PHT Success Story: Kara Haas

: We are interviewing Kara Haas on today's PHT Success Story. 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. Doing a bit of a theme around the Run Smarter podcast every second episode or so for five weeks I would do some success stories and it would be plantar fasciitis, it would be shin splints, knee pain, but there were a few PHT success stories in there and how could I not share it on this podcast? I interviewed Kara Haas who has had proximal hamstring tendinopathy for 15 years competing at a very high level in her younger years and has gone through the ringer. She has tried strength work, she has tried PRP, some tonotomies and most recently in the last couple of years surgery and has seen the other side and had tremendous success and we'll talk about those reasons for success along with all of her other hurdles along the way. She was a blast. I released at the time of recording. I released this on the run smarter podcast about a week or two ago and have received tremendous feedback and she was a delight to have on. So I hope you enjoy. Let's bring her on now. Kara Haas. Welcome to the podcast. How are you today? I'm great. I'm happy to be here, Brody. Thank you. Yes, thank you very much for agreeing to share your story. Especially when it comes to proximal hamstring tendinopathy, it can be extremely debilitating for a lot of people. I am quite invested in some Facebook groups, the proximal hamstring tendinopathy Facebook groups, and hearing a lot of people's stories and hearing how chronic it can be and how debilitating it can be. So first of all, let's start with a bit of an introduction. Who is Kara? Where are you from? And What's your life like outside of this proximal hamstring tendinopathy title? So I'm here. I'm from Chelmsford, Massachusetts. I pretty much lived in New England all my life. I was a high level competitive runner for a long time. The PhD really derailed me for the past, I'd say 10 years. I'm also a school teacher and I have two little girls, ages six and nine. So they keep me busy as well. So there is life outside of running. What sort of competitive running were you involved in? Um, back in my thirties, I was training to make the Olympic trials in the marathon and I came up a bit short, but I had some pretty good success in my master years. At one point I held the American record for the 1500 indoors. Um, and that was even with PhD, but I really had to shorten my distance. from the marathon once the PhD really kicked in. Okay. It just became debilitating. Right. And so you started developing the PhD in your, throughout your career as well. Yes, probably for the past 15 years I've had it. Wow. Okay. Talk us through those beginnings and could you identify any particular over-training or any training errors or anything that might have occurred that you've thought in hindsight might've led to the PhD? I think just marathon training, trying to run a hundred mile a week, it just didn't jive well with my hamstrings. Plus the surface I was running predominantly on the roads. So I think the concrete and asphalt, the combination of just running, not doing any strengthening or cross training was a recipe for disaster and like the perfect storm for PhD to develop. Yeah. How often would you be running? I know you said, well, it was about a hundred miles a week, but, um, how many days would that involve? Unfortunately every day. So I don't think that was in retrospect. It was more of a compulsion, I think just had to get out there and get the miles and then kind of a sleeve to the schedule. Okay. I do. When I do talk to people with this particular condition, it's, it comes on one of two things, either one, it sneaks up on you and It starts off as a bit of tightness for a couple of weeks. And there's just like a very subtle pain for a couple more weeks. And then all of a sudden you've had it for a couple of months, or it's a massive, um, session or like an overtraining session, working a lot of speed work or a lot of plyometrics. And then you have it the next day. It comes on quite rapidly. Um, can you fit the pattern of any of those two or what was your experience like? Yeah, the first pattern you were talking about beginning with the tightness and just kind of exploring the tightness and then pushing through and then the pain would come and trying to rub, you know, Ben Gay or any sort of lotion taking anti-inflammatories to be able to train through the pain, which was again, a terrible idea. So I definitely fit the first pattern. Yeah. I was actually trying to reflect back on when I first got PhD and I was training for triathlons and only just recognize now that my hamstrings, the top of my hamstrings would be so tight as soon as I finished my swim to get onto my bike and then try to cycle as fast as I can to like, you know, keep up with the speed. I think I remember thinking, man, the tops of both of my hamstrings are just super, super tight. And once I warmed up and got about 20 minutes into my bike ride, that would totally alleviate and I'd be totally fine, but might've been a bit of a warning sign, which is why mine came on anyway. So after that initial tightness developing into some sort of pain, were there any other symptoms? Were you getting pain with running? Were you getting pain outside of running? What was that like? Slip pain. So definitely for long car rides, the classic sit bone pain, and also a weakness that leg started, it was probably my right leg. It started to develop a weakness upon push off. I just didn't feel like I had the drive. And it was more pronounced at higher speeds. I could get by with shuffling on solar runs, but it was definitely a loss of power. Yeah. Right. And that's a really good, I guess, awareness of the body, especially once you start generating those high speeds. And if I know anything from tendons, when they start becoming irritated, it's, you just don't have the confidence. You don't have the confidence to push off with the same force that you do on the other side, and that might be too. bit of apprehension or a bit of pain or a bit of combination of the two. And so did you have a diagnosis quite quickly? Once it started developing into pain, you started getting sitting pain. Did you have a team or did you get it assessed? Did you get the right answers straight away? No. And I think that's all too common with PhD. It was diagnosed as a labral tear. So what I'm hearing is super common predict. particularly in women over 40, it's really common to have liberal tears and high distance runners anyways. So they were treating my hip when I think in fact, it was more the hamstring. Okay, did you have many injuries previously apart from proximal hamstring tendinopathy? Did you have any other hip or knee issues? Not really, a little plantar fasciitis here and there. but I think that was due to compensating. My gait would be a little bit altered if my hamstring really acted up. Okay. And so you were diagnosed with a labral tear. How long into your diagnosis or into your condition did you actually get the right answers? It took me about, I'd say five years after that to get the correct diagnosis. So it took quite a while. And how were you managing throughout those five years was what were symptoms like? It was mainly just the loss of function. It just, I couldn't push off. My coach would say, it looks like you're running on hot coals. Like you talked about kind of the tentativeness to push off. You don't trust your own body that it will push off. So I found I could run trails and softer surfaces better. So I kind of switched to that for a little bit and then had two children. And I think during that time with all the ligament laxity and everything, it really exploded and the tendons were just a mess. And then I said, all right, go back to square one and let's figure out what's going on here. Then I was diagnosed. Okay. So even before the diagnosis and you have years of this label tear, did you just think it's the label tear? That's why I'm running on Coles. That's why I'm so, it's so painful with sitting. Or did you start to second guess yourself and think there might be something else going on? No, I thought there was definitely something else going on. I mean, I thought everything from, is there MS going on? Is there some sort of very horrible muscle dysfunction? I thought of everything. Did you ever try and get a second opinion or see other health professionals? I did. They also checked me for the iliac syndrome where in your legs. So they did a test for that. Um, they did a couple of different diagnostic tests. The, um, I'm trying to think of the name of it where they test you with all the needles to test the nerve conduction study. All right. So I had that done and there was a little bit of an issue at the patella femoral head. So they thought that was just from crossing my legs when I sit. Um, but they, we found out eventually after a couple of MRIs. that my foot was somewhat going numb because of the tear and the compression and the irritation of the sciatic nerve. Right. And I guess by that stage, five years into it, the actual hamstring tendon itself probably isn't in the best condition because you haven't actually managed it the way you probably should have in the early days. And so what was it like getting that diagnosis? Was it just clean cut? Did you see someone who said, I think you have this? How did that come about? So I saw someone who said, this is what I think it is. And then they referred me to a specialist, Dr. Miller in the Boston area who this is kind of her specialty. She focused Dr. Susan Miller and she's a marathon herself. And this is pretty much all she does is hamstrings. When I first went to see it was a partial tear. It didn't seem too bad. So I had needle tenotony done on it. So the dry needling done, the needle fenestration where they put the needles in, PRP, shockwave therapy, I went through all those treatments. Okay, so did you find any relief or any help with those treatments? So I'm guessing the tonotomy is more like the, trying to help the conditioned tendon. I think they debrid or like remove some of the fraying tendon and keep the healthy portion. and the PRP just being the injection to help with growth and inflammation, that sort of thing. So any relief, any hope with those particular treatments? It worked really well for about a year. I had very good success. I think mainly the shockwave therapy was the most successful treatment. 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 hamstring tendinopathy video course which complements the podcast perfectly. Sometimes it's tough delivering concepts and exercises through an audio format, so the course brings a visual component full of rehab exercise examples, graphs and visual displays to enhance your understanding. Even if you sign up now, you'll have access to all current and future modules that I create. Sign up through my link in the show notes, then download the Run Smarter app. and you'll instantly have unlimited access to all the course resources on any device. And to say thanks for being a podcast listener, I want to give you a VIP offer. There will be a link in the show notes in every episode that will provide you 50% off the course price. Just click on the link and it will automatically apply your 50% discount. Okay. How many, just out of curiosity, how many shockwave sessions did you have? Eight. Okay. Over like how long in between sessions? Every other weeks. So every other week for two months. And then again, it took like a month off. And then again, two months later. Okay, cool. So you think the shockwave was the most beneficial out of all of those? Yes. I'm not sure about the PRP, the needle-ten autonomy, and you can't do anything once you've had that, the PRP, you can't do anything for a while. And I, just in my experience, tendons seem to respond better to some sort of movement and not just rest. Yeah, with my experience, I'd say that's definitely true. At the time of shockwave, did you also have some sort of strengthening exercises involved, any sort of resistance training? Yes, I started physical therapy then. And I think that's when I really started to see benefits as well. committing to a physical therapy program and working with someone who was experienced with PhD. Okay. Yeah. What was the, once you had the diagnosis, what was early management like? So what was your running like? What was your cross-training like? What was your strength training like? How often? Give us a bit of detail there. So I would cut back to three to four times a week running and doing the strength training three to four times a week. Okay. Well, do you have any, I guess, favorite exercises? Do you have any, anything that, any exercise that you think really helped? The Nordic, and I wrote this all down. The Nordic- Oh, cool. Nordic hamstring curl, number one, definitely for strengthening. Can you, I know there's a couple of variations with the Nordics. Can you explain exactly what position you were in and what you were doing? So getting a pillow on your knees and putting your knees on a pillow and having someone hold your feet behind you, trying to- or to the floor into a plank or push up and then pushing yourself back up. Yep. So you're following like a straight line between your head and your knees as you drop down and you're slowly trying to go down as far as you can until the hamstrings, or you don't have the strength to slowly descend and then you push yourself back up once you hit the floor and then repeat that. And okay, yep. Most people can be familiar with that. What other exercise do you have written down? The single leg banded glute bridges. So really loving the single leg glute bridges and having it banded. Deadlifts and squats. Okay, now we're talking. I do like deadlifts and squats for people with this particular condition. And I do think that they need to find the right balance for them to start with. Like every tendon is quite different. Every tendon will have a certain load capacity and just whether we start with deadlifts or we start with weighted deadlifts or maybe deadlifts or that level of compression might be too advanced for someone, depending on their level of tolerance. But eventually I think squats and deadlifts are really, really important throughout the management. I do know that you had surgery and I wanted to talk through like exactly when in the process, how long you had it before you had the surgery and kind of what the conversation was like. regarding whether you should go for surgery or not go for surgery, whether you try conservative. What was the discussion or the decision process behind that? So I had tried the conservatory with this particular doctor for a year. And then during a cross country race back in 2019, September 8, 2019, I felt a really sharp pull in my hamstring and I couldn't even put weight on it anymore. So I went back to her and she said, hanging by a thread. So let's just get in there and you've tried everything else. Let's get in there and give this a shot. Okay. And what stage throughout your running career was this? This was only two years ago. So pretty recently. Yeah. 28 years competitively. So pretty late. So I guess you were doing your management. You're doing your strength work once you had the diagnosis. You had the shockwave, which seemed to be really effective for about a year. And you said that you were implementing a lot of strength work three times a week. With just doing those conservative treatments, how, I guess, functional, how much did things improve? How successful was it? I'd say I got back to about 60 or 70% strength. And then, so... you would have continued that management, say a couple of years, and then you had this one race where you felt the hamstring sort of a strain, and then that caused the, resulted in the scans, then resulted in, hey, maybe we should try surgery. Right, I think at that point, she was very open to it. She said, you've tried everything else, let's give this a try. And she had really good success with hamstring surgeries, and she had... you know, got me in touch with some of the other athletes through the Facebook pages who had surgery with her. I felt confident that she was a good person to go with. Out of curiosity, that race where you started noticing the hamstring flare up, was that like an overreaching event or is it something that you thought you could handle in terms of like terrain, in terms of distance, in terms of the speed you were generating? Um, I was probably in a little over my head. I was probably running a little bit too fast for where my hamstring was. I think that just like motivation levels or just like the competitiveness side of you, competitiveness, I think. Okay. Yeah. Right. Near me for. Yeah. And so what did they, what did surgery actually entail? What, what did they do? So they, um, you bride it, the whole tendon, they put three anchors in because when she went in, all three were detached, just a couple of strings. So it was even worse than they had thought. And I had the sciatic nerve was also covered in some scar tissue. So they had to clean that up, which explained a lot of the kind of the numbness in my foot and the tingling and almost foot drop a weakness in my foot. So they went in and she put the three anchors in and then I was braced for six weeks. So no sitting, you had to either be on your back or standing for six weeks. Wow, that could have a big impact on daily life, I could imagine. Did you find much success with the surgery, like after that six weeks of lying down and not sitting? What was recovery like? What do you think the success was? I think the success was totally due to the physical therapy that followed getting it repaired. She had a super intensive program that I followed for six months. So I met with a physical therapist twice a week for six months and I didn't run at all. We just focused on getting the hamstring back to a functioning level. And then at about six months when running was introduced, it was on the Alter G. So there was really no impact, no loading on the hamstring. I also really started doing the dead lifts. really, really making sure that stays strong. Like my new motto has, if I wanna play, I have to pay. Even today, I still keep up with the exercises because I think it's, once you have PhD, it's always kind of ready to rear its ugly head again. So it's just a matter of keeping it at bay. I think that's a good point. And I think that's a good point with most tendinopathies. Like I've had several tendinopathies over the course of the years, whether it be in the knee or. planifacial or somewhere around the hips. And it does come back if you don't manage it properly. Like I know as soon as I will, if I increase my speed too quickly, or for increase my distance too quickly, like one of those tendons is going to rear its ugly head and it's all about management from here on out, like building up as much strength as you can, building up as much base as you can, and just making really sensible decisions moving forward. And if we do know anything from a risk of future injury, it's your past history of injuries is a pretty strong predictor of whether if you might, something might have rise in the future. So I think there's credit to you doing all that PT work before surgery, but I also think there's quite a lot of, maybe due to your success was all the strength work that you did prior to surgery as well. And like building up the strength of all the other muscles and tendons and conditioning your legs quite, to tolerate a good level of like after the surgery. And I do think people who suffer have really debilitating symptoms, but don't do any strength work and then have surgery. I think that's a bit of a recipe for disaster because you're repairing something, but everything's still quite weak, which then weakens again once you do have surgery. Would you agree? Do you see similar things? 100% agree. And when I went into the surgery, she said, I won't even touch you unless you're willing to commit. to six months of the physical therapy. And she said, it's my program, you're going to follow, you're gonna go to see my physical therapist and that's it. And I said, okay, I think it's a hundred percent due to the strengthening. I mean, the surgery helped, but. Yeah, were you quite apprehensive to start loading that tendon after surgery? No, and it's really interesting you say that because the physical therapist that I saw said, most people never come back from this because they're so afraid. Right. It's a fear factor of, but we took it in such baby steps. I mean, the first two weeks we're just doing simple heel pumps. You know, it was a couple of weeks before they even let me try to walk with crutches, putting weight on it. So it was very, very just baby steps. I think that's a good lesson. Yeah. With my... experience if someone has a lot of anxiety with loading up a tendon or a lot of anxiety with say sitting. I always say let's just start with the smallest dosage you feel comfortable doing and let's build up your confidence with that level and slowly make these really small steps to build your way back up because not only are you building up your strength and you're slowly building up your level of tolerance but along the way you're kind of getting more confident. your mind is starting to settle a little bit and you're taking really small steps. So you're not that anxious. You'd be like, oh, I could tolerate six minutes of sitting. Let me see if I can do eight minutes of sitting. It's not that massive jump. And like you said, if you start off with just these really gradual heel pumps that isn't really that threatening or not that anxiety driven, then you can just go the next step up from that. And then the next step up from that, all of a sudden, yeah. get back to doing say deadlifts, which is a really good lesson for anyone who has that sort of injury or that apprehension to return to sport or exercise. I think you really have to think about it for, it's long-term, you can't think, there's no quick fix, especially with any tendinopathies, as you were saying, it's really step-by-step and being patient and each tendon's different, it's going to take a lot of time and commitment to get it done. Your surgeon did say she recommends six months of resistance training, strength training, progressive strength training after surgery. How long until you were back running or doing some sort of like cardio based exercise? I was on the bike at four months. So I was able to do with light resistance, back running a little bit, as I said, on the Altar G at six months. And then at seven, eight months, you know, four minute run, one minute walk, the walk run for a while to just build the tendon load up. But I still continue the PT today. Cool. If you would get to that in a second, the Alter G treadmill, I've never seen one, I've seen photos and just to get a bit of clarity if someone isn't familiar with it. Is it the treadmill where you kind of have this big bubble around your legs that are kind of like, you kind of fasten your waist so that there's like a seal between your waist and the rest of the treadmill? Is that the one we're talking about? Yes, I believe it was based on NASA's work. So you're essentially, you can be weightless almost. Yeah, I think it's quite effective for if someone has a stress fracture. and returning to running after a stress fracture as well, because you're essentially, well, the alter G means that you're altering the gravity that's on the legs. And so if you pump, I guess, whether they're pumping air or just pressure inside that bubble. Blows it up. You're actually floating, they blow air into it. Yeah, and so I guess that's a really good approach, a gradual approach. You might not. It might not be that accessible around the world, but if you do have access to it, then I guess it can be quite nice. So yeah, you're altering the amount of weight that you weight bear when you contact the ground on that treadmill. So I think, I hope that paints a picture. If someone is still a bit confused, they can just Google alter G treadmill. That's great. I think that's a really good story. And then once you got away from that alter G treadmill, Was it like a walk run strategy after that to try and get back into and build up your running capacity? Yes, walk run for at least two months. Mm-hmm, all right. Very gradual, a couple of days a week, supplement with cross training, strengthening. Patience pays off. Yes. Throughout this whole recovery phase, you said that you had the surgery a couple of years ago. Have there been any flare ups since? Um, I, this summer I had a little flare up when I was doing a lot of mountain running and I think it was just too much uphill running, which is a lot on the hamstrings. So it would get angry and I could feel it getting tight that the same feeling I had 15 years ago. And so I would just stop at this point. I'll just say, okay, I'll take a week off, just focus on this opening again. And then we'll, we'll build back in again. Yeah. It's just listening to the cues now. I know what the cues are to make it flare up. So I just, once it happens, I shut it down and that's it. Yeah. I think it's learning more about your body and it's just being sensible with the history that you had and just like learning what your body can tolerate and learning to follow symptoms. I think it's perfectly fine if you might overdo things, overstretch things, change your terrain. Like I said, uphill can increase the amount of compression hamstring tendon. And so if it does get a bit sore, having some time off, but still maintaining your strength work in the meantime, because tendons can get quite weak or reduce their capacity quite quickly if they people decide to have like a week of complete rest or two weeks of complete rest backing off almost everything. But yeah, like you said, maintaining some strength work is a really, really nice tip. I do have a question down here regarding your most favorite and effective strength exercises. But I think you alluded to it before with the deadlifts and squats. Anything else you wanna touch on that question? A lot of banded work, like the banded cowboy walks, backwards and forwards, anything with bands, anything with single leg too, single leg step ups. Yeah, I think that there's some very good research to show that if you do have proximal hamstring tendinopathy, then strengthening the glutes is a really good approach as well. Yes, we wanna strengthen the tendon. hamstring tendon itself, but it increases the effectiveness when you do a lot of glute work and strengthen up the hips as much as you can. So a very good point. This podcast is also sponsored by the Breakthrough Running Clinic, which is my own online physiotherapy business where I treat clients all over the world. I always recommended that my clients build on their own knowledge and try to manage their symptoms on their own to build self-confidence. However, if you still require a tailored approach, and one-on-one guidance, whether you are a runner or not, I'm more than happy to be on your team. You can sign up for one week or one month packages and have me by your side every step of the way through the duration of your package. So head to the Breakthrough Running Clinic link in the show notes to learn more. One of the questions that I have written down here was, can you identify any potential mistakes or anything that you would change back in the early days, anything in hindsight? that you think might've avoided this particular issue from arising? I think if I had just listened to my body and instead of trying to reach goals, instead of more focusing on the long range plan, like running hopefully could be a lifelong sport and I was so caught up in trying to get a certain time or. get into a certain race that I was ignoring my body signals and that's just never smart. So I think that was a big mistake, just not listening to cues. They were there, I just didn't listen. How about those, that time of having that misdiagnosis and like constantly, I guess treating the wrong thing for such a long period of time. Do you think if you had your time again, you might have sorted a second opinion a bit earlier? I think so. Yeah, I think that would, in retrospect, that definitely would have been another good option. But I also feel like PhD is such a newly diagnosed entity. It's only now that you hear about it. Even five years ago, I don't feel like that many people even knew what it was. I feel like it's just becoming kind of an understood entity. People either thought it was piriformis or hip issues. Yeah, I guess that was just a factor of the time. And Like I said, that was quite a long time ago. It was like around about 15 years ago. So the understanding of it wouldn't have been like it was now. So it's hard to dwell on the past and say what might've changed, but if the health professionals don't have that level of understanding when you went to, it's kind of hard to change things. Right, definitely. And even just the imaging too. I mean, now everything's on a 3T, so the MRIs are so much more sensitive. You can see so much more. There's just... the testing is so much more specific now and so much more sensitive. We're very fortunate. Yeah. As we're wrapping up, I have a question around current prevention strategies that you have implemented. And you do say that you're diligent, very diligent with your strength training. I'll ask, how heavy are you lifting with your resistance training? I understand the band exercises won't be like heavy weighted sort of stuff, but with your resistance training squats, deadlifts, those sorts of things, how much of a strain is it on the body? How many reps are you working on? What's that sort of dosage? So squatting and deadlifts twice a week, with fairly heavy, I think, I don't know, I think my max deadlift was like 104, so not that much, but fairly heavy for someone who only weighs about 120 pounds. So almost body weight. So are you doing say three sets of 10 or what sort of rep ranges? So starting with lighter weights and then building up as we go. So maybe three to four sets of 10. So obviously by the end, I may only get three or four reps in because the weight's progressing to heavy weights. But I think it's important to load the tandem with a heavy weight. You answered it perfectly. That's what I was after. But learning to, slowly load that tendon, it can be really nice and help the tendon respond really well to heavy load. And sometimes you might wanna do like warmup for a couple of minutes, just doing body weight exercise and get that tendon kind of warmed up and used to, well, the tendon, first of all, used to tolerating load, but the confidence that you have to load that tendon, you might wanna work up in stages. So that's great. So starting off or doing about four sets, but progressively increasing the load every single set. And then are you just throughout that set, are you just going until you can't do another rep or are you just doing it until you feel a significant level of burning or tension in the muscles before you finish your set? Usually until I can't do anymore, until I can't lift it anymore. Okay, yeah. I have a coach who's really experienced too with strength training. And so she's really formulated a great plan with that as well. Yeah. And I'll probably have a bit of a safety message for those who are listening. Getting to like a rep max and progressing those weights does require months and months of training. If you haven't lifted weights before and you think, you know, Brody and Kara say I should lift heavy. And so they decide to start lifting heavy. You do need to allow your body time to adapt. And that might be a period of months and months to tolerate heavy lifting and especially tolerating to the point of getting to a rep max, so you can't do another rep. I think that's worth saying as well. Would you agree? 110%. I started with air squats. There was no weights. So I think that's so important just to get your body even used to that sort of position, getting into squats, deadlifts. I started with zero weight. So that's, it was about a two year buildup to where I am now. So yeah, that didn't happen overnight. Yeah. Any other prevention strategies outside of the gym, maybe around your cross training or cardio, or even like sitting strategies, those sorts of things? I bought a standing desk, so I never sit anymore. Okay, at all, like throughout the day? Not really, unless it's a meal time. Okay, are you standing now? No, I'm actually sitting right now. Okay, good, it's good to see that you are sitting a little bit. But I can sit, I can sit for long car rides. But I think as a teacher being at a, when I was at a desk, it's just not good to sit for six hours a day. Or I think it's important to have different positions, get your body moving around. Yep. And in regards to your cardio structure throughout the week, any sort of preventative strategies or are you monitoring your loads at all? So yes, definitely a lot of cross training. So I have an elliptical, treadmill, bike and a rower. So maybe three days a week and the rest is cross training just to keep up the cardio load but without super loading the tendon. Yeah, cool. I think that paints a really nice picture of the level of success you've achieved and those strategies to be implemented for that. And the level of success you've got back to I think a lot of people with years and years of proximal start to manifest some despair and being like, I'll never return back to cycling, I'll never return back to running, or I'll never return back to levels of sitting or car rides. So it's really good to see if you're patient and you put in the hard work that these things can come about, that level of function can return. And as we finish up, the last question I have is, are there any... takeaways you might have for those who are suffering with proximal hamstring tendinopathy at the moment, who might have had it for a couple of years and not really seen much success, any key takeaways? It's actually pretty much what you just said and I wrote it down. It just can really wreak havoc on you mentally. It's such a stubborn injury and you can just spare it really gets you down. I think the most important thing is to remain hopeful and really commit to the long term. and celebrating each little success. For example, I did a Nordic curl and my hamstring didn't cramp. That's a huge victory. Just little tiny successes along the way and they'll add up. But I think it's really important to stay hopeful and have a positive. I think that mental, the head space is huge. And when someone's had any condition, any like injury for several months, multiple years, it's easy to focus on the negatives and constantly focus on the negatives. And we do need to be more kind to ourselves. I say it quite often. We do treat ourselves or hold ourselves to a really high regard, give ourselves these high standards, give ourselves like really ambitious goals. And when we don't reach them, we're quite hard on ourselves. And I totally agree celebrating those small wins. I do have some runners who, when I talk to them when they're injured and they say, all I wanna do is run pain-free. And I event, they eventually work really hard and get to running pain-free. And I said, fantastic, do we celebrate? And they're like, well, I'm running pain-free but I'm not running at the pace that I used to. I'm not running at a distance that I used to. And they're just constantly fixated on, you know like maybe negative kind of attitudes or just focusing on something without celebrating those small wins. So exactly what you're saying. It needs to be a deliberate. practice to celebrate those small wins. And even just doing some banded hamstring curls without the hamstring cramping isn't something that most people would celebrate, but something that they need to celebrate because along the way that those small wins do build up momentum and with the momentum is a very powerful force. And so those smaller wins get into bigger wins and get into bigger wins. So something to really recognize. And yeah, the mental component is huge when it comes to recovery. A very, very good point. Any other takeaways that you had written down? Just that, and even when you think you recovered, you're not, so just keep training, keep strengthening it. Yes, yeah, that's good. And I think that's the same, but particularly with any tendinopathy, it is something that needs to be managed. It is something that you need to take care of and you need to be mindful of when you do have something that you need to prepare for, if you need to get stronger or... have a stretch goal to prepare for a marathon or something. You need to keep in the back of your mind, I have had this tendon issue in the past. I don't feel it right now, but let's just manage or build yourself up to make sure that there's no spikes in training or overload or things like that, because it will rear its ugly head as soon as you give it the opportunity to. And yeah, so it's not really like a cure. It's we're just successfully. treated it now let's manage it for the rest with strength training and with proper training structure. So really, really good point. Okay. There are all the questions I have written down, Cara. And it's, I think the lessons, just hearing your story is crucial for anyone undergoing these sort of conditions like proximal hamstring tendinopathy and any other tendinopathy, the lessons around strength training, the lessons around the like building up the level of tolerance, building up like the, um, I guess cross-training and lifting heavy and all these things that you've learned throughout your story are lessons that anyone needs to hear. So it's fantastic that you've come on and shared your story and I really thank you. Thank you for coming on. Thank you for having me. I hope it helps one person just have a little bit of hope and put the work in. Absolutely will. It's good seeing these success stories because your proof is in the pudding and you're just telling the story how someone can go from. years, years and years of having this particular condition and being quite successful if the patients and the dedication is put in there. So well done. Thank you. Appreciate it. 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.