Is surgery my best option? with Peter Fuller

: On today's episode, is surgery my best option with Peter Fuller? 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 am 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. anticipate that this will be a popular episode. A lot of people are asking questions around surgery, whether I should get it, what it involves, what's the recovery like, and Peter Fuller was fantastic to have on. He is a musculoskeletal specialist. He was the inaugural vice president of the Australasian College of Sport and Exercise Physicians. He has worked as a GP. and as a sports doctor and he's also a former elite middle distance runner and cyclist and he goes on to talk about his career at the start of the episode but we dive into a bunch of things. We dive into what surgery actually entails, who is most recommended for surgeries, what the success rate is like and what is actually involved. We do some deep dives into things like scar tissue and strength and conditioning and other options and he loves talking. I did say that this episode would go for about half an hour when, before I started recording with Peter and he said, Oh, I do like to talk. I might go for a bit longer. And he was exactly right. And yeah, he actually is closely working with David Young, who is a surgeon who actually operates with proximal hamstring tendinopathy. And like he said in the podcast, actually is probably the most common surgeon to do this particular surgery in Australia. And so we've got a wealth of knowledge here. We've got one of the best to interview and I'm happy to be the one to deliver it. Sorry if I, I did ask a few questions on Facebook groups to ask your surgery question if you had one and Peter just loved talking. I did have some written down, but I think the interview like indirectly answers your questions and everything that was written down. So hopefully you enjoy. Also, before I forget, Peter does talk about me giving a presentation in this interview. I did a zoom presentation for, um, spediatrists out there, the, a couple of nights before the actual interview with Peter, and so that's what he's thanking me for, it was a presentation around why runners get injured and what we can do about it. So, um, so you don't get totally confused. I've got you up to speed. Let's bring him on now. Peter Fuller, welcome to the podcast. How are you today? Brody. Um, I'm very well. Good to be talking with you. Yeah, it's a pleasure. Thanks for coming on. I wanted to just start with people who aren't familiar with you, maybe just introducing yourself and your background and how your career has kind of evolved to where it is today. Yeah, okay. Well, I was the middle distance runner in my youth. Very keen runner from when I was about 11 years of age through to 30. I ran for Boxer Athletic Club. I didn't quite make any Olympic teams. I got close, but I started having Achilles insertion problems in my late teenage years actually from the shoes we used to wear then. And I think also from the fact that perhaps something to do with my running action. And yeah, I needed surgery in my mid twenties, but I was in a lot of trouble well before that. and the surgery didn't go that well. I had about three operations on one side and three or four on the other through till age 30. And so I took up cycling in my late twenties. So I got interested in sports injuries then and started being a GP with an interest in sports medicine. And then I was involved in setting up the College of Sports Physicians in the mid-80s. And since then, you know, I've been sports medicine full time. We, um, uh, became a medical specialty, uh, sport and exercise medicine in 2010. So I've been a specialist physician the last 11 years. Wow. And so day to day sort of stuff. What, what clients do you normally see? Oh, well, I see, I guess I see money weekend warriors, older guys and ladies because I've been around for awhile. But I still see quite a few young athletes. I saw an acute ACL yesterday. So I see a little bit of everything. I see quite a few track and field athletes. I'm an old friend and running buddy of Nick Biddo, who's a prominent track and field running coach. And now he's got a position with Athletics Australia that he got about six months ago. And he's very highly regarded as an athletic coach. He's got the best record of any athletic coach ever in Australia, the number of athletes he has in various Olympic games and world championships. So he sends me a lot of his runners with their stress reactions and overuse injuries and overtraining syndrome, fatigue and stuff. Because I've been into cycling, I've been the team doctor for a national road team and a continental team called Drapac Cycling for the last 10 years. That they disbanded that team a year ago, but I still see quite a few cyclists as well. But most of my patients are, I guess, what you'd call weekend warriors who are just keen to keep fit. I do see some people that aren't athletes at all that have difficult musculoskeletal. problems. I do have a bit of an interest and expertise in treating chronic pain syndrome as well. I'm a bit of a favourite with certain GPs for difficult patients with multiple problems with chronic pain problems, unfortunately. So I get quite a few of those. But I think I'm reasonably good at dealing with that and diagnosing it. Yeah, so that's kind of the practice. I mean, I do a bit of half a day, once or twice a week. I mainly with my old mate who's the same age as me, David Young, and he's an excellent surgeon. I like working with him. He does very high level surgery. So, I work with him once a week. And occasionally, the other surgeon when they need an assistant who's away. So, you know, I enjoy it. getting out of the consulting room once or twice a week, getting on the bike and riding to some hospital like the Avenue Hospital this afternoon and doing a few all competing cases. It gives me a chance to get out of the clinic and away from my desk and also to discuss difficult cases and new treatments from a surgical point of view. Yeah. Well, it's good to have your expertise on the podcast just to share your knowledge and before we started recording, you were saying that David Young, that surgeon you are working with actually does some, um, PhD surgeries as well, which is going to be the bulk of this topic. So it sounds like a, yeah, he, he's probably done more. Well, um, he's probably done more than any other surgeon in Australia. I'm not sure. There is a surgeon from Sydney. I forgot his name now who presented at our national meeting in Christchurch early last year, early 2000. Uh, actually it was early 2019. Um, and he, he's done a lot the last 20 years also. Um, so, um, he might be equal to David, but I think, uh, he, he's, a lot of his surgery was acute avulsions, not just tendinosis, um, and David does both. Um, he's done a lot of both. Wow. Cool. Uh, I guess we just dive into the, the meat of the topic when we're talking about surgery of the proximal hamstring. or for proximal hamstring tendinopathy, if we're talking about surgical options, we're talking, we're not necessarily talking to physios here. We're talking to runners or like, yeah, like you said, weekend worries that do have PhD. So if you could try and describe to the best of your ability, what sort of surgical options are there? Are there different types of surgeries and what does it exactly entail? Okay. Well, it's, it's an insertional tendinopathy from the hamstring origin. So it's difficult because the pathology is right at the bone tendon interface. And we know with the Achilles tendons that it's easier to treat surgically a mid tendon tendinopathy where a runner gets a lump in his Achilles tendon an inch or so above the heel, which is where the tendon inserts onto the back of the heel bone. that surgery is a little easier, a little bit more predictable than surgery at the insertion, which has a bad reputation. It's often associated with bone changes, spurs of the bone. And quite often the surgeons have to take the tendon off the bone and then reattach it with little anchors. And that involves a long rehabilitation period. So the simple surgery, I guess, is where the tendon is just swollen and the deeper fibres of the tendon are degenerate, what we call mucoid degeneration, and there are often little small tears in there. And quite often what the surgeon will do is just what's called a tunnel lysis where they put multiple vertical incisions into the tendons to stimulate healing, possibly the bride scrape out if you like a little bit of the cheesy mucoid degeneration in the tendon at the same time. But if most of the tendon is attached to the bone, you can still leave it there. And that's the quickest recovery, maybe three months before they start running again. However, if a significant part of the tendon is pulled off the bone, then usually what they do is a take down. They take the tendon off the bone, remove all the damaged tendon, roughen up the bone so you get down to a nice bleeding bone. And then you... drill these little anchors with stitches attached into the bone and use those sutures to tie the bone down, tie the tendon down onto the raw bone. And then they have to be very protective of it for a few weeks before gradually getting back to walking and cycling, but not running for three months. And they're not running at a pace until maybe four or five months. So that's a longer recovery. Yeah. Well, it sounds like a longer recovery. If I like how you mentioned that they're in most cases, they're getting rid of some of the generative degenerative portions, because a lot of people would think that they have like based on the pain that they're in and the amount of, um, I guess inactivity or the amount of dysfunction that they have, they, they might think that the actual, the whole tendon is degenerative or the whole tendon is inflamed or sore and needs to. be replaced or something. I know a lot of this language gets used amongst people that have had this for a long time. But what I try and communicate with people with PhD is it's only a very, in most cases, only a very small portion of that tendon that is degenerative and generating a lot of that pain. And so if we're working on rehabbing a certain tendon, there's still a lot of healthy parts of that tendon that we can rehab. And I guess if we're doing this surgery and we're... operating on that tendon, we're only paying attention to that degenerative portion rather than that healthy tendon. Is that right? That's right. I guess the idea is to strengthen the healthy tendon around the damaged tendon. And that's of course the basis of a rehabilitation program. There is a theory of course presented by one of your physio colleagues to our group a year or so ago. that the pain in, he was talking about Achilles tendinopathy, maybe most of the pain comes from the healthy fibers next to the damaged fibers. And those fibers are getting extra, the healthy tendon fibers are getting an extra load on them. That makes them painful. And if we are very patient and put the patient through a long and patient rehabilitation program, the pain can gradually resolve as the tendon gets stronger. That makes a lot of sense because if, well, it's actually reassuring because if we think that the pain is actually coming from the degenerative portion, we know that certain parts of that degenerative portion may be irreversible and may just stay there. And so if people think that the pain's from the degenerative portion, that's almost like, well, then the pain just won't go away. However, if you're describing the pain from the healthy portion, that's actually encouraging because we can strengthen up that healthy portion and then pain would subside. Yes, it gives a good justification to a strengthening program and being somewhat patient in the long term and doing cross training for a period of time. And maybe if everyone followed that program to a T and it could be demonstrated that was the best way to treat it. And I guess some of your colleagues have tried to do that and perhaps presented reasonable evidence that that's the way to go. Then these patients wouldn't be tempted to try injection therapies too early. and other things to try and get a quick fix, which then in the long-term, um, doesn't work or makes the condition worse and leads them to requiring surgery. Whereas maybe they could have got by without surgery. It's one of the big questions in, um, you know, managing tendinopathy, I guess, isn't it? Yeah. And speaking of big questions, I've got this next one coming up. So are there any... protocols or something that might suggest someone is more suitable for surgery than not surgery, because I do hear a lot of runners or people in Facebook groups reaching out being like, should I get surgery? Should I not get surgery? Are there any sort of baseline characteristics or presentations or characteristics that might say, yes, you probably need surgery or no, we should try conservative? As you know, yourself, Brody, I'm sure you know, there's, there hasn't been a lot of research unless there's been some really good research in the last couple of years and maybe my colleague here at the clinic, Aidan, which is doing his masters on hamstring origin tendinopathy, I'm pretty sure, might come up with an answer to this but there's no, we don't really know the answer to that and what we do is, or what the textbooks tell us is that we use the principles of treating other tendon injuries like Achilles. where there is a bit more research in giving people advice about how to manage their Achilles, their hamstring origin tendinopathy, their proximal hamstring tendinopathy. And, you know, therefore recommend they trial a, you know, a long-term strength program and be patient and do cross-training for a while. But it comes down sometimes to the patient and what they've tried. If they've been talked into having a cortisone type injection early on, which gives them great short term relief in many cases, the long term or the medium term effect on the tendon is often detrimental. We know it damages collagen tissue and that makes them more likely to eventually require surgery. I know my surgical colleague, Mr. David Young, who does a lot of these. would say that absolutely avoid cortisone anywhere near any tendon, particularly a tendon insertion. Yeah. I did interview Peter Maliaris a couple of years ago and he had the same view. He's like, we really shouldn't be injecting many things, especially cortisone into the tendons because it just changes the properties. It just changes the structure and its ability to function as a tendon and it might settle down pain in the short term, but it's not very good for the long run. Yes, you know, we do get anecdotal cases of people who tell us they were in a lot of trouble till they had a cortisone somewhere near their tendon and then they got over it, but maybe they were eventually going to get over it anyway. We like to think that most of the radiologists now don't inject into tendon if they're requested by a GP to do a cortisone injection. They just do it a little bit around the tendon. and not into the tendon. And sometimes this can just settle it down enough that the patient can be okay. But we certainly don't recommend it anywhere near a tendon for an elite athlete. And so back to the original question, you did mention like for most cases, a long-term strength solution is good for everyone just to see how they go. And you need to be patient with this strength program. How long do you usually allow for them to be diligent and make sure they're executing their strength program really well before we actually can have a, an accurate interpretation of whether they're responding to it or not. Yeah, that's a very good question. I don't know the answer to that, but we're talking months rather than weeks and just being patient and being happy to do cross training and, and slower running. And my, you know, to perhaps avoid too much stretching, to maybe try. some other treatments which we hope don't harm the tendon like shockwave therapy, which desensitizes the tendon a bit and enables them to do their strength program with a little less pain or just put up with the condition, particularly if they're an older athlete, if you can just switch their pain off a little bit. We know that if they're gonna get better with conservative treatment over a long period of time, the degenerate abnormal tendon in the middle of the tendon at the insertion probably doesn't. go away, it stays there. I think that's been shown in patellar tendon, up with these basketball type athletes involved in jumping sports, who eventually resolve their patellar tendon pain. The changes on ultrasound in the tendon, do not, the tendon doesn't completely resume a normal structure. So... some abnormality remains, but it's just that the pain gradually goes away as the healthy tendon fibres around the damaged tendon fibres get stronger. Presumably that's what happens. But it takes time and some people are impatient and as soon as they feel a little bit better they might push on and do a race or a hard session and then they make it worse again because they haven't increased the load gradually. This is something that I always emphasize to them that if they're going to increase their loads, they have to do it in a gradual fashion. And if they get pain, they've got to immediately go back to where they were a week or two earlier and basically back off and then resume once again in a more gradual fashion. Yeah, which can be very frustrating. It's a bit of an art rather than a science sometimes. And in the end... We do see people that are very patient that follow a good physiotherapy program who just get sick of it and they hear about footballers having surgery in the off season for various things and getting right and they have this concept that surgery will fix them. And I think good surgery can fix them, but some patients just cry out for surgery early. They get a bit. inpatient with a long term structured rehab program. And they just have this concept of surgery is the way to go. So it depends on their individual nature. So some people request surgery early, whereas other people will absolutely avoid surgery. They just absolutely want to avoid it. These are probably more middle-aged, less serious athletes than the... elite athletes who just want to get better and back to their sport. Some of them are very anti-surgery, they've had bad experiences in their family with orthopedic surgery, whether it be for a joint replacement or something. So occasionally a young elite athlete who possibly needs to consider surgery after a year of not being able to run properly will request or submit themselves to surgery. I'm hearing a couple of things here, which is some nice takeaways. One, you mentioned that the, like someone could get a scan or see a specialist or see a health professional and they would communicate to the patient that there's portions of the tendon that's degenerative. And a lot of people might think, well, if it's degenerative, then I need surgery because how am I gonna get back to running pain-free and fully functioning if it's a degenerative tendon? But what you're saying is a lot of the time, well, our focus should then be focusing on the healthy portions of the tendon and you can resume a pain-free fully functioning tendon. It's just getting those healthy portions as strong as you can. And the other sort of thing that you're mentioning was the impatient type that tried something for a couple of weeks says, no, that doesn't work. Let's move to the next thing. Let me try a shockwave. Now that didn't work. Let me move to the next thing. And then it gets to a point where they're like, well, I've tried everything. Nothing works. Let's try surgery. That's, that's exactly right. Yes. 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 hand ring 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. I've spoken to enough people to get kind of a general gist of some people's mindset. A lot of people are very patient. A lot of people have, they work through the right things, but they shouldn't be anxious. They shouldn't, if they have communicated, they do have a degenerative portion of the tendon. But my next question is what about with like evulsion fractures or like high buildup of scar tissue? They have... some people get scans and it shows a scar tissue or shows this evulsion fracture, which is like part of the tendon coming off the bone. Can we do something for them? Can we rehab that or do they require more, well, are they more likely to go down that surgical path? Yes. Well, an evulsion fracture by definition is the bone, the tendon pulling off the bone. So the actual lesion is not in in the tendon, there might be a bit of a lesion in the tendon, but the weak point is usually in a young adolescent athlete, the growth plate initial tuberosity, just deep to the origin of the three hamstring tendons on the back of the issue of tuberosity. And that's a controversial issue as to what you do. If it's only a centimeter or two, they just require complete rest. for a few weeks and then eight weeks to 10 weeks for that bone to heal and they can make a very good recovery. The general feeling is if it's off more than two to three centimeters, they're better if they have surgery. And the surgery used to be to try and reattach the bone to the ischial tuberosity. And if that can be done very neatly by a competent surgeon, they can do okay. But the general feeling is that it is there is some evidence that it's better to remove the bone fragment and do a standard repair as if the tendon is pulled directly off the bone. What you might do in an older athlete, an older weekend warrior who avolces the tendons from the bone without a bone fragment. We know they do quite well if you just stick the tendon back onto the bone with a few little surgical anchors. And so now there's a tendency to say, even with a young athlete who pulls a big bit of bone off, it's probably better to throw that bit of bone away and stick the tendon back onto the bone. There's some evidence to suggest that there's an orthopedic surgeon in Sydney who's been the go-to man in Sydney for hamstring avulsions for about 20 years. He's got a reputation and presented all his work at one of our meetings in New Zealand two years ago. And he found in the early stages, he'd try and put the bone fragment back onto the pelvis, but they did poorly. And since he changed his surgery to removing the bone fragment and repairing the tendon directly onto the pelvis, they would do a lot better. All right, and what about scar tissue? Well, in a sense, you need scar tissue to get the tendon to stick. under the bone, that's part of what you're trying to do. I don't know that excessive scar tissue is, post-surgery at least, is a problem. I have seen one person where they seem to have a big lump there and probably it was a problem, something to do with the way the surgery was done. I can't recall if that patient had the bone put back by a fixation technique onto the, bottom of the pelvis or not, but excessive scar tissue post-surgeries is not usually a problem as far as I know. As part of tendinitis, just tendinitis, it's not an avulsion where the tendon pulls off with a bit of bone or without a bit of bone. Just in the standard tendinosis conditions where you've got a swollen tendon with fluid in the tendon, then fluid around the tendon, what we call edema, Of course, they don't seem to have excessive scar tissue on the MRI scan or at surgery. And this is where I get a bit confused as well because- It's just that they- Sorry, I'll go through this. I've had a fair few people approach me and they haven't had surgery yet, but they've ended up getting like MRI scans and the scans have shown there's excessive scar tissue, which I'm not sure why they're getting it, but that scar tissue is starting to impact the sciatic nerve. And that's why they're getting certain symptoms radiating down the leg or, and then they tend to sometimes be suggested that surgery might be appropriate to free up that sciatic nerve and free up that scar tissue. Would that make sense to you? Absolutely, that is another issue. There is a whole area. The sciatic nerve past is only a few centimeters lateral to the hamstring origin. So it can get caught up and seemingly involved in this hamstring origin problem. As part of surgery on the tendon, where there would be just a simple... procedure to make the tendon stronger or a detachment of the tendon and re anchoring it back onto the bone. The surgeons now always do what they call a neural lysis. They make sure that the hamstring tendon is not bound down with scar tissue so called to the hamstring tendons. I don't know that it's really been proven that a massive scar tissue builds up there. It's just that the nerve is so close to the tendon that it somehow, it can get irritated, whether it be scar tissue or just inflammation change or just the fact the patient's had a lot of treatment, perhaps heavy massage on the tendons and the nerve then gets a little bit irritated as well. I don't think in my reading of the literature that anyone's ever demonstrated excessive scar tissue there. Even on MRI scans, I don't believe we see it. It's just that patients do get some sciatic nerve symptoms quite often as a primary condition of the sciatic nerve being irritated in the buttock region or secondary to having hamstring origin tendon problems. There might be a couple of steps of like that. misinterpret somewhere along the way, like they get this MRI scan, the MRI scan has a written report based on what they find. Then it's the reports gone to the doctor or the health professional that whatever is communicated there is then communicated to the patient and then it's what the patient interprets based on what's said. There's a lot of steps along that, what they see to what they interpret that might be a bit misleading. I think so and I think in explaining what's going on to patients, maybe some doctors and other health practitioners say, you know, there's gonna be some scar tissue there. It's just one of those things that people talk about, but I don't know. There was that study from Finland or somewhere in Scandinavia back in the 80s. What's his name? Pyren and his coworker that talked about the hamstring syndrome where they were talking about some sort of fibrosis between the hamstring tendons and the sciatic nerve. But I don't recall in seeing actual fibrosis tissue at surgery when I was just the surgeon or on MRI scans where there's a massive scar tissue between the nerve and the tendon. It is an area that gets irritated, but with prolonged sitting and driving, the tendon or the nerve is very close to the bone there. And if the nerve itself gets a bit swollen and irritated, then it gets sensitive and painful. And then people talk about, oh, the scar in the tendon, in the nerve, or scar around the nerve, but there isn't necessarily, I don't think anyone's really proven that there is true scar tissue there. And what they do when they operate on these hamstring tendons is they just make sure that they visualize the nerve in order to avoid damaging it. And while they're there, they free it up so that it doesn't get caught up in any scar tissue that it forms as a result of the surgery where you've got to push a few muscles aside and dissect a bit of adventitial tissue. That's just padding tissue. fatty tissue that's around the tendon and around the nerve that's there just to provide some spatial protection, if you like, in that area where there's quite a lot of pressure and strain from normal daily activities as well as from athletic activities. I would agree with you. I'd say that like, people shouldn't be too caught up in thinking that there's scar tissue around the side of nerve, like it doesn't really happen and they can be miscommunicated or believe that there is scar tissue because they're getting say nerve symptoms like radiating down the leg and they're like, yeah, it's cause this, all this scar tissue is built up around the side nerve when what's most likely happening is that nerve is becoming sensitized and due to, like you said, maybe inflammation, like just pain generators, just the no co-ception of just being really irritated. Absolutely. Okay. Yes. And of course that can develop to some extent as a little bit of a complication after surgery, where the patient sometimes just has to be reassured that eventually any post-operative scar tissue that's there will mature and become softer and eventually stop irritating the nerve. So if you have someone come into your clinic and they do seem to have quite an irritated sciatic nerve as well as this proximal hamstring tendinopathy, do you discourage them away? If they're like suggesting, maybe I should get surgery, are you encouraging them, they try conservative and steer away from that surgical option? I can't really answer that. I guess it depends on the individual case, how irritated the nerve is. We do have the option of ordering an ultrasound guided injection around the nerve with a couple of good radiologists in town who are good at doing that. That can help settle it down. And maybe it's worth, if they've got an irritated nerve in the buttock region, that would definitely be worthwhile trying before surgery. It's not that simple, but it's a much less invasive procedure than surgery. So I often do that and then encourage them to be, you know, give it time and to work on cross training and activities, avoiding activities that irritate the nerve. Makes sense, makes a lot of sense. And just going back to those avulsion fractures, you're saying that they might be more likely for surgery depending on the more severe degree, like if it's between two to three centimeters. ofulsion, they're more likely to head towards surgery than someone who's, um, one centimeter ofulsion where you can just get away with conservative and, um, relative time off and then strengthening. That's right. Um, if it's only one centimeter, they, they can heal up quite well. Okay. Good to know. Because I think that some people can get MRI scans and then just have total fear when an, an evulsion fracture comes on and they don't care how big it is. Like one centimeter And then they just got this fear of if I load up that tendon, um, maybe we'll fracture more, like maybe more portions of that tendon will come off and, um, yeah, it can spark a lot of anxiety. Yeah, that absolutely. They just have to be told you have got a fracture here. It's a bone injury, not a tendon injury. And with a bone injury, you have to be very protective of it for the first few weeks. Uh, and then it'll start to heal and then you'll actually get a very good result because you're getting a bone to bone. union or healing, you're not depending on tendon fibers healing and the eventual healing is actually stronger. It's just a matter of being patient in those first few weeks. Back to the, I guess, conventional surgery when it comes to the tendon and I think it was called tenolysis, is that what you said? The usual process? Yeah, that's just pretty multiple slits parallel to the collagen fibers in the tendon to encourage a thickening and strengthening of the tendon. You would just do that to a tendon that's swollen and it doesn't have any avuls, any significant partial tears within the tendon where the tendon is usually pulled off the bone and you've got a defect, a gap in the tendon. They're the ones that don't do well with just a tenolysis, just putting vertical slits in the tendon with a scalpel blade to strengthen the tendon. because they're still going to have that hole or defect in the middle of the tendon. And that often doesn't go well in this particular type of tendon condition where the tendon attaches to the back of the bone and you get what, as you know, we call it a compressive tendinopathy because the hamstring tendon, when the patient's standing, it's actually coming off the back of the sitting bone. But when they're sitting, it's winding around it's winding around the sitting bone and it's getting compressed. And when that occurs, of course, when they're running and, um, flexing their hip, uh, so that their leg comes out in front of their body, then the hamstring tendon is winding around that bone and compressing the deep part of the tendon. And that's the part of the tendon that breaks down. I forget what your actual original question was there. I didn't actually ask a question. I was just clarifying first before I'd asked the question. Uh, so with that particular procedure, um, What idea do you have around success rates? This podcast episode is sponsored by the Run Smarter 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. Yeah, I asked David Young, my colleague, about this during the week. And he said about 80%. And he said further that the ones that failed, he probably should have been more aggressive with the surgery and done more of a takedown and a reattachment of some of the healthy tendin fibres back onto the bone. And that would be my impression too, from the ones I've sent to him, I would have thought it's even higher success rate than 80%, but I've definitely seen some that have not worked. And I've seen some that have worked for a year or two. And then because that patient has gone back to a competitive running, often a veteran type athlete, the pain has come back a year or so later. And it's, you know, they've got... problem again because there was more degenerative tendon that probably wasn't removed. And they've got it again for the same reason that they got it in the first place, some perhaps blood supply problem or aging process going on in the tendon that is still present even after they've had surgery to remove the badly damaged fibres. Well, let me follow on with that question. So This scenario out there, if you have someone who's had proximal hamstring tendinopathy for say like four years, like chronic pain, really irritable. Um, the level of functioning is quite low. They want to get surgery. They have surgery. And then afterwards, say, you know, several months down the track pain still persists. And they're frustrated because they said that they think of this like mechanical model. I've had this tendon it's been operated on, so it should be better up. And now. pain still persists, how would you communicate to this particular scenario? How would you? Yeah, I would do another MRI scan. I'd examine them and look at their muscle to see if maybe they've got quite bad wasting of the muscle because it's been, there's been a reflex pain response coming from that sore tendon for so long, for years before the surgery, and then for months or more after the surgery. such bad muscle wasting that the muscle and tendon unit cannot function properly. And they probably have to be told that their body just isn't up to doing what they're doing. However, if the scan shows that maybe there's a big defect still in the tendon or one of the anchors has pulled out, I've never seen that actually myself with my surgeon colleagues patients, but I know that can happen. So if you rule out some sort of failure in the surgical technique, then maybe, I know one or two patients have had what appears to be excessive fibrous tissue, excessive healing of the tendon, what you might call scar tissue, where you don't have nice collagen, nice parallel collagen bundles in the tendon and maybe the shape of the bone on. on the bottom of the pelvis where the tendon attaches is altered. They've still got some calcification there or bony prominence. Then they may have a mechanical anatomical problem for which there's no simple solution. And they just have to be told to look after it. It is a complex... Pardon? Where my mind would go if I have someone who has had years and years of... a particular pain like proximal hamstring tendinopathy, and they have surgery and they have an MRI afterwards and in the eyes of the MRI, the surgery has been a success. My mind would gravitate towards what we now know about pain science and particularly with your background with chronic pain syndrome, knowing how the brain has real influence on pain signals. And if it's been, if they've had pain for such a long period of time, like, you know, several years, we know that the brain reorganizes itself when it comes to pain. And so we have had examples of say, with low back pain, chronic low back pain, surgery isn't really that successful because visually everything's fine. They fix things up, they remove discs, they do these and pain still persists. And that's because we haven't targeted the brain yet. Would you say there's a connection with that? Absolutely. Yeah, some people just need to be reassured. Look, the surgery's gone, all the tendons been reattached. You've had pain here for so long that it's, you know, there's an area of your brain that's been experiencing where your pain messages are received. That area of your brain is still excited to some extent. And even though the original problem that caused the pain has been dealt with adequately or as best as possible, yeah, you are still experiencing and we need to use some techniques, reassure you that this could eventually resolve. There are clever techniques that you guys can use to help switch off the pain. Sometimes it's just a matter of reassuring the patient that the pain is normal after they've had pain for so long, it's not gonna go away. And to just to put up with it and not worry about it. Yeah. it's the whole thing is a difficult field. The first thing I have to do as a doctor is to make sure that there isn't a anatomical weakness or problem in the tendon that's the cause of their pain. It's a bit embarrassing for us if we talk to people about chronic pain syndrome and then find out that there was an actual mechanical or anatomical weakness in the tendon or whatever structure we're talking about in their back. that's the cause of the pain. Yeah, so we don't always know the answer to that. I have to first of all exclude an anatomical or pathological local structure in the musculoskeletal system as the cause of their pain before we can start talking about dealing with chronic pain syndrome in the various ways that we do these days. And you... from a musculoskeletal point of view, you're probably better at dealing with that than I am. Well, it's good to at least check the boxes and have reassurance. Like you said, you maybe get another scan and see if everything anatomically is fine. And then if pain still persists, then it might increase the relevance that there might be some brain reorganization. Yeah, yes. Sometimes, Brady, what I end up saying to people, I stand them up, I look at them. And I say, for your age, you are a good physical specimen. Everything's going okay. You have got pain. It's not quite right, but be reassured. I believe you can get right in the next few months if you just keep pushing at it gradually, focusing on doing a lot of the stuff that the physical activity, including a sporting activity, a fitness activity, and a strength program that you can do comfortably and just avoiding the racing or the really hard activity that's painful for a few more months, and let's hope things can turn around. And potentially they can turn around and pointing out to them some of the neuroanatomy behind or neuroscience behind the chronic pain syndrome and how we get centrally mediated pain after we've had pain for a long period of time where initial treatment didn't help much and it sets up this vicious cycle of continuing pain. Sometimes I just say to people, you know, you're actually okay. They'll come in and they'll say things to me like, I've got this imbalance or I've got this biomechanical problem or I've got this weakness. And I say to them, things like, well, you've had this for a long time, you've run for many years with all these biomechanical problems and your body has adapted to them very well. I think actually you're doing okay. You've managed okay with various injuries over the years. And I believe that you can manage with this one too. You just need to be a little bit more patient and focus on a bit of strength training, which I know you believe in strongly. And I was very interested in your comments. in your presentation the other night. I only saw the end of it, unfortunately, but I'm very interested in those comments about doing more than just body weight training for endurance athletes. And just getting them to focus on a few things that they haven't done before and being patient and continuing to do the things that they can do, the cross training, the cycling, the swimming, the brisk walking, maybe someone has told them they shouldn't do it. They've got to rest everything because it causes pain. But when you speak to them in more detail, you realize that some quite a lot of activities don't cause that much pain and they should just focus on doing that for a few months. And then hopefully they can eventually get back to doing their more intense activity that they. are obsessed with doing and which I like to help them get back to doing. Yeah. And I think there's a, it's pretty hard to, for people to wrap their brain around, but a painful tendon can actually be quite a strong tendon that can actually tolerate quite a lot. And I have like people who are running like ridiculous amounts, like really fast, really far or lifting really heavy, doing some heavy deadlifts and they're still getting these painful tendons, not getting worse, but still staying painful. And they think that, oh, you know, I'm, I'm I'm weak, I'm getting weaker. I can't do a run for 10 Ks anymore. And I'm like, yeah, but that's because the tendon is painful. But if we're talking about that degenerative portion versus healthy portion, there might be pain generated in that tendon, but there's a lot of healthy portion that is actually really, really strong. And it can actually be encouraging for them. And of course, some of your colleagues pointed out with their research with these... UH, what are they called? The fancy ultrasounds and high quality ultrasounds that if you look at the cross-sectional area of a damaged tendon with a big area of degenerate tendon in the middle of it, the actual cross-sectional area of the healthy fibers around that degenerate area are equivalent in cross-sectional area to a normal tendon. So they've got as much normal tendon. It's just a bit, it's being a bit irritated by the abnormal tendon in the middle of it. And they just need to be somewhat patient that normal tendin a bit stronger and doing slightly different exercise from their simple running that they love to do and get them to supplement that with some strength training. Yeah, I know you've touched on this a little bit but this will be my last question. When we're talking about post-operatively, the expectations of what people can return to. I know some people have been suggested by surgeons. Once you have surgery, you're not going back to running, but you're not going back to cycling. And I guess I know your answer will depend on the type of surgery and the type of patients, but, uh, is there a likelihood that people can return back to high quality exercise after having an operation of this magnitude? I guess that's the basic reason why I recommend they have surgery so that they can. If they're a slightly older patient and they've got quite a lot of degeneration in the tendon and not just from the area that's causing pain and maybe comparison views of the same tendon on the other side shows a lot of degeneration, then we do have to be realistic with them and say, look, really for the best long-term, you need to... maybe go back to slower running and more cycling and more gym work and more cross-training activities. But most people, you know, the reason why I'm sending them to surgery is so they can get back to doing what they want to do. And, you know, from the point of view of just looking at one of my surgical colleagues, from the point of view of joint replacements. So just as an example, as a comparison with another musculoskeletal problem, there's been a tradition amongst doctors and surgeons that people who need a joint replacement are considering having it. Having it in their sort of middle age, not late middle age. There's a tradition to sort of tell them, wait until the pain is too bad and you can't sleep at night. That's when you have the surgery. delay it for as long as you can, because you don't wanna have to have a revision, a second operation 20 years later, you wanna avoid that if you can. But the way some modern joint surgery is done without using cement, using high quality computer navigation and robotic surgery, you can... do the joint replacement in such a way that you can get back to your physical activity. And that's what we aim to do in most people who we're recommending surgery for proximal hamstring tendinopathy. We are doing it so they can get back to running. It's just that perhaps patient that has a lot of degenerative change throughout the tendons and on the other side, where maybe you need to be realistic with them and tell them that in long-term, uh, they probably shouldn't go back to racing. They should go back just to easier running. I had that answers that last question. It was, um, uh, in a bit of a roundabout. It does. I gave the answer. Yeah, it does. And it's reassuring to know. And I guess, um, as we're wrapping up the general theme, I guess, I wonder if you agree with me that there's several options before surgery. Like you said, you can do shockwave if something is quite dormant and we're trying to spark some sort of healing. And I have had some shockwave episodes in the past that people can refer back to. If there is some like real sciatic nerve irritation, there are injections or something we can do to try and settle that down. But first and foremost, like we need to try a really good strength and conditioning program. And what I've read, it's around about three to six months of you being really patient and Um, not following if you've had a really chronic tendon, it's not a week by week. It's it's several weeks, just following a very gradual, um, reduction in pain, a very gradual increase in function. And so a lot of people, you need to have a very dedicated three to six months to, to really see, reap some rewards and see some benefits because maybe in six months you're like, you know, I probably don't need surgery and that's a bit more liberating. Yes, and I've found this myself with hamstring origin, with Achilles insertion tendonopathy. I tell people, look, the surgery that works for this involves taking a bit of bone off and maybe taking some of the tendon off and reattaching it. It takes a long recovery. I'm recommending to you, before you have the surgery, that you try a prolonged rest, maybe associate with the strength program as well. But if it's gonna get better, with conservative treatment and a strength program and avoiding surgery. It's months rather than weeks. And I recommend you take three to six months off before submitting yourself to surgery. And I've seen a lot of these people again over the years with something else and they have in fact got better. And I think the same can happen with the hamstring. I originally prepared to give it a few months rather than a few weeks. of modified rest and a strength program. That is the way to achieve success without having surgery. Yeah, yeah, good to know. Peter, I wanna thank you for coming on. Is there any, like, are you active on social media or any websites that people can go to if they wanna learn more about you? No. I'm happy with that answer. I might get my colleague Aidan to update my website. You know, I do a little bit of Twitter, but I'm not very active. I'm not very good with IT. I get frustrated with it. I do follow other people, but I don't put out a lot myself. Maybe that's something in my latter years I can get someone to help me with and start putting out a bit of information. But I don't publish a lot on LinkedIn or Twitter. And I have had some information on my website, but that's currently not functioning. And I might talk to your colleague Aiden about helping me get that fired up again in my bloody years. Anything that makes my job easier is okay. So I don't need to include any links or anything. I've just got your name and that's it. So thanks again for coming on, mate. Thanks for taking the time and sharing your knowledge. Yes, and thanks a lot for your presentation to our group the other night. It was very good. I'm looking forward to watching the whole presentation. You're very welcome. 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.