Developing your PHT flare-up plan

: today's episode, developing your PHT flare-up plan. 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 bust the widespread misconceptions. My name is Brody 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. Okay, let's get stuck into today's episode. Obviously, I'm not too sure why we haven't come up with this topic in the past, like it's taken 33, 34 episodes, but this is what we're going to talk about today, developing your flare-up plan. And it's on the back of this, like to start off with, obviously tailored advice is always going to be the best because everyone's so individual. A flare-up plan... taking into consideration all of your circumstances, like all of your, your current strength, um, what goals, what fitness goals you have, what you do on a day to day basis, um, what duties you have outside of exercise and outside of your rehab, all of these things combine or should be considered within your flare up plan. And so knowing that I'm trying my best today to kind of come up and provide generic guidelines, I guess you could say. Um, at least give you some sort of template that you can take away and say, okay, I get this is kind of how a flare up plan works. Um, because it's super, super important to have a flare up plan in place. Along with your, like your rehab, along with your management plan, your journey to get back to where you, uh, where you want to be at, like your rehab ladder. Establishing a management plan is key. Um, having a plan is key and a flare up plan should just be a part of that management plan because, uh, it's almost expected that you, you develop a flare up along the way, but I know almost every single running related injury I've had. I've rehabbed it, done all the right things, but there's been some hiccups along the way, there has been some sort of flare up where it's just what I accept. I expect that when I rehab things, I am going to challenge my tissues. I am going to. um, challenge them through strength. I'm going to challenge them through exercise, through return to running. I'm just going to see what tested out and see what I can, what I'm, what I'm capable of, and if I get too close to flirting with that injury kind of boundary, or if there's a combination of several different factors, um, maybe I've exercised in a safe range, but then I under recovered and then, um, I was sitting for a long period of time outside of my rehab and like a whirlwind of combinations could just lead to a flare up. That's just what's expected. It's just a part of any sort of rehab. And I know it can cause a huge emotional strain on people when they do experience flare ups, when they experience multiple flare ups, when they feel like they've taken one step forward and then four steps back. And they feel like they're starting from stage one or step one. And I understand that can be extremely frustrating, but flare-ups are a part of recovery. And we know that recovery is in this linear line where your goal, this end stage goal that you have, is off in the distance and our rehab is just this nice, smooth, linear, trajectory towards that goal. Just doesn't work that way. There are hiccups, there are U-turns, there are downfalls, but generally week by week, month by month, we're heading closer and closer to that goal. Hopefully, if your management plan is right. So keep that in mind. Um, what might influence a flare up? Like I said, it could be a mechanical, you could just have gone from running 20 minutes to running 30 minutes. And that was just too much. It's still, um, on the mechanical side of things with your rehab, you might've increased your amount of. Deadlifts from, you know, four sets of 10 to four sets of 15, or just up the weights too much, so there's, there can be a mechanical component. it could just be under recovery, maybe not sleeping as well. Maybe just, you know, hydration, nutrition, sleep, all these sort of things just lead to under recovery and cause a flare up. But we do know that pain is very much influenced by a multitude of factors, this biopsychosocial thing that we talk about. So stress can heighten pain sensitivity. We know that stress can just... elevate pain levels and just spark up a flare up just without anything mechanically happening. Because we do know that pain is all to do with the brain and so multifactorial. And keep in mind that every flare up is different. Every flare up could be minor, could be major, could not disrupt your current strength program or your current rehab journey. Or it could have a significanting... influence and a significant disruption on the recovery of your PhD. And so when we're coming up with these management plans, or in fact, when I'm working with my athletes online who do have PhD and they want this, um, flare-up management plan, I often, um, give them a couple of choices. Cause we're not too sure about what current flare-up they have. We're trying to predict about a future flare-up and what the advice is. And so this is when it can get quite tricky. And the advice that I've kind of compiled in today's episode, I've taken a couple of my clients and kind of combined all the evidence, all the, um, all the advice that I've given and kind of just merged into one, but, um, I do provide different advice compared from a minor flat up to a major flat up. So, um, I will write down for. certain individuals, okay, if you have a minor flare up in the future, these are the things that might happen. If you have a major flare up in the future, these are some things that we might need to consider, this is how we need to influence your, your rehab. And once they understand those two extremes, then any other flare up in between, because it's kind of on a spectrum, right, you could, it could be minor, moderate, major, anything, anywhere on that spectrum. But if you know the minor things that we should do, if you know the major things that we should do, then we can kind of just through trial and error, just follow these guidelines somewhere in the middle. This podcast episode is sponsored by the Ransmata Physiotherapy Clinic, which is my own physio clinic where I help treat a wide range of PhD sufferers, both locally in person and all over the world with online physiotherapy packages. In the years I've been self-employed as a physio, Close to 70% of my entire caseload has been helping people with proximal hamstring tendinopathy, which is why I decided to launch this podcast. So if you're building upon your own rehab knowledge through the podcast, but still require tailored assistance, I'd love to be on your rehab team. Whether you are a runner or not, head to runsmarter.online to see your available options for working together. If you're still unsure if physiotherapy is right for you, or if you need a rehab second opinion, You can always schedule a free 20 minute injury chat with me. Find the free injury chat button on my website or in the podcast show notes to be taken to my online calendar to book in a time. Okay. So let's start with a minor flare up and what causes a minor flare up. Not important at the moment, but these are some instructions, some very generic template instructions. If someone were to have a minor flare up. Um, first. Never try not to progress too much through your plan. As your rehab journey starts, you'll notice that you want to increase, steadily increase your capacity, steadily increase the weights in the gym, steadily increase the amount of running you're doing or cycling or anything. During a minor flare up, we don't want to progress any of that. We either want to keep things really stagnant. We want to repeat what we did the previous week. Um, especially if you don't notice anything mechanical that cause the flare up, like if there was a spiking training, we don't want to repeat that. But if you knew that what you did the week prior was previously, um, okay for the tendon, then we might want to repeat that and just continue to monitor symptoms along the way, um, for the first one or two days of a minor flare up, just relative rest. So, uh, I'd say no running or reduced amount of running if you're a runner, but that could apply to gym exercises or. cycling or the rower, whatever cardio based exercises that you're involved in. So relative rest, let the, let the tendon just settle down a little bit day two. So we're not resting for a lot day two. We can resume some loading, which would be, um, depending on the symptoms. It could be anything that just. That just the aim is just to maintain the, the load tolerance or the tissue tolerance, and so that could be isometrics. It could be your isometric bridges or isometric deadlifts or, um, single leg, maybe out of compression, um, exercises like a leg curl. Um, those prone leg curls, everyone knows these can be some low level exercises that you might want to start day two and then again, following symptoms. So one to two days relative rest by day two or three, we're resuming our loading. Just, um, Just paying attention to symptoms along the way. If responding really well, if you're responding well, my dog Jasmine just decided to have a shake. If responding well to those loading exercises, then we resume your gym and rehab exercises at about, I say about 70 to 80% of your pre flare up. So if you're previously doing deadlifts, well, let me give you an example. If you're doing deadlifts at say 20 kilos, You might want to back that off to 14 or 15 kilos, just something that's, um, you know, that you can tolerate. Well, we're loading up the tendons. So we're being proactive that way, but we're just not doing as many. We're not challenging the tendon in the same way. And then pay attention over the 24 hours after that, just to see how things go. So just a very generic kind of, um, ratio 70 to 80% pay attention to symptoms along the way, but that's if you're responding well. to day two or three loading exercises. If you're not responding well to those loading exercises, then it might be more of a major flare up than you were expecting. And we need to take it a bit more cautiously. So let's assume that you started loading it up again and you're responding quite well. Then we can return to the gym two to four times a week. And let's just say you started at 70% of pre flare up capacity. Then we... Every time, every week you go back into the gym, we, or every, um, every session that you go back into the gym, we're plusing or minusing 10% depending on how symptoms went. So if you started conservative and you thought, Oh, let me go to 70% of my pre flare up capacity, we've done dead lifts at 15 kilos and we've responded well to that and responded well to 70% of all those other rehab exercises. Then next time we go to 80%. So we're increasing. our overall rehab dosage by 10%. Um, and if you respond well to that, then next time we're in the gym, we increase it by 10% again, and we go to 90% of your pre flare up dosage, whatever that may be. But, um, converse to that. If you don't, if it doesn't agree with you and it's the irritation continues, then we minus 10%. So we might go from 70% to 60%. And you'll notice that, okay, there's not a lot of time in this plan to rest, but we're being very proactive because the tendons love load. And as long as we foster the right environment, then the tendons going to respond well and settle down in that flare up plan, just like that. What is going on with Jasmine? She decided to ruffle up her bed. I thought it would be quite nice to have Jasmine in here while I'm doing my recording, because if I put her outside, she starts barking at the neighbors, especially at this time of the day when school finishes and we've got kids running outside. So I put her in here and now she decides to disrupt. As soon as we started the episode she was sleeping and it seems like as soon as I hit record she's like yeah let me try and be the center of attention. Anyway I digress. So you go through 60% of your pre-flare up routine and if that's still too much and there's a flare up then you might want to downgrade to 50%. Uh, and we're just constantly being proactive, constantly trying to find what sort of loading the tender responds well to. And once we hit that spot, then we slowly work our way back up. Um, so I hope that message comes across, um, also during like PHT specifically, if you experience a minor flare up, we want to be mindful of what you're doing outside of your rehab. So be mindful of sitting. We know, let's just say, if you could tolerate two hours of sitting without the attendant getting angry. And then all of a sudden you have this minor flare up, that two hours might cut down to maybe 40 minutes. And so we really wanna be careful in those couple of days while that attendant's sorting itself out that we maybe stand up and move around a little bit more. So sitting's one of them, repeating, bending forward. So if you're constantly picking things up off the floor, like say a kindergarten teacher, just constantly picking things up, If you're cleaning the house, if you're vacuuming, and there's a lot of bending forward, bending forward still okay, even if there's a little bit of pain, but that repeated bending, like, you know, sometimes it could be up to 50 times throughout the day. We really want to limit that during this particular flare up stage. And static stretching, again, very low amounts of static stretching can be okay. But during it, just say for an example, during a minor flare up, you might not want to go to a yoga class and just do a lot of stretching, even if it's, if you've tolerated that quite well in the past, if you've built up that tendon capacity to tolerate a lot of stretching during a particular flare up, you really don't want to be doing a lot of that. Um, so, uh, to kind of summarize the minor flare up management plan, it is one to two days relative rest. Don't challenge it. Try not to challenge it with a run or like a big cardio workout or some heavy weight sessions. Just take it easy. Um, then resume loading and you'll start, as you have more and more flare ups, you'll start to know more about that. Actually, I might put that in my notes. I might put down when I get to the bottom, what I do with my flare ups and then that might help provide a little bit of clarity. I've had a very recent flare up actually, I might talk about that. So we're going from the minor flare up management plan now to the major. So if you have a significant flare up, a significant increase in symptoms, what should we do? So first two to three days, we take relative rest and this time maybe some anti-inflammation tablets are optional for two days. We definitely don't want to take it for longer than two days. We know that anti-inflammation medication can be detrimental long-term for tendon health. So keep that in mind. Then we have after that particular relative rest, phase, maybe about day three or four, we resume some level one loading that might be same as before, might be some isometrics, any sort of loading that we can tolerate, so trial and error, and see how that loading response influences the body and influences the tendon. If responding well to those low levels, so it'd be similar to that isometric kind of advice in the minor flare ups. Then we can return back to our strengthening. However, we remove all plyometrics. We want to be sure that during a major flare-up, plyometrics are removed for maybe a week or two. But we resume back to the gym at about 50% to 70% what we were currently doing. So while the minor flare-ups was 70% to 80%, this one might be about 50% to 70%. So if your deadlifts were 20 kgs, now we're going to deadlifts 10%. kilograms. So not a lot, but just loading it up somewhere and seeing how the tendon responds. And like anything else, we're doing plus or minus 10% every gym session, depending on symptoms. If you do those 10 kilos and the tendon still flares up, then we might keep the 10 kilos but do less reps, might do a reduced range of movement. So only doing half deadlifts, we might dropped down to say eight kilos. Like there's a whole bunch of different variables that we can play around with, but just starting somewhere, seeing how the tendon responds and then, um, build on or, um, yeah, so if we're following this principle, if you're doing your rehab three to four times a week and we start at 50% and everything responds really well, then in about a week and a half, you're back to pre flare up symptoms. Sometimes it might take two weeks because you might have some sessions where tendons are a bit sore and you might reduce or keep at 50% for a couple of sessions. Then once the tender feels quite comfortable, you might want to increase the 60 and 70, 89%. Um, but it's usually about a, yeah, 10 days to two weeks kind of process before you're at pre flare up symptoms or play pre flare up dosages. Whereas with that minor flare up, might only take a week. Um, so again, every flare up is different, but these are just general guidelines. Once you're tolerating 80% of your strength training rehab, that's when we can resume some cardio, it's when we can resume some plyometrics, but you want to resume cardio and plyometrics at about 70% of your pre flare up symptoms. So, uh, let me just use a example. We've had a major flare up of the tendon. We used to run half an hour. So for the first week, we're slowly bit, we've, we've not been running, but we've increased our strength, um, all the way up from 50% all the way to 80% tenants doing really well. So we say fantastic. Let me slowly, um, implement my plyometrics again. So maybe kettlebell swings and let's slowly implement say some running, but we're starting at 70% of what we were currently doing or of our pre-flow up symptoms. So. that 30 minute run is now like a 20 to 25 minute run. See how things go. And again, we're paying attention to symptoms along the way and just fluctuating those dosages depending on the tendon. So we wanna make sure during these flare ups as well that we're recovering very well. Wanna make sure that our stress is addressed, wanna make sure our sleep is addressed and all those things that allow for good recovery. I had a list of how many is here about eight, um, seven or eight, um, factors that can influence, um, a certain flare up or things that I ask a runner or ask my clients to see how, um, significant of a flare up it is and just judging how much of a flare up it is, cause you might be sore and you might think, oh, it's not actually that bad or is it a mild, is it a major So these are some questions that I'd ask. One, what was your previous tendon capacity compared to now? So let's just say sitting. If you could sit for an hour, but now it's only 10 minutes, those sort of questions. Previous strength, so what sort of capacity, what sort of like either cardio capacity, how long were you running pre flare up compared to now? How much can it currently tolerate? How much strength can it currently tolerate? So. um, lifting, how many dead lifts, how heavy dead lifts was it tolerating compared to now? What are the pain levels? Was it a two out of 10? Now it's a six out of 10 irritability levels. So, um, after doing my dead lifts, pain used to hang around for 10 minutes. Now, after doing dead lifts, pain hangs around for two hours. Those sort of irritability levels is the pain itself localized to that area, or is it now quite widespread? And what's its response to low level loading like isometrics is how much pain is there during isometrics like a static bridge. Um, and just these sort of questions I like to ask to determine how significant of a flare up it is. Um, so that's what I have written down and now I have written down sort of my experience with a flare up. Um, because my tendons, my hamstring tendons, I focus really hard on building up a lot of capacity, a lot of strength. I do a lot of power-based stuff, strength-based stuff, even when the tendons are a little bit sore. When I have a mild flare up, I like to load up my hamstrings. I respond very, very well to heavy load. And so a couple of weeks ago, driving down to a beach house that we have in Ocean Grove, a lot of sitting, and then just while we're there, a fair bit of sitting. Um, so when I got home, the next couple of days, my tendons were, my hamstring tendons were just a little bit achy. That's a mild flare up for me. And I decided to dedicate the next couple of days to really heavy, slow loading. So that's single leg deadlifts for me. That's, um, deadlifts with a barbell and, um, Nordic hip hinges, just focusing on those for a couple of days. And then the tendons respond really well for me. I can't remember the last time I had a major flare up, but if I was to wake up tomorrow, well, I've got to play basketball tonight. So possibilities that it could be a major flare up if I do something very silly. But if I woke up tomorrow and both my tendons are really achy, definitely would do any running for the next two or three days. Um, I would focus on the static bridges. So, um, long lever. Isometric bridges, do those several times throughout the day just to load it up somewhat, limit my sitting, do a lot more standing. And then just pay attention to how things go. If I was to return to running, I'd do a walk run program and base symptoms along the way, slowly get more involved in my deadlifts, slowly get more involved in my squats. And yeah, pretty much just following what I've just said. Just Um, increase by 10% plus and minus depending on the symptoms and then just take from there. Um, so that's a hopefully, I hope that makes sense. Hopefully these, this template kind of makes sense. Everyone's gonna, uh, ask sort of individual questions or how your circumstances are different compared to what I've just illustrated. But these are just, like I said, very generic, um, any other advice, any other tailored advice, it just have to depend on the individual and which is why all of my. flower plans that I give my clients are so highly individualized because we're all human, we've all got lives outside of our PhD recovery and so we need to factor those in. I hope that made sense. I don't know what I have scheduled in for the next episode. At the time of recording this is going out in like three or four weeks and so I'll do some planning in a couple of weeks time for the future episodes but Yeah, hope you enjoyed. Hopefully this is almost kind of helps reassure you that flare ups are totally normal and hopefully you can write down your own flare up plan and if that doesn't work or you need more guidance, I'm always here to help. Um, but yeah, hopefully you enjoyed and we'll catch you in the next episode. Thanks once again for listening and taking control of your rehab. If you are a runner and love learning through the podcast format, then go ahead and check out the Run Smarter podcast, hosted by me. I'll include the link along with all the other links mentioned today in the show notes. So open up your device, click on the show description, and all the links will be there waiting for you. Congratulations on paving your way forward towards an empowering, pain-free future, and remember... Knowledge is power.