Q&A: Active Elderly / Pain Swapping Sides / Sit Bone Stress Fractures / Sciatic Nerve Scarring

: On today's episode, we have yet another PHT Q&A. 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. Once again, thank you to everyone who has submitted some questions. Like I said last time, I've got a lot to cover and that's why I decided to do a two-parter and thanks for everyone reaching out and you know, sharing how much they enjoyed last episode. I think I love the ability to answer questions and the quality of questions that come in and the variety of questions that come in. I'm really thankful for so really appreciate you also participating in this and yeah, it's helping everyone getting a better understanding and sort of sharing my thoughts. A lot of it might be my thoughts because a lot of these questions are can't necessarily draw from current evidence but you know, I'm glad that you're finding it useful. Okay, let's dive into this because we've got about five, six or so questions to go. We have Karma who says, can you address this condition in the active elderly? There's so much focus on rehab for runners. I'd like to get some exercises that I can reasonably do without exacerbating my PhD. PT hasn't helped me. Okay. Thanks for your question, Karma. You know, not everyone who gets PhD is a runner. I do get a lot of the active population, but also get some, granted not a lot, but some of the sedentary population as well. And it might be just triggered by too much sitting, sitting on firmer surfaces, doing some gardening or, you know, doing an unexpected hike with family or something like that, um, mixed with sitting combination of things. And so, um, I hope that a lot of these episodes aren't, you know, uh, I hope the vast majority isn't just meeting specifically for runners. I think the general principles are communicated fairly frequently on the podcast and that can be applied to a lot of people, given the circumstances, even in the sedentary population, if they've had it for a long time, I say, well, let's get stronger. Let's do it. And so if you're not a runner, I would say when it comes to the exercises, don't bother with, I probably don't need to bother with lunges. Definitely not Nordic curls or hamstring sliders, like those sort of exercises that are sort of preferencing the eccentric contraction of the hamstrings. So like, as the hamstrings engage, the muscle lengthens, like a slider. So you might do a bridge. with these slippery sliders under your heels and then slowly slide those sliders out until your legs are straight and then you know you passively come back go up to the bridge and do that again those sort of exercises or the Nordic curls where you have your ankles pinned down you're kneeling and you sort of drop your body to the ground like those totally unnecessary. Hip extensions as well if you're doing a standing resisted hip extension you know, bringing your straight leg behind you against resistance. I don't think that would be necessary. I suppose lunges might be necessary if you are one, two, garden, or, you know, be picking things up. A lot of housework that requires a lot of lunging. Just depends on what you're doing day to day. But, the other exercises are largely the same. No matter what condition you have, if you think, well, if you know you have PHT, you would want to do a deadlift and you would want to do a hamstring curl of some description. And I know, Kama, you're talking about these exercises, you know, probably don't seem appropriate for you. And you want to do exercises that don't exacerbate your PhD. We just need to find the right starting point for these specific exercises, because you might do a hamstring curl with a very light resistance band and that might be fine. you might do a deadlift with 15 pounds and you might do three sets of five at one quarter range of movement. That might be fine. I'm pretty sure that shouldn't exacerbate symptoms. But why are we doing a deadlift? Even though it's in the active elderly population in this scenario, why I always prescribe a deadlift is it's pretty much one of the only exercises that targets the upper hamstring. it like biases, loads, strengthens the, the area of the upper hamstring area. I can't really think of any other exercise that does it. Um, yes, you might think that like a single leg deadlift or an arabesque or like those sort of hinging type patterns would also do that. I would agree. Um, but you know, we want that slow control, hinging type of action. that encourages a little bit of compression and just trying to load that area that meets the demands of how much you can tolerate. So you might say, yeah, but I'm not doing deadlifts throughout the day, therefore I don't need to get better at it. Yes, but you do need to sit, you do need to bend, you do need to put on socks, you do need to go from a sit to a standing position, you do need to do all these that if you get really good at deadlifts, will carry over to meet those daily demands. So probably not the answer you're expecting or wanting, but I would still try to find some variation of a hamstring curl or a deadlift that you could tolerate. If you say PT hasn't helped you, maybe the exercises prescribed haven't been the best. Maybe they've given you other glute based exercises or bridges or some type of strength exercise that isn't really targeting the upper hamstring and therefore the proximal hamstring tendon isn't being exposed to the right amount of load that fosters the right healing. I'll say it again, tendons love and need slow heavy load for recovery. That's how they adapt, that's how they get stronger, that's how you raise capacity. So let's do that. But when I say slow heavy load, that heavy portion is different for everyone. So yes, like I say, it might be 15 pounds. It might be limited range movement. So start off light, start off with a reduced range, build up from there, eventually will meet your adaptation sweet spot. Hopefully you start seeing some improvements in symptoms and improvement in function, and then you can just continue progressing on your merry way. Okay, let's move on. So we have Sam who says, hi Brody, thank you for your podcasts. They are a huge help. And I return to them whenever I have a twinge or a flare up and or just need to reset. I had PhD on my right leg for around a year, but I've been pain free since around January. Well done, Sam, that's awesome. That is until two weeks ago, when my left started heading down the same path. Both legs have been through the same strength work, gradual running rebuild, et cetera. So why would the left leg start experiencing issues? This is a very tricky one to answer. I don't know for sure. Like you can't possibly know for sure, but we can try to come up with some hypotheses from a mechanical standpoint and then look elsewhere. So I guess from a purely mechanical loading direction, maybe there is a little bit of compensation when you're running. Maybe you're pushing off or swinging the leg or leaning on, hitting the ground harder slightly on the unaffected side and unspenown to you sort of nursing the injured side, well, the previously injured side, just because you've had that history there or maybe your brain's not, well, isn't necessarily activating and firing things to their full capacity and therefore you're having to rely on the other side, therefore more load goes to the other side, therefore, you know, opening up the possibility of more load. some people sit unevenly. I know I sit unevenly, even if it's just like a 60 40 on one side to another. My microphone is slightly to the left, and my mouse is to the right. So I'll usually lean on my left hand armrest so that I have my right arm available to freely swing. And just as I'm recording this podcast now, and I'm just appreciating what how my weight is distributed throughout my seat, I would say definitely, probably about 60% is going on my left hand side. So people can sometimes have compensations on one side compared to the other. Driving, for example, we need to move or depending if it's a manual or automatic, most people will lean to the left to actually, I'm not too sure in the US because the gas pedal will be on the other side. Anyway, because we need to move our feet when we drive, sometimes we shift our weight. Um, you might be favoring one side if you're doing double leg exercises. I try when I do my squats and deadlifts to try to appreciate 50 distribution throughout my feet. But when I was in, uh, working in clinics, sometimes we'd have like a pressure sensor and we'd get people to do squats and deadlifts and things on the pressure sensor. No one is ever 50 50. Um, it's often 55 45. Um, even though, you know, pending people's history and injuries and that sort of stuff, it's very rare that someone would be 50 50. Um, and just like daily bending, lunging, that sort of stuff. I know if we have to pick something up off the floor, we always favor one side. And so if we're gardening and doing that hundreds of times, we're favoring one side as well. So from a mechanical point of view, there may or may not, like I say, just hypothesizing some compensation. So if you were to run, then you were to sit. then you want to exercise, then you want to do some gardening, like there's something that might favor one side compared to another, especially if you have an injured, a previously injured site where there's still some like, neural tags there where your body's like, oh, let's just be a little bit cautious of using this leg and use the other one instead. But I will say, Sam, it's probably not worth trying to find the answer, because we're never gonna know for sure. And apart from the mechanical things I just listed out there are a ton of other things. It could be under recovery, it could be sleep, it could be diet, it could be stress, it could be a lot of things. But where my mind sometimes goes with these sort of questions is like, your brain is very sensitive to injury. And it's like a similar to like on both sides as well. Because if you have a slight, if your symptoms are slightly starting to emerge on the opposite side, your brain is automatically going to go into a bit of overdrive because you have had a long history of a similar symptom on the other side before and it's caused a lot of distress, a lot of, you know, pain, a lot of dysfunction, a lot of emotional stress. And so there's a lot of wind up there, your brain's gonna be very receptive to that. will likely amplify what is actually going on. And so I say that because, you know, sometimes you might overload a tendon and we just don't think about it. We don't worry about it and therefore it goes away. But sometimes there's a little symptom there and we do worry about it. We do freak out. We do, um, overreact and the brain will do that. And so, you know, uh, part of me thinks that's, you know, based on those set of circumstances, maybe that's a potential reason. But like I say, let's not focus on that rather than being disempowered, trying to look for answers that you're never gonna find the answers to. How about we feel empowered and just plan ahead. Create a plan moving forward. Make the necessary running and training adjustments. Plan on, you know, your return back to pre-injury status. Do all the right things. And emotionally, mentally, psychologically, it's going to be a lot more worth your while than just, you know, worrying about what the cause might be. I know sometimes I wake up and have foot pain without no rhyme or reason. I try to think about what could have happened. But if I can't think of anything, I just move on and try to forget about it. And hopefully, in most cases, it just fades off. And so, you know, and if There was a while ago when I very first started high rocks training that I did start getting foot pain and I did try to, I'm like, Oh, it doesn't really make sense. I'm not too sure why let me let it go. But two, three days later, it was still there. I'm like, okay, let's become empowered. Okay. Now I need, and this isn't going to go away. I feel like it's not going to go away. It's own let's create a plan. So I started doing foot strengthening exercises, being more cautious of the footwear throughout the day, testing out a bit more running, see what I could tolerate. and then just moved on and within a week it was gone once I was a bit more proactive. And I feel like Sam, I feel like you could do the same. So hopefully that helps. Like with these type of questions that are coming in, they're great questions. Unfortunately, the answers I have to provide aren't really that helpful, but hopefully it creates some understanding. Christine says, hi Brody. I have a partial tear plus frame and just turned 60. I have been doing PT for a while, but now my knees are killing me, especially when I sleep. The pain from the knees is now worse than the pain in my butt from the hamstring. Any suggestions? Thanks, Christine. This might, you know, we could substitute this for someone who might do their rehab and have back pain, or someone who might do their rehab and, you know, have mid hamstring pain or something like that. I would say my answer would be the same. Like I have when I work with clients and in my online courses and all those sorts of things, conditions that people need to meet before progressing to the next phase. Like they'll have their deadlifts and their step ups or their lunges or hamstring curls. And there's a whole bunch of progressions that they have. And I say, you need to meet these four conditions in order to progress to the next phase. Number one, symptoms allow. The symptoms, your PHT symptoms, so pain during the activity needs to be less than a four out of 10, needs to return to baseline in less than 24 hours in most cases. So that's number one, symptoms allow. Condition number two, you need to have adequate technique, quality of movement, form, wanna make sure that that's all okay, if you are okay with that, you have my permission to progress to the next phase, provided that the other two are met. Number one, So number one was symptoms allow, number two overall technique, quality. Number three is just your overall level of difficulty. Making sure that when you do a certain exercise, your symptoms could be fine, technique could be fine, but if you just find it's so tough to do, we wanna give it a couple of weeks before then progressing to the next phase. But if the overall level of difficulty is adequate, then we can move on. The fourth condition. is the rest of the body allows. We need to pay attention to the rest of the body away from your PhD to know that you are ready to progress to the next phase. And I say this because when you do deadlifts, it does strain the lower back. It's an exercise that strains the lower back. And so if you start doing your deadlifts and your hamstring is tolerating it well, but your back isn't, you shouldn't be progressing. You need to try to find your sweet spot for your hamstring and everything else in your body. And so why I say this, Christine, is most likely, I'd say your exercises that you're doing, there's been some sort of overload and there's been some overuse stuff through your exercises. That might be, you might be doing squats or you might be doing lunges or you might be doing step ups. They are pretty typical. They put a lot of load through the knees. So you've either progressed too much and need to dial things back. Maybe Nordics, if you are doing Nordics, maybe it's not the, it's the actual physical presence of kneeling and the kneecap not tolerating that pressure. That could be a thing as well. So if you are doing those sorts of exercises, we need to do what we do for every other injury. We need to modify it or reduce it or rest from it for a couple of days and let symptoms settle down. Definitely if you're getting pain throughout the night, you've overdone things. And so have a chat with your PT, maybe have a chat about what might be some appropriate modifications, let those symptoms settle down, and then really pay attention to the symptoms of your knees when you are progressing your exercises or allocating certain exercises. Okay, Jenny says, hey Brody, thanks for your help. I have... been having physio but due to limitations on my arm, due to lymphedema, cannot do things like deadlifts. I've had problems in both legs for four years. Can other exercises help if weights cannot be managed in the arms? Thanks Jenny, it is quite a unique scenario. I would say, if you can't do deadlifts, yes, you do need to hold on to the weights to do deadlifts. Maybe some Nordic, hip dips. Now this isn't a Nordic drop or Nordic curl. This is the same starting arrangement. So you're pinning your ankles down either someone holding your ankles down or you shift them shuffle them under a couch or a chair or not a chair, a couch or a sofa or something that locks them securely. You're kneeling, your posture is upright and then you hinge forward so you dip forward. keeping your thighs vertical. Now almost everyone just gently sits their butts back towards their heels. You need to resist that urge. Keep the thighs completely vertical as you dip forward, keeping your back straight and sort of doing a drinking bird type of action, then coming back up. That will put some load through the upper ham, it kind of mimics a deadlift. And this is what I prescribe to my clients who are going traveling and they don't have access to a gym or a lot of weights for their deadlifts and I say this is a good substitute for the deadlift. Not a perfect substitute but if you can't do deadlifts it is the next necessary type of exercise. So you could do that. Start off with a reduced range of movement. I would say a full range of movement would be going down to 90 degrees. So a 90 degrees angle from your thighs to your torso, your trunk. And so you can start with half range of movement, three sets of five, see if that is tolerated, and then adjust from there. You can do step ups if you would like, but instead of holding on to the weights, you can have weights in a backpack. Yes, you do need to put the weights in the backpack in your arms, do need to put like get the backpack around your shoulders. But if you're okay with that, then that's another one. And you can obviously do your prone hamstring curls because you don't need any arms for that either. So that would be my advice. Okay, Georgie comes in with an interesting one says, Hey, Brody, could you talk a bit about under fueling in tendon health, and also the co occurrence of pubic rami stress fractures? Thank you. So your pubic rami is essentially a sit bone. And a stress fracture is sort of like a over an overload of bone, a breakdown of the bone that then undergoes a reaction, that reaction becomes severe enough, generates a stress fracture. Let's start with this under-fuelling side of things. I'm not entirely sure what you mean by under-fuelling and tendon health but I'll try to answer it to the best of my ability. So tendons require the necessary building blocks like any other tissue. If you have breakdown of muscle because of exercise, you need the proper building blocks, i.e. through your diet to, you know, build them back up again. The tendon, 65 to 80% of a tendon is collagen, made up of collagen, which is a protein. And so your diet should have adequate protein. When you exercise. Even in healthy tendons when you exercise, we need protein to, you know, rebuild and strengthen up those tendons. When there's undergoing a tendinopathy, you know, that tendon that protein is very important to. So a diet should have adequate protein, what's adequate for you, I'm not entirely sure. Some might suggest that about, I think I've heard one gram of protein per pound of body weight, or maybe two grams of protein per kilogram of body weight. I've heard those numbers being passed around. Um, also opens up the conversation for collagen supplements. If a tendon is mostly collagen, wouldn't taking collagen supplements help, you know, restore and rebuild a tendon? I'm unsure. Like I'm trying to keep a close eye on the research and you know, I have no idea what I'm talking about when I say this. I'm no expert in nutrition, dietetics, all that sort of stuff. So take it for what it's worth. It tends to be my general feel, but obviously if you are taking inadequate amounts of good quality protein, obviously meat protein is different from plant protein, whey protein is different from other forms of protein. Like, you know, we do wanna be careful with the quality of protein that we intake, you know, pay attention to that. So I guess, not sure if this is the direction you're looking for, Georgie, when it comes to under fueling and tendon health. But that's where my mind goes when I hear that sort of question. I'm not sure about the co occurrence of a stress fracture with the presence of PhD as well. I haven't seen a huge correlation or a no coexisting diagnoses with my line of work, I think I've maybe seen a sit bone stress fracture, maybe five times in the hundreds of PhD clients I've seen. And that but it's often misdiagnosed is a lot of there's probably a lot more sit bone stress fractures that are going on that are misdiagnosed or just go unnoticed. But I would say probably symptom wise. a sit bone pelvic stress fracture, I think there would be a lot of difficulty weight bearing, like standing on that affected side, like just purely just weight bearing, hopping even, no warmup effect, like sometimes when someone runs with a tendinopathy, first couple of minutes is a bit angry, but then sort of warms up, feels a bit better, and sort of gets a bit worse towards the end with. Stress fractures, it's usually, it just gets worse and worse and worse and worse the more you load it. So there's some subtle differences there that might suspect that it might be something else. But if you suspect that it is a bone stress fracture, contact your medical team, get it assessed, usually because stress fractures are a lot more serious in terms of the protocols for healing that we wanna pick it up as quickly as possible. Usually an MRI. is the best scan for picking those things up. Thanks Georgie. Let's move on to Cynthia who says I have a two to three centimeter retraction on the 15th of March. Initially misdiagnosed, so healing conservatively. I'm doing PT, walking, swimming and diligent strength training. I am an expel arena, so very strong in the legs and fit. I'm 68 years old. Frustrated because I'm having calf pain. Severe at times. I understand it could be coming from sciatic nerve if there is any scarring. Any suggestions or exercises to release the sciatic nerve? Thank you. Thanks for your questions in the art seems like you're still unsure if it is the side of nerve because you mentioned I understand that it could be coming from the side of nerve. So I guess my first point of call would be try to get a good diagnosis or try to get a little bit more detailed accuracy of if it is generated from that or not. There's some good diagnostic tests, there are good neurodynamic tests, a PT should be doing a gambit of tests and really having some good likelihood to know if it is generated from the sciatic nerve or not. Some common things for the nerve, like prolonged sitting, if you are sitting for a long period of time and you start noticing worse and worse pain in the calf, maybe we can suspect it's sciatic nerve origin. Often burning pins and needles numbness. If you have burning pins and needles or numbness in the calf or in the foot, you with prolonged sitting, we can increase the accuracy that it might be as such. If you do suspect that it is sciatica or some sort of origin around there, you can try a few things to see if it works. This is on a trial and error basis. You can try some like lower back mobility exercises. Sometimes a Cobra exercise is something you might try. some light piriformis stretches, obviously something that doesn't irritate the PHT too much. You can do some neurodynamic tests or neurodynamic exercises at home to try to floss the sciatic nerve, to try to calm down its sensitivity. But you know, if you get an MRI and it's obvious that there is some scarring or scar tissue surrounding the tendon, which then impacts the sciatic nerve, it's impacting the sciatic nerve. You know, maybe surgery is for you. If you've tried all these things, if you're confident, if you're confident in the diagnosis, you're confident with conservative management and conservative treatments being ineffective, maybe it opens up the conversation. I would say go back if you haven't already listened to the episode with Dr. Hardian. Dr. Lefevre, they had talked about sciatic nerve scarring and some surgical options and when it might be appropriate in that episode. So you can have a look at that. Our last question comes from Fabian and says, I love listening to your podcast. I'm so thankful for science-based information. I don't know how science-based this episode has been, but thank you very much. My question, I have PhD in the left leg. all three tendons no surgery in the right leg three years ago. I'm 57 years old. So I'm so scared that the left tendons will also tear. When pain free, when pain free, I run a slow 4k, should I totally quit running to minimize the risk? Okay, so you've had a long on the right side and now currently you have PhD on the left side and you're scared about some for like some tearing and those sorts of things. Okay what I would say full evulsion tears mostly I'd say almost always come from traumatic events like slipping on ice, falling, doing the splits like something that's really abrupt to cause that effect. It's very hard to believe that there would be such a severe tear of all three tendons full of vulgian or like more tendon tearing from overuse stuff. Yes, small tears exist. You might be a runner and have no of none of those traumatic events I just mentioned but still have small tears. I am one to say that small tears are probably normal and it's depending how small it is, but we know in the healthy population, you scan people's hamstrings and they have small tears in their proximal hamstring tendons. So how much weight we put on that? Not too sure. What I would say is that if you do have PHT, we want to keep the tendons as happy as possible. How do we keep them happy? We keep them strong. How do we keep them strong? We exercise and we strength train. How do we not keep them If I had this like upside down world where I wanted to try to tear my tendons, like, you know, dive into the fear that you have Fabian, I would say what's the complete opposite of that? It is complete rest, complete rest, weakening the tendon and try to after like when there's complete rest, I would then try to sprint or do my heaviest deadlift possible or like, you know, just totally try to. overload it when it is really, really weak. But that's not what we're doing. We're good. We're nowhere near that. If anything, I would say running is keeping you healthy. It's keeping you mentally strong, physically strong, in a good physical state. But also keeping your attendance strong, keeping your attendance happy. So I get that you might be worried. But if you're doing slow running, you're perfectly safe. If you wanted to do some sprinting, yes, we would just make sure it's very gradual. But like I say, I hear the, like I get the fear all the time. I listen and watch and jump on chats with people with PhD all the time. And there is a lot of fear there about it getting worse, about their tears and all those sorts of things. It is so, so hard to tear a tendon. It's so, so hard. We are more resilient than you probably think. A lot of people that go from injury to injury and injury think they're really vulnerable, think they're like this time bomb waiting to go off. The body's stronger than you realize. And the injuries and the pain and the symptoms are more like, well, all pain comes from the brain, but we're not falling apart. Like the body can adapt and is stronger than you probably realize. And so I would say keep the tendons happy. keep reassuring yourself that tendons are happy if they're strong. And if they're fit, if you are physically fit, if you are doing cardio exercise, as well as strength training, you are giving yourself the best chance to reduce the risk of a tear. So we actually need to be heading in the opposite direction of what your fear is of I don't want to tear this tendon should I quit running altogether? No, we should keep running, continue running, continue being active. Just make sure that we're doing so appropriately. We're doing so with, if you want to progress things, progress to speed work and heels and all that. We just do so gradually and let your body build up its capacity. So I feel that's reassuring for a lot of people because I know Fabian, your concerns are shared amongst a lot of other people. So thanks for. sharing that question and thanks for everyone else who've submitted their questions. That's all for today. Maybe in a couple months time we'll do another Q&A. I really have fun with doing these, really have fun reading these questions and seeing how I can best help. Hopefully you did find it helpful and yeah, I'll catch you in the next episode. In the meantime, best of luck with your rehab. If you are looking for more PhD resources then check out my website link in the show notes. There you will find my free PhD five-day course. other online content and ways you can personally connect with me, including a 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.