Expert physiotherapists perspectives on PHT (a 2020 paper)

: On today's episode, expert physio perspectives on PHT. 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. course, 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. Welcome back. We have a paper to review today and the paper is called proximal hamstring tendinopathy expert physiotherapist perspectives on the diagnosis management and prevention. And we have some authors, Anthony Nassar, we have Tanya Pizari, who was one of my tutors at in at La Trobe in Melbourne. We have Alison Grimaldi, we have Bill Vincenzo who familiar with, I've read a couple of his books, Ebony Rio, who is the gun when it comes to tendon rehab. And we have a good paper that's investigating the management, the treatment, the diagnosis of PhD, but it's nothing to do with randomized control trials or blinded studies. It is just sitting down with experts and asking them about this condition and what works, what doesn't work, what they have seen in their experiences. And so they interview people and they transcribe their views and their opinions and they compile the data and systematically go through and organize it into categories and subcategories according to the study's aims. And so when it comes to finding who they interview, they, it's not the authors that I've just listed, they didn't interview those. The authors that I just listed were the ones who compiled everything and put it all together into categories. But when it came to the expert selection, when they interview these experts, they say as a quote, we selected participants using purposeful sampling with the authors, ensuring that the sample of experts were from a range of geographical locations and had experience across different sporting populations. And so, um, there's a bit more of a criteria, which I'll delve to in a second, but you essentially want to get expert opinions from all different corners of the globe because we don't want them to go through the same training, go through the same university, have the same perspectives of things, the same biases of things. So it's really good that we get a nice sample across the world and across a different, um, population. So they say different sporting populations. So. maybe some working with runners or working in team sports or working with cyclists or working more with the, with older age groups, different age groups, those sorts of things. So they're going to say that the expert physiotherapists that were selected by the authors and by the investigators, they had to have published a topic within this area. They had to have extensive clinical experience in treating people with PhD and expert physiotherapists were also required to be. So there's a bit of a criteria here. Registered physiotherapist with experience treating people with PhD that to hold a master's degree or a doctorate in physiotherapy and they had to have a minimum of 10 years clinical experience. And so we're looking at whoever they interviewed, they don't exclude, they don't reveal who these people actually are. They keep them confidential, but they do say that Everyone in here has at least published a paper on this topic. They're, they're classed as kind of like an expert within this particular field. They have a doctorate or a master's degree. They have been constantly working with people with PhD and they've had a minimal experience of 10 years. And so, you know that what they're, we trust their opinions, we could say, and then you interview a whole bunch of people under this umbrella of expertise. And then you see if there's any common findings. if there's any categories, subcategories to help people with the management and treatment of PHT. So I'll pull up the article itself and we're going to read out a couple of sections that I think is really important for you to listen to and for you to learn. So let me just pull that up. Okay, so the first category was the patient interview findings, and this is kind of what you would call like the subjective story or the subjective questioning offered by the physiotherapist and answered by the patients. So they say all experts reported that an onset of PHT was insidious and associated with an increase in mechanical load through the proximal hamstring tendon, which makes a whole lot of sense. It follows the mechanical kind of patterns, the adaptation patterns that we talk about in previous episodes. They say that all experts reported that patients described the pain at the proximal at the insertion or tuberosity is kind of around like your sitting bone is the, the classic kind of terminology or the description of that location. Um, 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 if it wasn't localized to the sitting bone and was spread to somewhere else, um, In most cases, the people that they ask would say, okay, that's an indication of something else going on. So a different diagnosis altogether, or something happening in addition to PhD. However, for experts, so 31% reported that the symptoms primarily occurred in the hamstring insertion, the sitting bone, although pain did times at times spread down the hamstring, but not past the knee. And so I guess there's not a general consensus here. There's not like an exclusive kind of consensus because some experts say, okay, it does travel a bit into the hamstring, but most of them, so around 60, 70% of the people they interviewed said that it mainly resides really localized to that sitting area. Typically patients described a spike in this energy storage release loads. So it could be running, it could be cycling, it could be more explosive kind of activities. particularly with the combination of hip flexion. So they used as an example, increased volume of running up hills is a good example of this adaptation or training, training error you could say that has led to PhD. Provocative activities included activities such as lunging, running up hills, hamstring stretching, or activities that place compressive loads through the proximal hamstring tendon unit, such as sitting. And so that's what they said around the the patient interview findings. The next subcategory they had, which is kind of around the diagnosis side of things, was loading tests. And they said that all experts performed a battery of clinical tests to form a diagnosis. So there wasn't one particular test that they used. Most respondents used a progressive load-based response. So they would load the hamstring, see how it felt, and then if it was okay, then continue loading up the hamstring. more and more and more, so a harder requirement to see how it would respond. And so they use these sequence of tests to see what the response is like. So tests were considered positive if localized pain at the ischial tuberosity, the sitting bone was reproduced and there was increased pain with the tasks that were placed along with greater loads. So if you increase the demand of the tendon and there's local... increased localized pain to that area. That's kind of how they would hone in to say, hmm, maybe it's a proximal hamstring tendon issue. Experts commonly use loading involved trunk flexion with a standing like straight, straight knees. So they use the example of single leg deadlifts, arabesques, or just trunk flexions of bending forward with a straight leg. Other isolated pain provocation tests commonly used were single leg bridging in 90 degrees of hip flexion, isometric knee flexion. So just a whole bunch of tests to stretch tests and loading tests to try and produce pain. They did mention when it comes to palpation, so like actually feeling the tendon and poking and prodding around the tendon, it says that some experts believe it was important to be able to produce the patient symptoms on palpation, whereas other people interviewed. thought that palpation was either of no use or had limited diagnostic value. So if someone's poking and prodding around the sitting bone and it can't spark pain, doesn't produce pain, the experts would say that it could still be PhD. Um, whereas there's some that say it might produce pain and some has some sort of relevance, but based on this study, based on me reading this, um, this section, it doesn't seem like palpation is very high. on the priority list in terms of diagnosing PHT. They did talk about imaging. So they said experts rarely used imaging to diagnose PHT and were more referring to the use of information gained in the patient interview. So subjective questioning and the physical examination. Experts usually refer to imaging when they believe a different condition was masquerading as a tendinopathy. So we call those maybe kind of red flags. If you think that maybe there's a stress fracture to the sitting bone area, or if there's some like potential tumors or something that just doesn't make sense and you wanna get it checked out, that's when they would refer for imaging or when the condition was unresponsive to management. And so if a particular patient followed the correct management to the T and they were... abided to the general management principles and they still weren't getting better, then they would send them off for imaging. They did say that absence of tendon changes on imaging, so like an MRI or ultrasound, so if there was no changes whatsoever, it was suggested to be useful to help rule the condition out. But they do say that, well, I would interpret this as if the tendon did show changes, then they're still on the fence of what it could be. because we know that tendons, depending on age and depending on your lifestyle, we know that some tendons can be fully functioning, pain-free, totally healthy, but still on imaging have some findings, like some mild degeneration or something. So if you scanned it and everything was totally fine, then it would increase the likelihood of ruling out a tendinopathy. So that was interesting to hear. Still on the kind of diagnoses section, there's a subcategory around common differential diagnoses. And they say that experts highlighted that the primary differential diagnosis was pain originating from the sciatic nerve or the tendon sheath. This pathology was reported to occur either concurrently with PHT or just separate entirely. And a theme that was more widespread of... So the theme of more widespread distribution of symptoms. through the buttock and down through the hamstring or the back of the thigh was more of a common feature of this sciatic nerve involvement with the local location slightly more outside to the attachment of the hamstring tendon compared to PHT. So if we think of the anatomy, we have the hamstring tendon that attaches directly onto the sitting bone and just if it's the right, hamstring just right of that so to the outside of the tendon is where the sciatic nerve resides or passes through and so If the location is slightly laterally or slightly more towards the outside That's where the localized pain is and they're reporting pain up into the buttock pain down into the hamstring We're suspecting that it's more of a sciatic nerve involvement They continue to say that three experts highlighted that symptoms the sciatic nerve symptoms could also be localized to the ischial region without peripheral widespread symptoms. So not only can it spread up into the glutes and down to the hamstring, but it can also be quite localized to the area as well. So tests used to diagnose the sciatic nerve involvement included a slump test, which if anyone's, if anyone's had me as a physio doing online physio, you'll know that I do a slump test with them online and they perform it with both lumbar flexion and extension. And also a straight leg raise, which is another kind of nerve test that people can do. And so they, they go on to say that several experts mentioned that undiagnosed, um, inflammatory conditions that were sometimes present in patients referred to PhD. So examples of a systemic drivers included and closing spondylitis or some other, um, form of arthritis or some sort of inflammatory arthritis. So those. inflammatory systemic conditions may also be a common differential diagnosis, something else that might be going on. 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. Let's continue because we've got the diagnosis side out of the way. Now we're on to management or like treatment management, those sort of things. And so the first thing that they did, well, the first statement when it comes to management, they said that the primary management options utilized were education and exercise. So those were the two primary things when it came to helping manage PHT, educate the person about the diagnosis or about the condition as much as you can. And exercise, which should be no new revelations when it comes to the podcast. They said that passive interventions were included by some experts, but only as an adjunct to education and exercise. And so I think they might mention some passive interventions down here, but Usually when they talk about passive interventions, they talk things like massage, things like joint mobilizing, things like dry needling, those sort of hands-on treatment modalities. So they say that they do use them, but it's only in adjunct to the education exercises, the two primary things. So the, I guess the subcategories, they talk about education. So patient education covered a variety of different elements. The delivery was... delivery was adapted to the individual goals and specific limitations. So some people have, say, issues around self-efficacy, so reassuring them. Some are quite anxious, so trying to empower them when it comes to motivating roles, but obviously different athletes have different goals when it comes to returning to sport or returning to activities. And so that's where the education side of things is quite tailored. Tendinopathy specific pain education with the key message to being that pain does not always mean harm and pain 24 hours after activity could be used to judge how well the tendon has tolerated an activity. Again, nothing new, hopefully, if you've listened to previous episodes of the podcast. All respondents agreed that the condition required significant rehabilitation time. So often a good three to six months. in most people what they said, but others mentioned six to 12 months. So that's when it came to the expectations and the timeframe side of things. That was the, uh, what they recommended. So it's the education side. This is the exercise side of things. So they said targeted hamstring rehabilitation, all respondents prescribed targeted exercises to load the hamstring, uh, from early to late stages of the management. exercises were progressed from low load exercises in positions with minimal hip flexion. So I guess that's what we call out of compression. And so they use the example of an isometric long lever bridge. So the bridge most people are familiar with long lever just means the feet are further away from the hips or a supine plank, which is just when your face is is facing up towards the ceiling and you do a plank kind of like a reverse plank, I think it's also been called. So they progress from that to high loaded exercises depending on factors such as the individual pain response and what their tolerance is and what their goals are. So experts reported that athletes could often tolerate heavy load performed slowly early on. So doing a single leg prone hamstring curl or a long lever hip bridge. And so they did describe that like slow heavy stuff in early days is quite good for management. They mentioned here that key characteristics of exercise selection shared by the experts included that initial exercises were in near neutral hip flexion, so out of compression, and were performed unilaterally as early as possible. So unilateral being single leg based exercises. What else do they mention when it comes to the exercises. Kinetic chain rehab, they said the increased capacity of the entire kinetic chain to improve the load distribution was in concurrent theme, was a recurrent theme, so something that kept popping up. Other areas targeted the rehab were, let me see if I can find some, or they said just depends on the deficits of the individual, but when they're talking about kinetic chain, they're talking about the whole leg. So making sure they're integrating some calf work, some knee exercises, some glutes, definitely some glute-based exercises seems to be very common. Late stage exercise management, they said that rehab was progressed by increasing the load, increasing the speed of the exercise, or increasing the range of hip flexion, increasing the complexity of the exercise. I think that's all of the management. So experts progressed athletes into more hip flexion in controlled environments in a gradual manner and then just paid attention to symptoms along the way. Again nothing new here. The examples of the exercise that they used they said were step ups, were split squats and stairs, split squats, stairs and slow sled pushes. So that would definitely increase the load, it would definitely increase the speed of contraction especially if you're doing. sled pushes, it increased the amount of flexion, the amount of compression, and so there's some really good mid to late stage exercises. They did mention that deeper deadlifts were another progression in this sort of late stage, especially when it came to whatever requirements they had to say, different sporting requirements, and yeah, I think that's one of the general themes. Passive interventions, I guess it's worth going into this one when it comes to say management. So passive interventions such as manual therapy and injection therapies were not considered an integral part by the expert physiotherapist. Most experts used massage therapy in an adjunct in the early stages and felt that it would assist in settling down the tendon or settling down this reactive state of the tendon. Manual therapy was used in adjunct to target associated physical impairments such as flexibility or such as stiffness. So one expert mentioned that they sometimes utilize shockwave therapy alongside their loading programs. Other expert physios didn't use any passive management strategies. More invasive managements included injection therapies and surgery. They were not recommended. amongst these experts, they didn't recommend any injections or any surgeries. No expert physiotherapist referred patients for a platelet rich plasma injection or a corticosteroid injection. So it's interesting to know, cause it seems like a very common path for a lot of patients that reach out to me on social media, a lot of them do end up getting PRP or getting some sort of corticosteroid injections. So interesting to see that these physiotherapists. None of them actually refer patients onto that sort of regime. They mentioned return to sport. I think we've covered that when it comes to, there was one around preventing the recurrence. Here we go, preventing. The rationale for ongoing management was reiterated due to the high potential for recurrence in this particular condition. We do know that if you manage this tendon quite well, you return to sport, you're then pain free, fully functioning. We do know that the odds of pain returning is quite high. And so, they say in particular the importance of strength of the hamstring, the strength of the whole kinetic chain was echoed across the respondents, as well as addressing areas that were vulnerable to atrophy, such as past injuries, if you had injuries on other sides. or other areas of the lower limb, it's best to address those as well to reduce the risk of these sort of things popping up again. They've got a quote here from one of the experts, I would say people have sufficient strength and kinetic chain strength, so hamstring strength and the whole entire limb strength, and then have tendon loading that's really consistent. And that's the best way for injury prevention. So making sure that we address the strength, we build up the capacity of not only the hamstring, but the entire leg, and then maintain a very consistent loading routine to reduce the prevention. Another expert said, so getting a program that targets the lumbar spine, the lower glutes, the hamstring strength, the adductors, all of these exercises, they need to make sure they continue. reducing the risk basically. Another expert, is there another quote in here? They just say that retesting key objective measures, I'll say that again, retesting key objective measures such as strength with a handheld dynamometer or gym-based exercises following breaks from sport was seen to be important since a spike in load upon returning to sport would increase the risk of recurrence. And so, Yes, we know that building a whole ton of strength is very good, but if you have some time off your sport or some time off strength, it's good that we have some objective measures to return to see if you have lost strength and then sort of build you up to make sure there's no atrophy, no weakened state and those sort of things. So that is the paper. They go on to talk about to summarize what I've just explained in a bit more detail, but that's essentially when it comes to the diagnosis, when it comes to the management and prevention of PHT, this is what the experts are saying. And hopefully these lessons are echoing throughout podcast episodes, which that's what we really like. We really want to see consistency. We want to see similar lessons popping up here and there, because that's when we know we're onto something. And so it's not only just shown in other papers and other randomized control trials, but the experts are also saying, we've been working with this population for years and years. This is what works. And so keep in mind of the expectations, keep in mind that, um, three to six month range, and in some cases, six to 12 month range, and that's with really good management that's with once you start doing really good management, it's just not going to get better on its own in six months. It's once you implement these strategies and once you implement proper education, strength and conditioning, proper management. That's when these effects will slowly start to take form. And yeah, hopefully that's helped highlight a few things, help maybe remind you of a few things. And that's why I thought I'd do this paper. It's quite a nice one. We're all done for this episode. I hope you you've learned a ton. Hopefully it's reminded you to start implementing a few different things. I hope you enjoyed and we'll catch you next week in next week's 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.