PHT Assessment & Management: A 2016 Research Paper

: On today's episode, we are delving into a research paper around assessment and management. 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'm an online physiotherapist, recreational athlete. creator of the Run Smarter series and a chronic proximal hamstring tendinopathy battler. Whether you are an athlete or not, this podcast will educate and empower you in taking the right steps to overcome this horrible condition. So let's give you the right knowledge along with practical takeaways in today's lesson. I have my notes and I have a research paper in front of me that we're going to go through today. It's the first one in the podcast that we're going to discuss because why just trust me? I know I have learnt from a lot of the research and I do a lot of reading the literature myself, but why take my word for it? Let's start delving into some research papers. If you are one that's drawn to the content heavy sort of stuff or drawn to the what the science actually shows. I'll add a link in the show notes to this paper that we're going to discuss. The title of the paper is proximal hamstring tendinopathy clinical aspects of assessment and management. And it's originally intended for physios. and the authors are Tom Goom, if you're not aware, Tom Goom is one of my idols. He is running physio and extremely knowledgeable. The second author is Peter Maliaris, who you have heard of. He was interviewed a couple of episodes back to talk about tendinopathies. Michael Rehman is another one I haven't heard of, but the fourth author is Craig Perdom, who has done. tons of work around tendinopathy. He's worked with Jill Cook and published some key papers that have changed our thoughts of tendon pain and tendon management. So yeah, a bunch of legends and to produce a paper and it's to do with proximal aging tendinopathy. So I thought this would be a very good paper just to start with as our first episode delving into some research. If this isn't for you, I understand some people don't like the content heavy stuff. The language that they do use is designed for physios. So you might get tripped up on a little bit of terminology, but I'll try my best to reframe it or simplify it so that you can understand. But I've got it all written down here. The aim of this paper, they've written, so the aim of the article is to review clinical aspects of the assessment and management. and including a differential diagnosis and exercise prescription, what exercises we should be doing, recommendations on how, on what the current evidence shows around our understanding of this pathology. And let's just delve into what they first talk about, the actual characteristics of proximal hamstring tendinopathy. They include a deep localized pain to the region of the ischial tuberosity, which is your sitting bones. So a deep kind of sensation that is localized to that area and it often worsens after activities of running, lunging, squatting, sitting, were some of the activities that they listed. Makes a whole lot of sense, we already know this. And when they're talking about these aggravated activities, it's not uncommon in more chronic presentations that the hamstring pathology may have some sort of coexisting pathology that might lead to aggravation of other things as well, adding a further complexity to the management and diagnosis of this condition. Let's dive into extrinsic factors. So the extrinsic factors are the environment or the load that you put it through that might lead to someone developing this. That's what they increasing volume or intensity too quickly. Sudden introduction into things like sprinting, lunging, hurdles or hills. So if you've changed those, I know lunging if someone goes to a gym class and they haven't done a lot of lunges before and all of a sudden they're doing like a hundred lunges in that class, that could increase the risk. But yes, hurdles and hills as well. These activities result in a provocative tensile and compressive load. on the tendon as it inserts into the sitting bone. And symptoms may also occur due to excessive stretching. For example, if someone has just started taking up a lot of yoga or doing a lot of Pilates postures that involve such end range like flexion, a lot of end range hamstring stretching. In some patients, compressive load simply from sitting can be a factor as well. So there are some of the intrinsic factors that might contribute to someone developing proximal hamstring tendinopathy. Some other, they call them systematic, systemic factors, sorry, which is kind of like intrinsic, so what's happening within the body that could lead to this or put you at risk of developing this. These are suggested to include things like genetics. We know that there is a specific part of your genetics that some people have and some people don't. that lead people just more susceptible to developing any type of tendon, tendinopathy. We know age, the more advanced in age you are. High BMI, so body mass index, how much fat you have, how heavy you are. Metabolic issues, we know that if someone's diabetic, glucose intolerance, lipid level imbalances, and insulin resistance, we know that that's a link to. developing a tendinopathy. We know hormone changes and sometimes very rarely medications like antibiotics can be a risk factor as well. Okay, so we know kind of what causes it. Let's dive into if someone has it, how do we diagnose what's going on? And there are some what health professionals call subjective assessments. So that's when they're talking to you and not doing any tests. They're just asking a couple of questions to try and figure out what it could be. And in that portion of this paper, they mentioned that during the subjective assessment, a typical tendon behavior should confirm it's well localized to the sitting bone and becomes less symptomatic after a few minutes of activity. So within tendons, we know they have a warmup effect, especially in the early stages of pathology, and it may worsen afterwards after activity. So just paying attention to that 24 hour response, we can... kind of hone in, okay, is this a tendon issue? The aggravating factors can be things in deep hip flexion such as squatting, lunging, sitting for long periods, especially on harder surfaces. They're often provocative. Things that usually don't aggravate symptoms would be activities that don't involve a lot of store, storing energy or compression such as slow walking on a level surface. standing, lying, those sort of things. There may be stiffness in the morning or when starting to move after prolonged rest. So if this is starting to fit a pattern during the subjective assessment, we might think, oh, we're kind of increasing our confidence that it might be a tendon issue. We should be aware that there are psychosocial factors that influence pain as well and influence management of this condition. and we need to adopt this biopsychosocial model. So what that means is some patients may have certain negative beliefs such as pain equals damage, such as pathology is very serious and very limiting and very unlikely to improve. These sort of beliefs tend to associate with heightened anxiety, heightened attention to that area, hypervigilance, anxiety, fear avoidance. And we know these sort of behaviors spark central sensitization, which essentially means that the central nervous system becomes a bit hypersensitive to pain. And so that's when we start to see that, um, when we ask these questions around what aggravates things and might not start to fit a total classic tendon response. And so this highlights pain is not simply the tendon. It's not simply just the tendon damage or tendon overload. but it's more complex. The output that you're explaining is more complex. And so symptoms that would arise, symptoms that would raise a suspicion of this central sensitization include diffuse pain. So it's no longer just localized, it's now more of a widespread area without a key stimulus response relationship. What they call secondary hyperalgesia. So... what would usually spark a little bit of pain, all of a sudden sparks a massive amount of pain and it lasts a lot longer than what it should. And pain that is disproportionate to the nature of the injury. So if we were to do say things like once the tendon pain is settled down, if we were to do 10 squats, and that flares you up for three days, that's a very disproportionate nature to what we've exposed the tendon to, to the flare up in the reaction. So we know that these it's very multifactorial and this central sensitization can change the subjective assessment a lot. So hopefully that made sense. The diagnostic tests, the tests that a physio or a health professional should do for this particular condition. So pain that is provocative during loading tests and what can be can help confirm the diagnosis of this condition. So they said that, for example, progressions from a single leg bent knee bridge, progressing to a long lever bridge, progressing to an arabesque type of movement, progressing to a single leg deadlift, these motions can start slow. And if that doesn't produce pain, we can start to integrate speed into these sort of movements. And we should see that pain starts to increase the more we go through those progressions. Therefore we know it's more of a tendon issue and pain should increase as we load up these tests and so that can help confirm our diagnosis. Palpation seems to be quite inaccurate and might have quite low specificity. So palpation is just when you feel the tendon, feel the tendon on those sitting bones. Yes a physio can feel the as the tendon as the hamstring attaches onto the sitting bone and you can say oh that really hurts but how accurate once we have that positive test how accurate are we to say okay we know that this is proximal hamstring tendinopathy and the science tends to show that it's not very accurate because if you press and it's sore it could be a couple it could be a number of things could be a bursar could be the sciatic nerve it could be the glutes it could just be sore compared to both sides because we know when we poke and prod on anywhere in the body. Sometimes it can be sore. And so it has very low specificity. So if it's positive, our likelihood of it actually being positive is quite inaccurate. So keep that in mind. It's important to combine tests and do things like these loading tests, but also combine it with the patient history and the questions that we've asked and the answers and the behavior of the tendon. Based on the questions that we ask, we wanna combine all of these things to come up with a diagnosis. The other things that we could do with our testing once we are doing the assessment and doing our tests is identify any other impairments. So the kinetic chain deficits, which could be like a hamstring. We do know that there is glute max atrophy or weakness in people with proximal hamstring tendinopathy, and also the same with glute mead weakness. associated with proximal hamstring tendinopathy. So we can test these out. We can test some movement patterns. We can test how you're squatting, lunging, how you're going upstairs, how you're landing and see if the kinetic chain, which is like the entire body, how those movement patterns are happening and as if there's any other weakness other than the hamstring, any other weakness around the hips, glutes, trunk, that sort of thing. Okay, so that's going through the whole assessment. Let's dive into the management and rehab component, which will take us to the end. You might want to listen to this episode a couple of times over, because once we get into this management, working through these stages, you might be at a certain stage now when you think, Oh, that's a nice tip. And you implement that into your rehab, but a few weeks, a few months down the track, you might be at a different stage. You might want to review this episode and say, Hey, um, Now I've progressed what's kind of the next stage is where should I be at? So management, we're talking about like the first steps you should really take. And they talk the this paper mentions load modifications. So if you've overloaded the tendon, let's just say you've gone from running 10 Ks a week to running 50 Ks a week and the tendon saw and overloaded now. We need to look, we need to modify your current loads. So any abusive compression, which would be into hip flexion, where that tendon gets compressed, and any like energy storage loads, like sprinting or like doing box jumps, anything that requires a lot of force, they should be limited until the irritability settles down to a stable level. And stable pain should be mild during activity. So they said on a... pain score of between zero and three out of 10. And then settle within 24 hours of the intervention. I've just knocked my keyboard and lost where I was talking. Here we are. Settle back within 24 hours of that intervention. And that's how we know that it's quite stable at the moment. And we know this from earlier episodes. We know that a little bit of pain through some load high. tendon load is okay. And we know that as long as it settles down after 24 hours, back to baseline symptoms, we know that we've negotiated that dosage. Okay. If it is quite sore, if you're getting higher levels above like four or five, six out of 10, uh, out of 10 pain, then we know that you're not tolerating the very well. And we need to continue with modifying the loads you're currently doing, but not uncommonly the patient still may be able to do some steady state running within sort of that pain guideline. However, if you are a runner and if you are running, then we wanna avoid things like hills, wanna avoid things like sprint starts, we wanna avoid hurdles, and we should start introducing those in the later stages. So keep that in mind. If despite this partial load management symptoms are still present greater than 24 hours afterwards, then we need to cease these... these loads, these dosages and returning to sport may not be advised. Provocative sporting activities can be temporarily replaced with cross training to maintain cardiovascular fitness. So maybe swimming, maybe, um, walking, hiking, maybe cross trainer, maybe cycling, depending on the tendon, um, some sort of alternative, just to maintain cardiovascular fitness. So that's what we're talking about when it comes to load management. 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. We're getting into the nitty gritty stuff now practical takeaways because this paper does talk about rehabilitation and Talking about four stages of rehab and it's very similar to the three stages of rehab I had in the earlier episodes But does into a bit more detail So what do they say the authors recommend monitoring pain the same the same time daily? Just to like load up the tendon and see what your symptoms are currently like So if we start introducing these stages, if you have a provocative test, some sort of loading test like a short lever bridge or a long lever bridge or an arabesque or something that sort of makes you notice, yeah, it's still there. This is good to repeat day over day at the same time of the day just to make sure that symptoms aren't getting any worse, make sure there's no significant flare up and just to make sure week by week is actually getting better. So some pain is accepted. while we go through these four stages, like we said, between zero and three out of 10 is great, as long as symptoms settle after 24 hours. And we should not progress if there is worsening over the course of this loading program. So these four stages, they recommend, it probably takes about three to six months of rehab as we work our way through these stages. And stage one is the isometric hamstring loading phase. which is very similar to what I was talking about earlier with my three stages of rehab, but they go into a little bit more detail. So this can be used as a pain relieving option. As we know, sometimes with tendons, we could load up the tendon. This isometric definition is just when you load the tendon, but don't move as if we were to do a bridge and we were to thrust our hips up towards the ceiling and we were to hold that. We're not moving up and down in that bridge action, we're just holding. That's what we call an isometric because the tendons contracted, the hamstring is working, but we're not moving. We're staying in that position. So that's an isometric. And we do know that this can relieve some pain. And so dosages should be based on symptoms, based on the severity, based on the irritability with shorter and less intense contractions, if necessary. Examples of appropriate exercises at this stage could be an isometric leg curl. So, either getting like lying on your stomach, getting a band wrapped around your ankle and pulling that, that the band towards your bum or moving your heel towards your bum, putting tension on that band, but then moving say halfway and just holding that position. Another example could be, like I said, a bridge, either a short lever or a long lever bridge. We could progress from two legs to one leg and just hold that. And we're doing these exercises. We can do these daily. We can do these quite often. Let's see if they mention bridge holds. Oh, a straight leg pull would be a good option. So if you're lying on your back, your leg is straight and it's up onto something, you wanna pull down towards the floor, on digging down through the heel and just holding that. That can be quite nice. So that's what we can do. And we do recommend that you can do it little and often. So you can do it several times a day and just make sure we're monitoring loads throughout. Stage two, we're looking at isotonic hamstring loading with outside of compression. And so that would be, isotonic is just now we're going through movement and the aim is to restore hamstring strength, hamstring bulk. and just build up the capacity of your hamstrings. And so we should take into account, we want the approach to be slow, heavy resistance. We're not talking about eccentrics or concentrics, like divvying them up, we just care about it being slow, being heavy, controlled, and making sure that it's progressive enough. We can start with a 15 repetition max, so actually quite light, just to see how the tendon tolerates it. So, but you should be able to, with the weight that you have, do up to 15 reps. But then we want to progress to an 8 rep max around 3 to 4 sets, performing every other day. And so, stage 1, we're doing our stuff daily. This one, we're doing a little bit more heavy. We're doing 3 sets, or 3 to 4 sets, and we're approaching 8 rep max. And we want to do this every other day, so every second day. Some examples will be a single leg bridge, a prone hip extension, a prone leg curl, some Nordic hamstring exercises, bridge progressions like up on a step or with some weights, and a supine leg curl. Did I say leg curl? A prone leg curl or supine leg curl depending if you have a gym membership, what exercise, what position you are, what weights or what machines you have available. So we're doing those every other day. Then we transition to stage three. Once you have negotiated stage two, you're doing really well, you're progressing with your strength. Our symptoms are staying stable. We then can progress to stage three, which is the same isotonic exercises, so through movement, but the position is now increasing hip flexion. So we're trying to tolerate more levels of compression. And so the goal of stage three is to continue with this hamstring muscle strength, So increasing the muscle bulk, and we're trying to get a more functional position. And so a slow and controlled technique is important. Some exercises, I won't explain all of these. If you're not too familiar, you can just YouTube them. So a Romanian deadlift is a good example. Step ups, walking lunges, hip thrusts, and single leg deadlifts, they're all very good examples of us compressing that tendon, moving through hip flake. flexion movements and just loading up that way. Do I have dosages? I think the same thing goes for stage three. We have like doing these exercises every other day. So we're just progressing from stage two to say stage three with the dosages remaining relatively the same. We wanna start at a 15 rep max and we wanna progress with the weight so that we're progressing through to an eight rep maximum. Okay, stage four, we have our very last one. And this is only required if you are returning to sport or returning to high levels of activity. If you're a sedentary individual, you don't necessarily need to do this, but stage four is our energy storage loading phase. And we're reintroducing things like power, elastic stimulus, we can start with limited levels of flexion. So when we start this stage, we can reduce our range of movement and then we can slowly work our way into deeper levels of flexion if needed. But this energy storage requires power. We're doing it quite fast. And so it's a high demand on that tendon. And it just bridges the gap between what your tendon is currently doing to like high level sport or high level running, whatever you need to do. So we're just trying to bridge that gap. So some examples will be sprinter leg curls, there will be A-skips, which is like a running drill, there would be sled pushes or sled pulls, most people have seen that on TV or like in fitness classes when they do the sled push. Alternate leg split squats we can do, we can do bounding exercises, we could do stair or heel bounding, kettlebell swings, which is a nice one that I enjoy, and gradual reintroduction into sports specific. squats and lunges, whatever the movements might be. So we're looking at power, we're looking at fast movements. And so they are the four stages. They did mention that once you get to this stage four, we're not doing this every second day, we're actually doing it quite, we're doing it less. And they did mention that we're not giving up on stage two and three, we're not just transitioning straight to four and getting rid of all the rest. Sometimes we might do a bit of a cycle. And so we might do on Monday, we might do stage four, where we're putting our attendance through high load. On the Tuesday, so day two, we're now going back to our stage one exercises. So giving our attendance somewhat of a break and going back to stage one, just doing some isometrics and just having a low load day. Day three, which would be the Wednesday, would be like our medium level loading. So either back to our stage two or stage three exercises. And then day four can be a rest. And then we just repeat that. So we're going on a, we're cycling through this, this high, low, medium rest cycle two times a week. And that's usually really nice balance. So keep that in mind. They did not talk much about surgery. They said surgery is outside the scope of this paper, but I'll be doing future episodes on surgery. So keep that in mind. So let's do a bit of a recap. Yes, the aim of this paper was to work out the assessment and management of PhD. The assessment we want to like a typical classic responsive attendant is to have a similar warm up effect so after a couple of minutes pain tends to reduce or go away. Aggravated with things like squatting, lunging, sitting for long periods, sitting on hard surfaces that's what they've mentioned here. give a great diagnosis. We're more talking about tests and loading tests that we can do combined with the subjective assessment. Management, we wanna make sure that we're doing those load modifications early, particularly if it's quite irritable and sensitive. The rehab side of things, we've got those four stages. So stage one, isometric loading. So those load and holds, you can do those daily. Stage two and three is just progressing. We're doing it every other day. and we're progressing from outside of compression. So things like single leg bridges, prone leg curls, to more, progressing to more hip flexion activities. So deadlifts, single leg deadlifts, walking lunges. And then our final stage being that the storage power kind of exercises. So your A-skips, your sled pulls, all of those kettlebell swings. Cool. I thought I would finish off with just some things to recognise, some patterns that we may have talked about in the past that are well present within this paper. One, rehab needs to be progressive. It needs to contain tensile load, it needs to contain compressive load, it needs to eventually contain speed work. So we want to make sure that we're not just doing our bodyweight exercises for six months and wondering why we're not getting better. We're progressing and we're challenging that tendon once you're tolerating a certain level. progressing, progressing. The second thing is that the multifactorial nature of pain and talking about that central sensitization, the central nervous system becoming quite hypervigilant and how anxiety and fear avoidance can all have direct patterns on pain because we have done those pain episodes in the past. The third one is... See how we're transitioning from this little and often, so stage one is done daily, to a high demand, less often option. So stage four is done like, you know, once to twice a week, whereas the stage two and stage three are done maybe two to three times a week. Keep that in mind, very important. And the last one I had written down is that pain could be fine, we just need to. make sure it's low levels of pain during exercise. And we just wait over 24 hours to see how it responds. Very classic, but something we, it's worth repeating over and over throughout this podcast. So that is the paper. I'll attach it into the show notes. Thank you to Tom Goom, Peter Maliaris, Michael Raymond, and Craig Perdom for releasing this paper, publishing this paper. Very informative. I will continue to do some papers every now and then. similar to like I do success stories every now and then. And there will be something different, it'll be a different aspect like say surgery or say different diagnosis, what else it could be and papers that are talking about this sort of thing. So hopefully you like this style of format, hopefully you learn a lot. Like I said, you might need to come back to this a couple of times, depending on what stage you are in your rehab, but hopefully you take away a lot from it. So thanks for listening and we'll catch you in the next episode. Thanks once again for listening and taking control of your rehab. If you are a runner and love learning through the podcast format, then go ahead and check out the Run Smarter podcast, hosted by me. I'll include the link along with all the other links mentioned today in the show notes. So open up your device, click on the show description, and all the links will be there waiting for you. Congratulations on paving your way forward towards an empowering, pain-free future. And remember, knowledge is power.