New MRI Positioning for Better PHT Accuracy (2024 Study)

: On today's episode, new MRI positioning for better PHT accuracy. Welcome to the podcast that gives you the most up to date, evidence based information on PHT rehab. My name is Brodie. I am an online physio, but I've also managed to overcome my own battle with PHT in the past. And now I've made it my mission to give you all the resources you need to overcome this condition yourself. So with that, let's dive into today's episode. This is with a novel hip flexion scanning position for diagnosing proximal hamstring tendinopathy. As is the way a lot of these studies, they're very lengthy in terms of their title, but gets to the point of what the paper is about. And I thought like it might be very relevant or useful for you to know, potentially if it comes to you having an MRI in the future, maybe something that you might want to ask. your doctor or ask your radiologist or whoever's doing the scanning if they have this as an option. Well depending, depending how accurate or much it improves which we'll have a look in a second. So when it comes to the background of this paper it says that making a diagnosis of PHT may be challenging as patients with correlating clinical symptoms may have normal or minimal findings on MRI scans. This might be hard for people to imagine, but it's considered, like most people consider an MRI in a very high regard. It's like the gold standard. If it's there, MRI is gonna find it. If it's not there, it's not gonna find it. We're all gonna be in the clear. Not necessarily the case, particularly for tendinopathies. MRIs are very good at finding other things, but as we'll soon find out, it's not that. 100% foolproof when it comes to MRIs. So the purpose of this study was to assess the effect of a novel hip flexion scanning position, essentially very fancy term meaning instead of just having everyone lie on their back, legs out straight, let's have them lie on the side with their hips flexed or their knees bent. So sort of bringing your knees more to your chest, keeping the hips bent closer to 90 degrees. And it was hypothesized that the hip flexion position, which simulates the symptom provoking sitting position would reveal PHT pathology more accurately than the standard scanning position. So let's dive a little bit deeper into this. So I've just highlighted a few things within this paper. Within the introduction, they say that the typical MRI findings of PHT are swelling and or thickening of the tendon. at the insertion area of the hamstrings. Also swelling and edema in the ischial tuberosity, which is the sit bone, and a degenerative partial tendon rupture and or longitudinal slits can be found at the insertional area. However, patients may have a typical symptoms of PHT, but imaging findings on MRI are minimal or even normal. That is correct. You can have PHT and the scans themselves come back completely normal. Why is this? Well, tendinopathy doesn't always present with swelling and or thickening. The tendon can be painful without any physical changes to it whatsoever. It can just be sore. Soreness is only just nerve pulses saying that something is painful. doesn't have to have some swelling, tears, slits, ruptures, doesn't have to have that. Or there could be some very, very minor degenerative tendon portions in the middle of the tendon and isn't so obvious when you go and scan things. Yes, large tears, yes, ruptures, all those sorts of things can be easily identified if you know. you've got a trained clinician, however, in most cases, it's a bit of a open to interpretation, and can be a bit more harder to define. So unfortunately, that is the reality that we're faced with. These participants, symptoms themselves were classified as chronic if they had lasted more than three months, we had to the participants in this study were of chronic in nature, and included To be included in this study, a patient had to be clinically diagnosed with PHT and have typical symptoms, which they put in brackets was pain in the lower gluteal area, especially during sitting, running or stretching that radiated to the posterior thigh. So meaning like the hamstring, I don't know how far down it needed to radiate down, but, you know, safe to say if it's in the, you know, lower gluteal area and radiating to the high hamstring. And the symptoms themselves had to be lasting for more than three months. So classifying themselves as chronic. Patients incapable of going into the novel imaging position. So, you know, flexing their knees up. Those having previous hamstring injuries and those having contraindications to the MRI were excluded. So that's the criteria that they had for those. When it comes to the MRI technique, they say, the MRI protocol consists of two parts. So the first part, a standard pelvic examination was conducted. So the patient was supine, meaning face up, lying on their back with their hips in a neutral position, aka legs out straight. That was part one. And for the second part, the patients lay on their asymptomatic side. PhD leg was up as they were on their side. So the one they weren't lying on their PhD side. And they say that the symptomatic hips, both hips were bent into and hips were flexed. The hip flexion angle was aimed at 90 degrees, which was estimated visually. So they just sort of pulled one, those up and so they aimed for 90% for 90 degrees. get into the weeds of a little bit because I know that they were a bit more inconsistent with that. But when it came to the study themselves and the interpretation of the MRI results, they had two radiologists with approximately 30 years of clinical experience, and they independently and systematically assessed all the MRI signs of PHT. So they looked at all the scans of these participants. both with the straight legs lying on their back and also lying on their side with their knees bent. They looked at all of those independently and they tried to classify what they found. So the classifications they went through is labeling these images either normal, having a tendinosis, which is a pathology of the tendon, or a rupture. The tendinosis was further categorized into either slightly thickened or clearly thickened. And the tendon ruptures themselves were classified as small, meaning there was less than half of the cross-sectional area ruptured. Wide, which is more than half of the cross-sectional area or complete, the loss of the complete rupture. So tendon ruptures, either small, wide or complete. Okay, what are the results? So the number of participants, a total of 38 participants with typical PHT symptoms were included in this study. The study group included 10 male and 28 female participants. And this is where I was talking about before, the mean hip flexion angle in the hip flexion position was 54 degrees and it ranged between 28 and 81 degrees. So like wide ranges of different hip flexion, I thought they'd try to keep consistent if they're trying to eyeball 90 degrees. Most people can eyeball 90 degrees pretty closely. But to get the mean average of 50% or 54 degrees, not too sure. But the knee the hips don't need to be that bent. I'm guessing based on this study, the hips don't need to be at 90 degrees. There could be a wide range and like we say here there was a wide range. Okay the interesting stuff the MRI findings. So compared with the standard position of lying on your back the hip flexion position revealed more severe injury in 71% of the patients. The hip flexion position revealed a rupture in 16% of 10. in 16% of tendons diagnosed as tendinosis in the standard position. So we've upgraded the severity in 16% of people originally diagnosed as having a tendinosis, but when rolled onto their side, scanned again, it's like, Oh, actually we can see a tendon rupture. So tendon rupture completely missed in 16% of people just because they were lying on their back. I found that pretty interesting. In 6% of the tendons classified as normal in the standard position, a rupture was classified in the hip flexion position. So it's only 6%, and there was only two people. So two people in the 36, but the MRI lying on your back came back completely normal and when rolled onto their side and hips bent and scanned again, Hey, actually there's a rupture in this tendon, completely different. Okay, additionally, in 11% of the tendons diagnosed as normal, in the standard position, the hip flexion position showed there was a tendinosis. So we're looking at 6%, 11%, and 16%. All of those sort of upgraded the severity, in some cases, quite a large jump. really starts to tally up. There's small percents when talking about individuals, but you know, 16, 27, 33. So 33% of the total field actually increased the level of severity. Some might say more accurately. And so big difference, I would say. Especially if it's come back all clear when they actually have a rupture. I found that quite fascinating. You'd think a rupture would be easier to diagnose compared to a tendinopathy, but they're still missed. So in conclusion, this novel MRI scanning position of the patient image in hip flexion offered additional value in the diagnosis of PhD and symptomatic patients when compared with the standard hip in neutral position. Therefore we recommend this additional position be included, especially if an athlete or an active Discipline with gluteal area pain has normal or minimal MRI findings with the standard scanning position. Okay, what is some things we can unpacked here? It's hard to, I don't know, argue or talk with your radiologist or medical team if they don't routinely do some MRI findings in side lying position to which maybe you print out this paper and maybe pass it to them. Maybe they look at this in the future. But if you're going I know people obsess over their MRI results. So I thought this might be useful. And, you know, maybe if you are one who does obsess over MRI results, well, I'll get to some of those points in a second, but maybe you want to review in a different position. What are some takeaways here? Or at least my final thoughts. When it comes to MRIs, recognize it is only a piece of the puzzle. It is not the whole puzzle. A lot of people, they go to doctors, chiro's, osteo's, physio's, physical therapists, and they get a whole bunch of different diagnoses, or they get a whole bunch of different plans, and they're like, let me just get an MRI, and I'll just work out what the diagnosis is. Let me just bite the bullet, pay a bit to get scans, and then I'll have my answer. Unfortunately, you don't get a complete answer. You just have more data with an MRI. It's not the whole puzzle, it is just a piece of the puzzle. And sometimes when we see clients, we look at their history, we see like their onset of symptoms, what their symptom behavior is like, what their response to previous treatment is like. We do some tests, we do some strength tests, some movement tests. You know, we ask about the symptoms the whole entire way. These are pieces of the puzzle also. Because I guarantee if someone comes in and says that my MRI is completely fine, and all the other pieces of the puzzle point to PHT, you bet we're going to treat it like PHT. We're not just going to throw out all of that other data just because the MRI is completely fine, and vice versa. We could have someone that has PHT on MRI, yet if they're not showing clinical signs of PHT, we would look at other options because yes, your scans might show PHT, but hey, PhD is present in the healthy population also. I think it was 13% of the general population that don't have any history of PhD, go into an MRI, get scanned, and they have proximal hamstring tendinopathy on both sides, not even just one side, bilateral PhD. People that never had symptoms before in their life. So this is why it can't just be the be all and end all, let me just get the scans, let me just get the answers, and let me just. move on from there. Unfortunately, it's not the case. So just consider MRI as a piece of the puzzle, not the whole puzzle. And it's not necessary in a lot of cases. If you go to a physical therapist or a healthcare professional and they're, you're very happy with how they conduct themselves. You're very happy with the routine, the thorough routine, the assessment, going through and gathering all these data points and then moving away with a... treatment plan and that treatment plan is working for you, you don't need an MRI. We usually get MRIs when we want to rule out something quite sinister or we think there is another pathology there that can be easily ruled out with an MRI or easier I think like stress fractures is one of them. Someone can have a stress fracture of their pelvis or their ischial tuberosity and that's a different diagnosis but that should if it's in a reactive state light up quite and we can essentially say, you know what, let's treat it like a stress fracture instead of PhD. You know, another back pathology, like if you see that there's a severe pathology in your lower back, we can then consider that instead of PhD. So these are some options of why we might. We might, it might also be useful to look at the degree. Like if you, the degree of severity, I should say, like if you slip on ice, and you feel a pop in your upper hamstring, you get a lot of bruising, get a lot of pain, and getting an MRI to assess what has been done or the damage would also be fairly routine and something that we would definitely do. We could say, okay, all three tendons have been impacted or just one tendon has been impacted. And the retraction is one centimeter or two centimeters. Like all of these are good points of indication. to work out whether it's indicative of surgery or not. I've done some episodes in the past to work out what severity classifies someone who might be more appropriate for surgery compared to others. So an MRI is definitely something that we'd do for that. Okay, remember that pain does not always equal severity also. This is the final takeaway that I have. making sure someone like might be in a lot of pain, you know, seven out of 10 pain discomfort, really struggling to get through day by day. They get a scan and it shows mild tendinopathy and that really irritates them. And they get the doctor scans and doctor said, yeah, it's just a mild tendinopathy. Just treat it like a tendinopathy in a way they go. And it's crushing for people because they're in a lot of pain and they're just, they feel like they've been dismissed because the symptoms shown or the signs shown on the MRI is mild. Pain does not equal severity and vice versa. Like someone can not really have a lot of pain, get an MRI and they have a lot of degeneration, very, very chronic, grumpy, like disorganized tendon. That can happen also. In fact, it happens a lot with people with ruptured Achilles. They can be symptom free and have this really degenerative tendon in their Achilles. Achilles tendon, and then they go and play sport and it completely ruptures just because it's been so just because the pathology is there yet doesn't have to have pain. So bear that in mind as well. MRIs have their place but we need to interpret and figure this out with a bit more education and be a bit wise to these decisions. So like I said this was a quick one today but a very useful I'm learning more and more about PHT every day, especially as these papers come to light and I hope you enjoyed this type of episode. If you are, I'll be doing more like these in the future. And yeah, best of luck with your rehab this week and we'll catch you in the next episode. If you are looking for more PHT resources, then check out my website link in the show notes. There you will find my free PHT five day course, other online content and ways you can personally connect with me. free 20 minute injury chat to discuss your current rehab and any tweaks you might need to make. Well done for taking an active role in your rehab by listening to content like this and together we can start ticking off all of your rehab goals and finally overcome your PHT.