Expert opinions on PHT treatment (2021 paper)

: today's episode expert opinions on pht treatment. 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. I haven't done an episode releasing a paper in a while and I've got a good one that came out last year. It is in the Journal of Physical Therapy in Sport. The title of the paper is Proximal Handshake Tendonopathy Expert Physiotherapist Perspectives on Diagnosis, Management and Prevention. The leading author is Anthony Nassar. There's a fair few others. five other authors to which the ones I recognize, Tanya Pazari, Bill Vicenzo, and Ebony Rio, all Australians, which is nice. I'm pretty sure this would be an Australian paper and really well versed in tendinopathy management, not just specific to, to PhD, but just yeah, world leaders in the development understanding management. prevention of tendinopathies. And so, yeah, I thought I would do an episode on this because this episode particularly dives into a whole bunch of subjects and essentially, um, interviewed a whole bunch of experts on PhD management. And then based on those interviews, categorized things in terms of, um, symptoms in terms of location. diagnosis, treatment, prevention, those sorts of things. And we'll dive into all of those particular sub topics, I guess you could say. So I've got the paper in front of me and the objective that they said was to explore and summarize expert physiotherapist perceptions on their assessment management and prevention of PhD. The methods, so they conducted a semi-structured interview with expert physiotherapists. And then they analyzed systematically and organized them into categories and subcategories according to the study aims. And so, um, it says it in the introduction, which I'll talk about now. So the introduction said that the research on the prevalence is limited. However, PhD has been consistently identified in sports involving such sports as Australian rules, football, tennis, track and field, as well as the sedentary population. Pain is frequently aggravated by activities such as hill running and sitting. But recent systematic review identified multiple potential interventions, including exercise, corticosteroid injection, platelet rich plasma injections, shockwave and surgery. But this review, so they're referring to a 2020 review, and they said that this review reported a lack of unbiased estimates of strong. treatment effects to guide treatment selection. So amongst all of those options, exercise, corticosteroid injection, PRPs, shockwave therapy, surgery, there's not a lot of research or high quality evidence to point people in the right direction to say this is the most beneficial treatment. It's not that these treatment options aren't effective or ineffective, it's hard, it's hard to know just because there isn't any research done on this specific condition. And so there's lack of guidance, I guess, just because of the lack of research. And so with no high quality evidence, it's left to ask the clinicians, clinicians are left, um, with the lack of direction to guide management. Therefore expert opinions can be used. And so that's why this paper has recognised that gap in emerging evidence, we're just, we don't have. paper to point to help health professionals with the management and treatment of this condition. So let's start conducting interviews with leading experts. I don't think I put it in my notes, but the leading expert, I think they interviewed 14 of them, and they had to have at least 10 years experience had to have at least a double degree like a doctorate or a master's and need to be Uh, yeah, interviewed a whole bunch of experts in the aim to try and come up with best guidelines for the management treatment of this condition. So I have all these subcategories. I have the onset of pain, the location of pain, aggravating kind of tests that therapists might do, and you could probably do at home. Um, I've got contributing factors, getting scans, differential diagnosis, and then we'll dive into say treatment. passive treatments, prevention, and some conclusions at the end. But let's start with the onset of pain. And so this is just, like I said, interviewing experts and getting their particular take on what they have seen in their past. So all experts reported that the onset of PhD was insidious, meaning that there was no particular one event. and associated with an increase in mechanical load through the proximal hamstring tendon. So there's been something in the history of a person developing PhD, which is pointed in the right direction for making sense, as they say, an increase in mechanical load to that tendon. So that might be increasing running speed, increasing exercise intensity, doing more increases the load beyond its capacity. The location of the pain, all experts that were interviewed, reported that patients described pain at the proximal hamstring insertion, at the issue of tuberosity, so high up on the sitting bone, and most experts agreed that the pain did not shift or spread. A shift or spread in pain was often expressed to indicate a differential diagnosis or a comorbidity. So, um, most of the experts said that, uh, you know, the, the pain was around there. Most would say that the pain stays at the sitting bone, but if there is some wide, wider spread of symptoms. So if it's traveling further down the leg into the hamstring belly, further up into the glute, up into the back or, you know, somewhere more widespread, it may signify that there is something else. um, not PhD and another diagnosis, or it could be PhD and have a comorbidity. So something else concurrently going on at the same time, interviewing these people for experts reported that the symptoms primarily occurred at the hamstring insertion, although pain did not did at times spread down the hamstring and, but not past the knee. So I've had most experts say that it stays localized. I've had some other experts. say that sometimes like yes, primarily it is in the sitting bone, but sometimes pain can travel down into the hamstring. But it doesn't pass the knee. If it passes the knee, then it's something else. They then were asked about things like provocation tests or diagnostic tests. And they said that the provocation activities included activities such as lunging, running up hills, hamstring stretching. or activities that placed compressive loads through the proximal hamstring tendon unit, such as sitting. So all of these things would be aggravating factors for someone with PhD, or a person who came in with PhD might have one of these factors. So things that load up the hamstring. Tests were considered positive if localized pain at the issue of tuberosity, so that the sitting bone was reported and increased with tasks that placed greater loads on the hamstring tendon. So this is what a lot of therapists would do if they suspect a particular tendon is involved, they would do a test that, you know, mildly requires that tendon and see what symptoms are like. And then they'll do another test which requires or demands more of that tendon and see what symptoms are like. And then if warranted or if justified, they'll try something that's quite higher again in load or demand and then see if as you ask more of the of the tendon, does symptoms increase more and more? And if it does, then it might increase your suspicions that it is that tendon helps you confirm your diagnosis. So this is kind of what the, the experts were saying when they were interviewed. Um, and so they, the paper said that experts commonly used a single leg RDL, a single leg Romanian deadlift. They did Arabesque, which is very similar to a single leg. deadlift just more with a straight leg. They did a single leg bridge test at 90 degrees hip flexion so they had pretty much like a single leg bridge just with the knee bent. They did a, but I should probably say with the hip flexed at 90 degrees so their foot's probably up on something, they probably pushed down onto a chair like when their back is with their hip and knee bent at 90 degrees up onto a chair. And then they're pushing their heel down into the chair and coming up into a single leg bridge. They also did isometric knee flexion at 90 degrees of hip flexion. So if someone say sitting and their legs are dangling off the edge, so let's just say they're sitting on a treatment table with their legs dangling off. And then they're asked to dig their heel under the table. with someone applying resistance. And they also did like a bent knee stretch, which is just like stretching the tendon to see if that produced anything. So these were the tests that demand more of the tendon and to see if it produces symptoms. And if it does produce symptoms, it might suspect that it is PHT. There was a lack of consistency, I guess, with palpation. So palpation is just touching, feeling around the area. because some experts believed that it was important to be able to produce the patient symptoms on palpation. So poking around and feeling through the tendon as it attaches onto the sitting bone. Some believed that was helpful in the diagnosis of PHT, whereas other experts were thought that, you know, palpation was neither of any use or had limited diagnostic value. So that was kind of hit or miss depending on the expert that they asked. I suppose it depends on the pathology. I don't know. This is just me going off on a whim, but when you look at a hamstring tendon and you see that it's quite thick, it's like the size of like an Achilles and Achilles is quite thick, but when you have a, a tendinopathy, it's not the entire tendon that's saw, it's not the entire tendon that has the pathology. It's only a very small part of that tendon. And it depends where in that tendon that might, well, it will produce pain on like, demanding tests. But then when you touch it, I guess it depends where that tendon has its pathology would mean whether it's sore or not when you touch it. Because it could be directly in the center of a tendon. It could be around the outer skirts. It could be the surface of the skin. So I guess that's probably why there's such discrepancy in opinions when it comes to that. Nonetheless, tests for contributing factors was also a subcategory within this paper. So not only are you honing in on the hamstring and saying yes, we believe this is a pathology of the hamstring tendon. You're also looking elsewhere to see, okay, well, is there any other weakness, stiffness, um, you know, just discrepancies that might be relevant in the management and treatment of this pathology. So they listed off some tests for contributing factors. They looked at hip extension strength, which is just testing out the strength of your glutes, um, your glute max. Looking at knee flexion strength. So just seeing overall dislike strength of the hamstring. half endurance and capacity tests around the calf complex was measured. Range of movement of the hip, knee, ankle, and the big toe joint were also things that they would look at. But then they'd also look at performance analytics. They wanted to look at it specifically for runners or any other sports people that require running, just looking at how they move, looking at what sort of characteristics they have in their gait movement, just to see if there's things that might be a contributing factor. So when looking at sporting athletes and runners, they commonly observed features that were say overstriding or they're looking for characteristics that fit overstriding, a low cadence, sitting low or like runners who kind of crouch when they run and excessive anterior pelvic tilt, which is just people who have a really big arch in their lower back and their hips kind of a tilted forward. So if someone's moving in that particular posture, it could put a little bit more strain on the hamstring tendon. Therefore, maybe correcting it, maybe increasing the cadence, changing their posture, those sorts of things could help, it would maybe help their return to sport. So they did mention that in there. Scans. So the paper mentioned that experts rarely used imaging. to diagnose PHT. They rarely used it as a mode or something that was useful. Preferring to use information gained in the patient interview and physical examination. Experts usually referred for imaging if they believed a different condition was masquerading as a tendinopathy or when the condition was non-responsive to management. So this is very important. I think I've discussed similar opinions or similar information on the podcast before. Most therapists will use their tests, do their strength tests, do their loading tests, ask about the history of the symptoms, ask what aggravates it, what eases it, ask about the time this came on, what you were doing, was there a change in training, was there a change in sitting, was there a change in anything else, and use all of that information gathered to come up with a pretty solid diagnosis of PhD. If all of this just lines up and all says PhD and doesn't say anything else, you don't need to get a scan. It's all pretty relevant. And if someone's, if it's not really fitting the pattern, if you do all these tests and you say, well, it does look like PhD, but there's all a whole bunch of other things that might suggest something otherwise. That's when the therapist might use their clinical opinion or clinical justification, say, let's treat it like a PhD because most of your signs and symptoms are pointing to that. So let's start treating it as such and see how you respond. If you respond favorably, then let's just continue treating it like a PhD. But if we start treating it like a PhD and doesn't get better, maybe it's not PhD and maybe we need to start it. looking at other investigations and consider something else a little broader horizons a little bit. And then if it's masquerading as a tendinopathy is actually something else, then maybe some scans might be effective. If something is showing signs that it's something more serious, maybe like a hip, deep hip stress fracture or something. they might send you for scans straight away and not go through the trial and error of treating it like a PhD initially. Um, but then again, if you treat it like a PhD initially, and you're non-responsive to treatment might be warranted for scans. And so, um, it says that all the experts kind of had that same opinion. And I know it's probably depending on the amount of education that you got delivered during the diagnosis of PhD. You might have some. uncertainties and you might feel the need to get a scan, just keep in mind that it's probably not high on a therapist priority list if you're fitting the signs of PhD and everything's pointing to that particular diagnosis. They did mention differential diagnosis, they did mention the cause or the irritation or the pain originating from the sciatic nerve or the nerve sheath as a potential for a a different diagnosis. This pathology was reported to occur either concurrently with PHT or as a separate entity. And so that might mean if there is the sciatic nerve or the nerve sheath that is playing a role, either the complete role or, you know, subsequent role of PHT, we're usually talking about widespread distribution of symptoms, particularly into the buttock. particularly down into the thigh, sometimes even past the knee and further down the leg. But this deferential diagnosis could be identified by doing certain nerve tests. We call a slump test or a straight leg raise test for diagnosis and potentially could see if there is some involvement of the sciatic nerve or nerve sheath. And so the experts that were interviewed did mention that this is probably a common differential diagnosis if it's not just PHT. So the nerve can be concurrent with PHT. So you could have both or you could just have purely PHT without psych nerve or you could just have psych nerve without PHT. So it's up to the therapist to try and work out exactly the structures that are involved. Okay, that's enough in terms of the understanding the tests, the scans, and let's have a talk about treatment. 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 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. Okay, the first subcategory was management of PhD. And the paper said, um, the primary management options utilized were education and exercise, passive interventions, which are usually just like, um, hands on therapy in most cases. Um, so passive interventions were included by some experts, but only as an adjunct. to education and exercise. So education exercise was always included and sometimes some therapists might do some passive interventions. Tendonopathy specific pain education with the key message of being that pain does not always mean harm and pain 24 hours after activity could be used to judge how well the tendon had tolerated an activity. That sounds very familiar because we've talked about that several times on this podcast, uh, essentially talking about education, honing in on sometimes pain and symptoms and making sure that the patient understands that if the tendon is a bit sore, doesn't necessarily mean harm, doesn't necessarily mean, um, that it's doing more damage or that you should avoid it. What it does mean is that it's something to observe. and then just see how it responds within 24 hours. Say a lot of people with PHT have a fear of bending, picking something up off the floor because when they stretch that tendon, it causes pain. But then once you stand up again, the pain goes away. Everything dropped back down to baseline, there's no ongoing irritation. That's usually fine. You can continue doing that. If you pick something up off the floor, it goes away completely, and you go by the rest of your day still with baseline symptoms. continue doing that. If you pick something up off the floor 100 times, and then later on in the day, it's a bit achy, it's a bit sore, the next day, it's a little bit achy above baseline, then maybe that was too much. So it's just education about pain management and understanding your symptoms, accurately interpreting your symptoms, which is really crucial for the management of PHT. A bit of reassurance, I guess, for the most part. But then the second part, Um, aside from education was exercise. And so this paper said that exercises were progressed from low load exercises in positions with minimal hip flexion, such as a long lever bridge or a supine plank and progressed to positions of high load exercises, depending on factors such as the pain, the individual's pain response to that exercise exercises were advanced as earliest tolerated. which was determined primarily by pain responses, i.e. the pain response 24 hours after exercise. So again, not much different to what we've talked about in the past. They have, as soon as able, progressed to heavier loaded exercises and they've progressed based on symptoms. because some clients that I see, they might not even need to start with the low loaded exercises with the long lever bridges. They might jump straight into something that's a lot heavier, something like a nautic hip hinge or a deadlift or a lunge or a step up. They might jump straight into those just because they can tolerate those things. And we work out if they can tolerate them by their pain response. The paper mentions that rehabilitation was progressed by either, well they've got four options here. by increasing the load, increasing the speed of contraction. So how fast you're doing that exercise, hamstring exercises with increased ranges of hip flexion and increasing complexity. So the complexity might be challenging their balance, challenging their coordination, something that's a little bit more, I guess, return to sport specific. But good to know they're either increasing the load speed, or compression of the tendon. They mentioned that some examples of these exercises included step ups, split squats, stairs, and a slow sled push. So slow sled push would be great. It's kind of like really tough uphill walking, which can be provocative for some people, which just means they're not ready for that particular level yet. But if your goal is to. return to running, return to sport, return to, you know, um, I guess, stronger gym exercises than a slow sled push will eventually be in your rehab ladder. So yeah, that whole management side of things, nothing too new from the podcast, but good and reassuring that, um, the experts are agreeing with what has already been said, there's nothing revolutionary changed about the, the opinions and the management of PHT. Um, they had a subject on passive treatment. And so, like I said, that's like the hands on manual therapy, shockwave, injections, those sorts of things. Anything essentially that isn't exercise based, I think might be a good way of, um, ruling out what's what, but they said passive interventions such as manual therapy and injection therapy was not considered integral in any expert physiotherapist by any expert physiotherapist. Most experts used massage therapy as an adjunct in the early stages, as they found it would assist in settling down the tendon when it was in a reactive state. So if someone comes in really irritable, really high levels of pain, this is what we call like an acute reaction. Some therapists have found justification for doing some massage just to settle down the pain, just to try and calm down the pain severity. so that they're able to, I guess, get by life with a little bit more comfort. And like they said, it was always an adjunct. So that education and exercise was always an integral part, but, you know, plus or minus manual therapy in the early days, um, just to help sell things down, make things more comfortable. They continue. Manual therapy was also used as an adjunct to target associated physical impairments. So they used manual therapy. soft tissue massage to address, let's just say mobility work, because as we said above, with they looked at hip range of movement, knee range of movement, ankle range of movement and like movement of the big toe. And they looked at other stuff in terms of flexibility and mobility. But if any of those things came back as a important finding, let's say they're really are rigid or really stiff through their hip and that might have been contributing to the pathology, then they would do manual therapy to address that associated physical impairment. So again, that justification was there. One expert mentioned that sometimes utilizing shockwave therapy alongside a loading program. Other expert physiotherapists didn't use any passive management strategies. More invasive management, including injection therapies and surgery was not recommended. No expert physiotherapist referred patients for platelet rich plasma injections or corticosteroid injections. So they're essentially staying away from the injections. They they're staying away from surgery, um, kind of that serious stuff. And I've talked about a bit on the podcast before. Doesn't seem to be that effective. Um, the shockwave I think is more of a pick your battle. Some people might respond really well to shockwave, others won't. And there are some criteria about what would make you a good responder to shockwave therapy. I've got um, Benoit Matthew in the earlier episodes to kind of highlight to you what the, what that criteria is, but good that the, the experts are kind of on the same boat with that. Prevention. Um, so we've talked about the management. mainly hovering around education and exercise, which is great because this is what this podcast is about. Passive treatment, yes, can be used, but exercise and education need to be in the treatment. It can't just be passive treatment. And it seems like the passive treatment only is justified when it's in the early stages, pain's a little bit higher, and there's other co- associated physical impairments to justify, you know, some release work and that sort of stuff can be used. When it comes to prevention, the paper says that a rationale for ongoing management is reiterated due to a higher potential for recurrence. In particular, the importance of strength in the hamstring and kinetic chain was echoed across respondents, as well as addressing associated with past injuries. So essentially what that means is they're highlighting the importance of keeping up your strength, keeping up your the rehab that you have been doing. So that the strength is maintained as once you've overcome PhD, you've maintained the strength of the hamstring, you've maintained the strength of the entire leg. And so that just helps build up the capacity help maintain the capacity to high range so that reduces the risk of the PhD flaring up in the future. Because a lot of people, they do their rehab, they feel better, they get pain free, they return to sport, they continue to do their sport and drop off their exercises. Very, very common, just because they, you know, the motivation isn't there, the perceived level of importance isn't there, and that they've just reiterated that the potential of recurrence and the importance of maintaining strength and the importance of following up with any deficits that might be occurring with other past injuries. So if you had an ankle injury, if you had a hip injury or a knee injury, making sure that that's all taken care of, there's no other compensations and things that might lead to PhD popping up in the future. Okay, the conclusion of this paper. They say expert physiotherapists diagnose PhD using a combination of findings, including patient interviews and pain provocation tests, implying no single test is adequate. So they can't find one test that says, let's do this. You have PhD, you don't have PhD. They use a combination of a bunch of things. There was consensus that progressively loading the tendon to check The pain response was useful diagnosis was useful for the diagnosis. Whereas views on the value of palpation differed. So they use loading tests to kind of determine if the tendons involved, but palpation, so touching the tendon yet varied from in opinion education to improve patient understanding of pain and tendon load to allow self monitoring and progression combined with a progressive rehab program were the cornerstones of management and prevention and for the prevention of recurrence. So again, they used education, so the understanding of pain, the understanding of the importance of loading the tendon, allowing the person to interpret those symptoms, progress and knowing how to progress with a progressive rehab program. All of those were just the key cornerstones to the management of PhD. And they said that passive management strategies were perceived to be of little benefit. Um, so that's the paper. That's what they've come up with. I think this is a very, very recent paper and to know that these experts are on the same wavelength as, you know, the, what has been taught on the podcast so far is reassuring. It knows that, you know, this management is still on the right track. Yes, we could have more data, we could have more randomized controlled trials, blinded trials, just more attention being drawn to PhD in the research space. Unfortunately, it's not there yet. But I guess this helps solidify our current understanding. And hopefully you've at least taken a couple of tips away from today's episode and today's paper. I'll leave the link to the paper in the show notes, along with everything else if you need a a 20 minute injury chat that's that link is there in every episode. We can jump on a call and have a chat about your management and see if you're on the right track, if there's anything that needs to be included or if you'd like something that's a lot more tailored, a lot more robust, we can have a talk about online physio options for you. So that's it for today. Thank you for listening. Good luck with your rehab over the next two weeks and we'll catch you next time. Thanks once again for listening and taking control of your rehab. If you are a runner and love learning through the podcast format, then go ahead and check out the Run Smarter podcast, hosted by me. I'll include the link along with all the other links mentioned today in the show notes. So open up your device, click on the show description, and all the links will be there waiting for you. Congratulations on paving your way forward towards an empowering, pain-free future, and remember to stay safe. Knowledge is power.