Q&A: Avulsion vs Tendinopathy, Nordics for Prevention, Burning Symptoms, Surgery Advice

: On today's episode, I'm covering all of your PHT questions. 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. Thank you for joining me once again. If you listened to the last episode, you'll know that we've had a flood of questions coming in and this episode is answering some of those now. So the first one we have comes from Jen, and she says a couple of questions mixed into one, but she says, there are several post-op questions here. My understanding is that PhD and evulsions are different. So my questions are, one, how does PhD differ from an evulsion? Two, How often does PHT result in an evulsion? Three, if one has PHT, how can they prevent an evulsion? And four, how does PHT rehab differ from evulsion rehab? Let me break all this down and we'll start with how does PHT differ from an evulsion? So PHT, proximal hamstring tendinopathy. Tendinopathy is what we would call pathology of the tendon essentially. It is some onset or usually brought on by an overload, usually brought on by doing too much too soon, usually brought on by external load exceeding the capacity of that tendon and therefore when load put onto the tendon exceeds its capacity, it starts undergoing a certain reaction, what we would call a tendinopathy or an acute tendinopathy. And certain changes start to happen within the tendon to make it sore to make it irritated, those sorts of things. If that continues, and the tendon continues to be mismanaged with more and more overload, then it can sustain. then the condition may start to become chronic. Within a chronic tendinopathy, certain changes occur within the tendon, we sort of have an acute and a sub acute phase where as soon as you manage it correctly, it just reverts back to a normal healthy tendon with normal tendon structures. But if it's mismanaged goes longer than six and 12 months, it starts to become a little bit more disorganized, the tendon structure, the cells, the weaving of the fibers and the collagen itself just starts to become a little bit more messy. Not to say that you can start to restore and rebuild and regain full function and be pain free, but it does become a bit harder when it's more chronic and those conditions and those changes start to happen. And avulsion is completely different. And avulsion is something that's more of an acute onset, more traumatic and results in what we call similar to like a tear. And avulsion is essentially like a tear of the tendon at its attachment onto the bone and. that is often brought on by a lot of different mechanisms. It's often brought on by trauma, like we would say, classically someone like trips or skids or slips on ice, or like say, water skiing, some sort of an abrupt force that pulls on the hamstring and results in the tendon pulling away from the bone and creating an evulsion. And so might've answered Jen's question a little bit. So the second one was how often does PhD result in an avulsion? It's hard to really say because an avulsion can happen in a healthy tendon and there could be a chronic tendinopathy that goes asymptomatic lurking in the, like in the background without anyone knowing as well. So if someone goes water skiing and they have a fall and their legs split and the hamstring tendon becomes an avulsion. Was there a tendinopathy there beforehand that might've led to an avulsion on that side compared to the other side? I don't know. It's really hard to say. What I would say is that avulsion can happen. in a healthy tendon, absolutely. It's not just as simple as a tendinopathy is mismanaged to get so bad that it eventually becomes an evulsion. It doesn't really work that way. The tendinopathy itself, the pathology just gets more and more severe and harder to treat. But it's not like a, some people have this belief like they have a scan and see there's little tears in the hamstring and they think that if they do slow, heavy deadlifts or if they... you know, continue running the tear itself, it's gonna get worse and worse and worse and eventually become an evulsion. I'm not one to really believe that or yet see that happen or, you know, buy into that narrative. The tendinopathy just gets worse and the evulsion is usually just with, like I say, a freak accident, essentially. If one has PhD, how can they prevent an avulsion? I think I'm mainly dissented. I don't really think there's, it correlates. I don't really think there's much of a transfer over to that. How does PhD rehab differ from an avulsion rehab? Well, for an avulsion, you could be a candidate or some people can be a candidate if it's a very severe avulsion for surgery. And I've done episodes on this in the past. I might talk about it later on, but. there's certain classifications to put someone as a candidate for surgery, but sometimes, and often, people have an avulsion and it's not severe and therefore you just wait for that initial trauma to calm down. There might be some bruising, there might be some, you know, dysfunction, a lot of pain, we might let that settle for a week or so. But in my eyes, after that, we'd probably treat it similar to a PhD. If you do, if it's severe enough to eventually have surgery, yes, it would be different. Exercises would follow like your post-op, like surgical instructions. I've had two surgeons on in the past to talk about, you know, standard protocols for a vulgen surgery. But then... you know, once we're past that acute phase, healing phase of the surgery, we're treating it very similar. The rehab itself is very similar to BHT. Don't wanna delve too much on the rehab itself when it comes to like within this episode, cause I talk about it in every other episode, but essentially we're trying to find what capacity you have, what capacity the tendon has. that might be doing hamstring curls, that might be doing bridges, that might be doing deadlifts, lunges, step ups. trying to build up your capacity, find out where that starting point is, and then gradually build up with slow, heavy, progressive strength training. Next question comes in from Craig who says, "'Even at my age, I've never had any hamstring issues, "'but what conditions generally lead "'to a hamstring tendinopathy? "'It may have been earlier in the year, "'but you may have discussed Nordic curls, "'and can this help reduce this issue?' Okay, so... What conditions generally lead to a hamstring tendinopathy? I would say often it's runners or triathletes. Often those runners or triathletes have picked up their mileage too soon. There might be hills, but very commonly would be speed work. And the speed work is something that is very much linked to the demand of the hamstring. If you look at a graph and you look at how quickly a runner or how the muscles behave based on how fast the runner is, the faster and faster you run, sure, the calves might increase a little bit. The quads, the glutes, they might work a little bit. In fact, like the quads and glutes, they don't really grow linearly as the speed increases. They kind of just plateau out a little bit. But if you look at the hamstring as you increase your speed in a linear fashion the demand of the hamstring is exponential. It climbs and climbs and climbs quite a lot when you just pick up your speed. And so that's why I often see someone say, yeah, around about the time of this hamstring tendinopathy coming on, I was preparing for a race or I was building up a mileage or I was trying to work on my 5K, 10K time, and I was doing more speed work than what I usually do. It might be accompanied with sitting, it might be accompanied with. I mean, I just got off a call with someone who just moved to a full time job for their first time and they've just been sitting for longer than they usually have at the time onset of these symptoms. But it could be a combination. It could be I was traveling at the time, but also wanting to do a lot of exercise. I had to travel for a marathon. So I flew, you know, 12 hours to land, ran the marathon, had to fly 12 hours back home. sitting has led to the tendinopathy, it could be a combination of those things. Um, but that's what is often seen and it's, you can almost always point it down to load exceeding capacity, whether that's in sitting, whether that's in sitting on hard surfaces, whether that's running, whether that's, um, deadlifting or like another common scenario will be someone will join like a gym that attends a lot of sessions, a lot of like exercise sessions, all of a sudden they go from doing one class a week to five classes a week and it involves a lot of lunges, a lot of jumping, a lot of squats, a lot of deadlifts. And yeah, the load is exceeding the demand or the load is exceeding the capacity of that tendon and therefore starts to become irritated. The second part of your question, Craig, about the Nordics and if it helps reduce the risk of a hamstring tendinopathy. I don't think I've ever discussed it. There might be a slight link there, but it always comes back just to general training principles. So the Nordic exercise might help build up the capacity of the hamstring. doesn't necessarily target the proximal hamstring very well. It mainly targets the mid-belly of the hamstring, maybe the distal hamstring a little bit, but I don't really see your traditional Nordic curl. So for anyone who's not familiar, you kneel down on your knees, you hook your ankles underneath something, and then you try to keep your torso and your body from your knees up to your shoulders, completely straight as you lower yourself down. As long as you can until you can't possibly control that descent any further, then you fall to the ground, you raise your hands up, you catch yourself, you go back up to the starting point, you repeat. So that builds up the eccentric strength of your hamstring, which is good for runners. It's good for wanting to do speed work. It's good for sort of building up the capacity for that. And so theoretically, if you got really good at Nordics, you could have a little bit more of a buffer. in your speed work before you exceed the capacity in theory. But another way you can avoid it is just if you have speed work in your calendar or if you wanna increase your amount of speed work or if you wanna run faster, just do it in a sensible manner. Just slowly progress those variables slowly or give your body time to adapt to those conditions. And if there is some slight soreness one day, like adjust. maybe you're doing too much, maybe your recovery strategies aren't adequate. Trying to make those sensible adjustments and listening to your body rather than, well most people do, they build in their speed work, they don't listen to their body, they start getting a bit sore and they just continue onwards. So there's a few ways to go about this, but it all comes back to knowing where your capacity lies, making sure if you overshoot it a little bit, make the necessary adjustments, but having the correct training principles in place. that would be a good way of reducing that risk. It's pretty convenient now or a timely question because I haven't really had proximal hamstring tendipity symptoms for about five or six years, nothing significant anyway, but I've kept really strong. I've deadlift really heavy. At the moment, I don't know, my deadlifts are about 110. kilos, which is, I know, 250 pounds or something. Um, but over recent weeks, I've started having proximal hamstring tendinopathy symptoms again. And it's because I've deviated away from my training and I've been training too hard and not listening to my body. I've been preparing for a high rocks race, which was last weekend. And yeah, just the excitement. doing like attending some classes here and there doing my own thing. Um, sort of veered away from my schedule that I had, had the training plan that I built for myself down there and I deviated away from that and now symptoms have returned. Um, after the high rocks race, I did have PhD symptoms like the day of like the day off the remainder of the day, but the next day, you know, I don't really recall anything that was yesterday and today. I am, I don't, I haven't recorded any symptoms. So I've been strong so that the stability and the strength that I've built over the last couple of years have allowed me to, you know, keep my symptoms stable. And yes, now that race is over, I'll be moving forward with a bit more of a sense of sensible structure and I won't. DVA for my plan for my next race. I'll learn from my mistakes, but this all just comes back to the load versus capacity. There's reason behind my symptoms now are reoccurring. There was reasons for me having no symptoms for the last five years because I've been training sensibly. That's the things we should be thinking about. Okay, thanks for your question, Craig. The next one comes in from Lien who says, "'Hi, Brody, I believe I fit most of the puzzle pieces for PHT as explained in your podcasts. I have seen a number of physios who have dismissed PHT since I have some other non-typical symptoms like burning pain on the outside of the affected leg and also sometimes pain in the groin from squats or step ups. The burning pain on the side of the leg also immediately flares up with cycling. Could these symptoms potentially be related to PhD or do I most probably have something else going on? Thank you very much for your question. I would say typically a tendinopathy is localized. When we say localized, it's fairly contained within a... local region and you can usually point to it, you can usually say, yep, here's my symptoms. Anything that's very vague and moves around and has a whole bunch of other symptoms going on, it's less likely that it's just a tendinopathy would be my answer. Sometimes the proximal hamstring tendon can radiate into the upper hamstring. So it will go from the sit bone area to the upper hamstrings. It doesn't travel too far. Sometimes that can happen. That happened to me after my high rocks race. Um, but you know, if it's anything else than that, often other structures are impacted if things are more distal, if it goes into the mid hamstring or closer to the knee, if it passes the knee, it's definitely not just the hamstring. Um, But also if we talk about other symptoms like burning, numbness, pins and needles, this more starts to sound like some sort of nerve involvement. What exactly that is, it's hard to say because you know other investigations would be required. But you can also have coexisting conditions. You can have proximal hamstring tendinopathy plus you know maybe some impingement or some bursitis or some or like ischiofemoral impingement. You could have some sciatic nerve irritation, you could have some referral from low back issues, you can have some piriformis syndrome going on. Often like if it's referred from the lower back, piriformis syndrome, those sorts of things can create some burning and radiating and distal symptoms and when I say distal I mean further down the leg. Not always the case, but sometimes. And yeah, this is where the whole scenario gets very complicated. It's why a lot of people with PhD are often misdiagnosed or just don't fit the adequate classic PhD scenario, you might say. And yeah, it does become tricky. But what I usually fall back on, if you've tried some other things and it's not really getting anywhere and you think it's mostly PhD, but you have these other symptoms going on, Just treat it like PHT, see if it improves. See if you notice an improvement. If you notice an improvement, let's just double down on it and continue treating it like PHT. We can't just usually rely on scans, we can't just usually rely on one test or one characteristic or you know, it's a whole collation collection of data points that leads us to a likely diagnosis of PhD. We're never really sure because yes, a scan could reveal a tendinopathy, but that's not to say that tendinopathy is the cause of your symptoms. And so that's why we need to investigate and use treatment as a diagnostic tool in some ways. We can say, yes, with all the data points that we have, this is a likely diagnosis, let's treat it like PHT. If it starts to get better, let's double down on that and continue heading in that direction and see if it continues to get better. And you might notice that your sitting pain improves, you might notice that your hamstring symptoms improve, but the burning itself down the outside of the leg when you cycle is just. in status quo, unchanged, indifferent. Might mean that we are treating the PHT and getting better, but it might also mean that there are other structures going on that aren't being addressed with our current treatment plan. And so that's when we broaden our horizons. So, okay, now this is getting better. We know the PHT symptoms are getting better. Let's add in something else that we think might help address. the other structures that might be going on. And it depends on what that might be. We might do some nerve flossing or nerve mobility stuff. We might do some lower back stretching. We might do some manual therapies, might do some dry needling or, you know, we might look further to see, do scans and see if there's like a bursitis. And if there is a bursitis, maybe corticosteroid injection into the bursar might help reduce that inflammation. Every case is very unique, but often less to start with treating it like a certain diagnosis and seeing if it starts getting better rather than you know not pursuing any treatment because we're not sure of a diagnosis yet and then you're just in the lurch for several months because a clear diagnosis hasn't been made. We don't really want to do that or prolong that. Next question we have coming in from Mark who says, I've likely suffered PhD for around 20 years, but misdiagnosed due to herniated discs. I've always maintained a high level of fitness, but it's sitting that causes the most discomfort. I've been following recommendations from an osteopath and in recent months from advice from your podcasts, I can now deadlift my body weight plus 15 kilograms and do several reps. I've done a lot of work on my pelvic floor, hips, core in the recent years. My question is, given I've likely had PhD for so long, should I look towards some surgical or medical treatment? If so, what's effective? Or should I just accept I'll always have some discomfort or is there something else I can try? Okay, thanks for your question, Mark. First of all, like, should you look for a surgical option? I don't think so. there was a paper titled like the management of proximal hamstring injuries, non-operative versus operative treatment. And I did a podcast review on that paper, like several months ago, but they have a certain, you know, inclusion criteria to have you as a good candidate for surgery. And it's often due to like an avulsion. And so your criteria would be okay, does it impact the three tendons or two or more tendons that attach onto the sit bone? Cause there are three tendons, three hamstring tendons that are attached onto the sit bone area. So is it impacting all three of those tendons? Is all three of those tendons an avulsion? Is two of those tendons, including a retraction greater than two centimetres? So as the tendon pulls away from the attachment point, retracts, it moves away from the attachment point, if that's more than two centimeters on two or more of those tendons, then that's fitting the inclusion criteria for surgery. So doesn't sound like that's you. Usually with the evulsions, usually like I say earlier, it's like an abrupt sudden traumatic sort of episode usually a lot of bruising afterwards usually a lot of discomfort, like really difficulty walking, a lot of difficulty weight bearing that sort of stuff with such a traumatic severe injury, which then leads them to more down the surgical option. Um, but chronic tendinopathy, I should say in that paper as well, um, they do mention, which not entirely sure I agree with, um, that's for like complete evulsions, but they do say for partial injuries or partial tears that have failed a non-operative management for a minimum of three months to then maybe consider them for surgery. I don't see that because you know partial tears can be an incidental finding and someone who's had a tendinopathy for longer than three months is very common. Do I think all those people should require surgery? I definitely don't think so. So yeah I do think I do feel responsible to adding that in because that's what the paper says but I don't necessarily agree with it. Okay so should you look for a surgical option? I don't think so. Should I always accept some discomfort? I would say we want to look at addressing the sitting itself. Like you probably have a what we call a strong yet sore tendon. Just because it's sore doesn't mean it's weak. A lot of people make that association but because you're deadlifting so heavy and seems to be managing that quite well, I would say yes the tendon has a quite a high capacity for deadlifts at least. But Should you always accept some discomfort? I prefer to have high standards and sort of always continue to improve those standards and try to eventually get symptom free. Yes, it does become quite tricky when you have had a tendinopathy for 20 years. I have done previous episodes talking about research papers that have highlighted chronic tendinopathies tend to have more... proliferation of nerves, like there's more nerves that surround that tendon and they embed themselves deeper into that tendon the longer you've had a tendinopathy for or the longer it's mismanaged, I guess. So it can become overly sensitive, but we can decrease that sensitivity, I would say, but you know, it's tough, it's difficult for a chronic tendinopathy and depends how long you've mismanaged it for. Cause some people can have it for 20 years, but it's managed very well for 15 of those 20 years. So, you know, depends on the circumstances. make start making some slight adjustments if we want to continue try to make improvements or change things if you're not seeing an improvement week by week month by month that longer term that longer scale make some adjustments it might be adjustments in sitting it might be adjustments in the surface or the posture that you're adopting or like sitting differently maybe having a sit stand strategy to see if we can build up that tolerance and bring down that sensitivity. It might be just making slight adjustments in your strength training or your other fitness routines. It might be changing up the frequency of your exercises. Yes, you might be lifting deadlifts quite heavy, but maybe you're doing it too often throughout the week and it's requiring a better, needs a better balance of load versus recovery. Maybe we need to adjust the range of movement or maybe we need to adjust the tempo of the exercise. There was a previous podcast episode that I did looking at a case study of a weightlifter who had a tendinopathy, I'm trying to remember now, doing deadlifts, getting stronger and stronger and heavier and following the protocol didn't really get better, but then just made a slight adjustment to the tempo of the exercise, made the eccentric or the down phase of the deadlift. more accentuated, so like lengthened that time under tension. I think adjusted the weight slightly differently. I should have looked this up before recording this, but it's only just come to my attention now. But then started seeing improvements. So just made a slight adjustment in some of those variables to current rehab train that they're already doing and then start seeing an improvement. So, you know, just keep tweaking, testing and tweaking and seeing what works. Mark, you said anything else I should try? You might be a good candidate for shockwave. I'm not entirely sure. A good candidate for shockwave would be someone who has a chronic tendinopathy, who has very low levels of pain and is non-responsive to treatment. So someone who has like a one or a two out of 10 PHT pain that just doesn't budge with treatment, just stays at one or two, stays grumpy, just non-responsive. the shockwave is designed to sort of like wake up a dormant, non-responsive tendon and it becomes a little bit sore, becomes a little bit more reactive and as a result, becomes a little bit more responsive to treatment. That's the overall aim. So maybe you might be a good candidate for shockwave. But I think before trying that, just work out those other adjustments that I discussed earlier. That would be my advice. I hope that's helped. I hope that... those who are listening, even though the questions themselves don't directly relate to you who's listening, hopefully discussions of these information just might get you thinking a little bit differently, get you coming up with some new ideas and at least and hopefully a better understanding about PhD in general. So that's all I have for this episode. Hopefully enjoyed. Thanks for listening and we'll catch you in the next episode. If you are looking for more PhD resources, then check out my website link in the show PhD 5-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 PhD.