, how much do we think the person can tolerate? Have they been running? If they haven't been running for more than two months, then we're starting from baseline. We are starting from the most basic fundamental exercise. a lot of walking with a little bit of running. I usually incorporate a, um, progression chart, run walk progression chart. And the very first one for most people is they do four rounds of running for one minute, walking for two minutes and just, just do that. So all in all, the exercise itself probably goes for about 12 minutes. Um, and we have four minutes of running in there and that is slow. That is. level flat terrain and just seeing how people negotiate. Exactly the same with the deadlifts. We pay attention to symptoms during, symptoms afterwards, symptoms the next day. And if that's successful, then in a couple of days time, you can do the next thing. That's for someone who hasn't ran for a very long period of time. So it is a very conservative, very slow dosage, but some people are like to start halfway down that progression chart and say, let's give this a go and see how things go. And then once they're into say 30 minutes of running, or say 45 minutes of running continuous without issues. Then let's start to introduce some speed work and speed works very subjective, which is where a lot of runners do sort of get it wrong. Um, because speed could be a flat out sprint, or it could just be a very, very slight uptick in your current slow running. That's introducing speed, but where do we, how do we introduce it? Usually I. introduce either speed like as in just measuring their miles per minute or their kilometers per minute, um, or just measuring their rate of perceived effort. So their RPE out of 10, how intense they feel that exercise is, and then to slowly introduce, introduce again. So let's say let's do a 30 minute continuous run, but throughout that continuous run, let's do 60 seconds of a slightly faster speed and let's see how that feels and do that four times in that run. And then we're slowly introducing more and more and more. And so you asked at the start, like, what are some common mistakes and where, where do people go wrong? And usually it's, uh, doing things too quickly, not being patient, not interpreting symptoms, um, appropriately, but then just not knowing that there are all of these little, um, these little steps, these little like progressions forward, they think that, okay, I've done my strength work. I haven't ran for 12 months, but let's see how running goes. And they run for four miles. And then they, then it flares up and they say, Oh, running, I'm not ready for running. Um, maybe I'll wait for a couple of months, but you know, you can run really slow and you can run really short and that's a success. And then we just build up from there. And so it's trying to work out those little progressions and diligently going through those progressions, which is the safest possible way. Yeah. And unlike that, um, other end of the extreme we were talking about where, you know, They're like, well, maybe I'll fight fire with fire and see what happens. I think sometimes like ego or just comparing your past performances can get in the way where you're like, yeah, it's just for miles and that's an easy run. But if you haven't run in several months, or if you're kind of baseline has decreased a little bit because of the week tendon, then you got to start maybe at like a run walk or two miles or something like that. Um, so I appreciate throwing that in there as well. And I know this could probably also be another podcast episode within itself, but for this particular. issue, I know you talked about the research supporting, um, like the kind of slower, heavier loads and strength training and some nuances to that. Are there any other, what I like to call like fancy therapies that are also effective for this, like dry needling shockwave therapy? There's a lot of things out there right now. There are tons. Um, I will start by saying that a lot of the hands-on stuff is just based on the individual response. So sometimes dry needling can be really effective. Sometimes a massage can be really effective, but they're usually for short term only massage guns. I've seen people use that a whole bunch. Um, it's, it's for a short term only. It's only settling things down. If it does sell things down at all, it all depends on the individual, but it might sell things down for one to two days. And in those ones, two days, that's when we like to have the opportunity to do your strength exercises. That might be a little bit sore. beforehand. So it gives you an opportunity or a bit of a window to be more proactive with strength training, all the stuff that we know works really well in the long term. But that's all individual preference. The shockwave, you need to pick your person that there's different responders to shockwave. I've had Benoit Matthew on my podcast, who's a shockwave specialist, the right candidate for shockwave. is usually one who is low levels of pain and is really stubborn, just not responding to good management treatments. So if people have applied progressive, heavy, slow loading, their load management is, um, on point, they're doing all the right things and it's still stubborn, hovering around this one or two hour 10 pain all the time. The shock wave is designed to, um, wake up a dormant kind of stubborn tendon and actually makes things a little bit worse, but then it at least kickstarts things too. So you can start seeing benefits with all that stuff that we've mentioned before. So people get confused because I think shockwave heals tendons. They think it helps recovery, but it actually makes things worse and stirs things up. But the intention is to stir things up so that you start responding to good management, heavy, strong loads. And so usually if you are a good candidate, Three to five sessions is what we recommend. By three sessions, you should start noticing some benefits. If you don't, it's probably not worth going to four or five, but I've seen people have like 20 sessions and they say it's not getting any better. I'm like, why have you done 20 sessions then? Because Shockwave is relatively new, there's a lot of different opinions around candidates and how effective it is. The other touchy subject is like PRP is really highly recommended in the US for some reason, really popular, and I just haven't seen any benefit. There's, when it comes to PRP in tendons themselves, the general consensus is we shouldn't really be injecting things into tendons. For the most part, we really shouldn't be doing it. PRP isn't great, doesn't show a lot of evidence for the longterm. If anything, the... the outcomes are slightly worse in the longterm, but it's like a little bit better in the short term, just because it might have some sort of pain relieving or placebo kind of effect. Um, but in what I've seen in all my PhD clients, a lot of them have had PRP and they said, just didn't do anything. So, um, be very, very careful with approaching that surgery is another one that people need to be very, very cautious about because you're not healing. the tendon, you may be just repairing some tears here and there, but the capacity and the strength and the pain would probably still exist. Definitely. We're not doing anything to strengthen the tendon or build up its capacity with surgery, maybe cleaning some things up here or there, or maybe some scar tissue, if that exists, but you really need to pick your battles. But the most part is do the long-term stuff and the evidence, evidence-based stuff really well. So that's the load management. That's the heavy strength training, progressive. with your strength training. And if you don't see any benefit with that really good management, then you can start looking at some alternatives, but I rarely see someone doing things really well that doesn't respond. I appreciate that because I think, um, you know, it's really nice to be like, Oh, I just go and I get this thing done and I just sit there and I don't have to do anything. Um, and it heals me like that is the magic bullet we're all looking for. And I think it's important to say, yeah, like Some of these can be helpful, but you really still have to be doing these other things, especially when it's a tendon, because the tendon has to get stronger and none of these are going to make the tendon stronger on their own. Um, so I appreciate that because there's so many options out there now. And a lot of people have Thera guns in their home, so, um, they use them, use them smartly. Um, but man, yeah, I mean, we could talk for such a long time on this. I know you're such a wealth of information on so many injuries, but in particular. this one, especially if you have such a huge client caseload who deals with this. Um, I'm sure they really appreciate you, but where can everyone listening find you and your practice and your podcast and all the resources that you offer. So you can go to the run smarter podcast is wherever you find your podcasts. And I always recommend people go listen to the first 10 episodes. So the 10 universal principles to overcome and manage and reduce your risk of injuries. Um, and then. once you had a listen to those 10, you can flick through the feed and find topics that you're interested in. I also have a second podcast that not a lot of people know about. It's called the Overcoming Proximal Hairspring Tendonopathy Podcast, which is a mouthful, but is addressing PhD specifically. If you do have PhD, it'd be a wealth of resource for you to go to. Anything else like on Instagram, I am at Run Smarter Series. If you are interested on just where the evidence lies with a lot of these. particular issues, um, you can go to there and on my podcast in the show notes as well is a link to, um, a free injury chat. If you wanted to have that, just to have a chat to see if there are ways or to better understand your injury or online physio is appropriate for you and how that exactly works. Um, the link to that is on my website as well. And it's run smarter.online. Awesome. Yeah. I appreciate that. The PhD podcast also sounds very appropriate for this conversation. So I appreciate you plugging that as well. Um, well, and I'm going to ask you my end of the podcast question. I don't know if I warned you about this or not. Um, but basically you are about to cross the finish line of like the best race you've ever had great day. Um, your hamstring did not bother you the whole time and what song would be playing to embody what you're feeling in that moment. Uh, I would say Macklemore can't hold us is usually the one that gets me up and going. So I'd pick that one. Oh, that's a great song. People have no one said that before, but that's, that's a good one. I am quite different with my music selection, but yes, it would get me pumping. Oh, I love it. Well, Brody, thank you so much for coming on the show and I hope people go check out all of your resources and yeah, thank you so much. Brilliant. Thank you for having me. 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 to stay safe. Knowledge is power.