Q&A: Damage when sitting / Preventing tears / Genetics / Bursitis / MRI scans

: On today's episode, I am answering all of your PHT questions. small hamstring tendinopathy. This podcast is designed to help you understand this condition, learn the most effective evidence-based treatments, and of course, bust the widespread misconceptions. My name is Brodie Sharp. I'm an online physiotherapist, recreational athlete, creator of the Run Smarter series, and a chronic proximal hamstring tendinopathy battler. Whether you are an athlete or not, this podcast will educate and empower you in taking the right steps to overcome this horrible condition. So let's give you the right knowledge along with practical takeaways in today's lesson. I haven't done one of these for a while. Um, I have been doing a lot of Q and A's with my PhD members, those who are paying a monthly subscription and we are doing Q and A's every second week in alternate weeks to the release of this podcast on the main feed, but in relation to a Q and A on the main feed, yes. Um. It has been a long time coming and I thought I would do it slightly differently this episode, just because usually I would get through about four questions and sort of expand upon them and dive deeper and sort of give long winded answers and maybe separate the responses to come in into maybe two episodes. But I've got a long list of episodes that I want to release incoming, you know, incoming blocks. So I thought I would, you know, try to answer about eight to 10 and just do a quick fire response, um, sort of quicker answers and maybe it's more valuable for you because we're covering a lot more questions. So thanks to everyone who has submitted questions. I put the call out on the run smarter Facebook group, but also in the PhD. Uh, Let me just pull up the actual title so you can go to it if you'd like. The proximal hamstring tendinopathy and Evulsion Facebook group, which I am now owner of, have been for several months and loving helping people. And so if you wanted to jump into that, you can definitely do that. So questions have come in from both of those Facebook groups and I'll kick off at the top. We have Sandrine who says, 100% recovered from PHT. I am running marathons without issues and all because of you. Thanks, Sandrine, she continues. I want to give you a huge shout out. Thank you for sharing your knowledge. Two weeks leading out, leading to race day, I typically stop all lower body strength exercises. That is when sometimes I feel a little ache in the proximal hamstring. Now I do some deadlifts, which helped up to a week leading to the race. I know body weight exercises like squats will not help, but I wanna hear your thoughts on body weight squats leading up to race day. Thanks, Sandrine. If those aren't familiar, let me talk about the taper process that most people go through when training for a marathon. So it's usually two weeks before race day and you start tapering off your training volume, start reducing the overall volume. duration, running duration, and sometimes we like to back off the strength exercises as well. Now the reason that we do that is to feel as fresh as possible come race day hitting the start line. You've got that sweet spot between feeling fresh yet feeling fit. And if the taper was too long, you'd probably lose a little bit of fitness. But if the taper is too short, you probably still have some residual fatigue coming into race day. So it's trying to time that and balance that as perfect as possible. And yes, like I say, we do like to reduce some training, some strength training within the taper. I usually do it in the last week and maybe only do one to none strength sessions. But why this ache is probably coming on is because that load to the high hamstring just isn't there. You know, if you do your typical two to three strength sessions per week, we can elicit that analgesic effect, which is just a fancy term, meaning a reduction in pain while loading that has some effect thereafter, like you can carry over for the rest of the day. And that can be quite nice for some tendons. And so if we remove that over the course of two weeks, and then maybe continue sitting, continue running a little bit, continue you know, doing things that the hamstring might not like that much, then sometimes that ache can come back. And so, important to know that the level of strength and level of stimulus required for that analgesic effect doesn't necessarily need to be that same amount that triggers strength. Cause when we're strength training, we do it twice a week and we do it strong enough that it elicits enough of a response to then get stronger. And it usually needs to be heavier and heavier and heavier as you get stronger and stronger and stronger. But like I say, the analgesic effects doesn't need to be really, really heavy to stimulate strength. It can be all the way down to body weight exercises sometimes, but might not have as large of a response or might not have as effective a response, but it still can be done. Like even when I had PhD, sometimes just doing body weight, long lever bridges was enough to elicit that analgesic response. And that's just body weight, no weight whatsoever. And then when I was doing my deadlifts, that was, you know, north of 60 kilos or something to stimulate the strength. And so, um, bear that in mind, because then if we know that we don't need to stop doing strength exercises during the taper. you can still feel fresh and do body weight exercises that still has that analgesic effect. So I guess for Sandrine and anyone else who's interested in this, your job should be to try to find what the minimal amount is that still triggers that analgesic effect. And then if that ache comes back, hey, just start doing bridges or long lever bridges or really, really light deadlifts and just do that once or twice a day. won't carry over any fatigue or any soreness, you'll still feel fresh come race day, but you know, there's still enough loading there to then move that on. So I would say that and I would say that deadlifts are better than squats. I know you mentioned that what do you think about bodyweight squats leading to race day? I don't think that would have as much of an analgesic effect as doing something like a deadlift or a long lever bridge. So that would be my advice. Thanks for your question, Sandrine. Lara says, any issues with strength training, the quads and glutes while rehabbing PHT? Definitely not. No, I'm fine with you. Strength training the quads and glutes provided that symptoms dictate. You know, you might do an exercise that triggers the glutes, but then aggravates the hamstring. So in that case, we would want to modify that exercise. An exercise that comes to mind is, say for the quads, an isolated quad. exercise would be your seated knee extension or leg extension where you have those weights, where you sit and you have those weights around in front of your ankles and you sort of push against resistance to straighten out your leg doesn't work the hamstring at all, but you have to sit to do that exercise. And so for those people who might get irritated by that, then we want to be careful. The you might also be interested to know that if you do deadlifts, which are in your PhD rehab, hopefully Lara, that deadlifts strengthen your glutes, and you might also be doing weighted step ups to which that also works your glutes and quads. So you're still getting some strength there. If you're doing, say squats, to work the quads and glutes, yes, that's fine. We do need to be careful with symptoms though, because sometimes if people do a full depth squat or fast body weight squats, for some reason when I do really fast body weight squats during like a CrossFit style workout or something, if it's a lot, if I'm upwards in the hundreds, I used to do a gym routine where it was five chin ups, 10 pushups, 15 air squats and do that. as many rounds as possible for, you know, 15 to 20 minutes. And so I do north of like 150, 200 air squats. And the next day my hamstrings would be like, would have a lot of doms. So that bouncing action does stimulate some sort of hamstring action. Uh, but if I do my slow heavy deadlifts, I mean, my slow heavy squats, my hamstrings are fine. So, um, That's not triggering symptoms, but just so you know, it's working those particular muscle groups. And if it is too much for the PhD, then your body will know. They will start to become more sensitive or more symptoms. So provide that you've found enough modifications that hamstrings feel fine, then yes, strengthening, strength training the quads and glutes should be fine. If you want to do something on the lighter side of things, you can do crab walks, they're perfectly safe. more of a conditioning rather than strengthening, but bands around the knees and just doing side stepping 10 times to the right, 10 times to the left. Three sets of those should be particularly safe. Hip thrusts are another glute max exercise that people like to do, but that does apply some load to the hamstrings. So need to be careful with those. But again, symptoms will dictate. Thanks for your question, Lara. Let's move on to Jeff who says, prevent healing for PHT? If I have a desk at work with and I have PHT, should I invest in a standing desk? We need to be very careful with how we interpret certain things, certain information that's on the internet or what you may have been told. Sitting doesn't cause damage to the PHT, but it might in some people prolong or increase the sensitivity of the pain. So you're making something more sore, but not necessarily doing more damage. If you get your finger and you bend it back towards your wrist, it's safe. You're not really causing damage, but if you do it for a long time, it's gonna get quite sore. If you press on a bruise and you do that multiple times a day, yes, it's going to become more sensitive, but you're not doing any more damage. it's light touch to a bruise. And so we can consider it that way. But we don't want to just say off, it's not causing damage, let me just sit for 10 hours a day and just put up with the pain. We don't want to do that because we don't want to propel sensitivity because if the nerves become sensitive, and that's prolonged, and we do that for a long period of time, it could be hard for those nerves to settle down. And so we do want to try to find the balance there. So But this is this is kind of different because you Jeff you're asking does it prevent healing from phd not necessarily does cause damage I would say it's unaffected by healing Because what heals tendons isn't poking a bruise what heals tendons is loading and load management and Progressive strength training. That's what changes This the structure of the tendon. That's what adapts and what the tendon adapts to it adapts to load and so sitting on a bruise, it doesn't make it better, doesn't make it worse in terms of healing properties in terms of the structure and what's actually going on. It's just ineffective, but it does affect sensitivity. So we do need to be very careful about how we interpret and position ourselves in this. So my advice would be a sit stand desk can be helpful if you're finding that the required amount of sitting is too sensitive, like it's contributing to over sensitivity. So yes, it can be helpful, but we want to continue sitting within certain tolerance because swinging the other way and just standing all the time, first of all, you're going to get plantar fasciitis or low back pain or something if you just stand still for too long. But it also deconditions you to sitting. And so we need to find that really healthy balance of how much sitting can I tolerate currently. Let me do that if it's 20 minutes. Well, let me just sit for 20 minutes and then I'll stand for 15 and then I'll sit for 20, then I'll stand for 15 and we'll see how we go throughout the day. If it becomes a little bit more sensitive in the afternoon, maybe I will do 10 minutes of sitting and 20 minutes of standing and do that a couple of times. Everyone's unique with their level of tolerance, but if we do something this way or we have a cushion or we have a pillow adjust ourselves in whatever particular modifications we choose. We are still preserving our tolerance without contributing to perpetuating that sensitivity. It is a fine balance, but hopefully that helps, Jeff. Michelle asks another question. For those of us who are recovering from proximal All right, I need to be very careful with how I answer this one because, um, my assumption is that Michelle, you've had a scan, maybe an MRI and maybe that MRI has shown tears and now we're wondering what we, how it got there or what we could do to prevent it. Um, tears, hamstring tears on scans. I am constantly baffled and puzzled and confused by because as often as I see tears on scans, I see tears in the healthy population as well. I have seen people with. PhD on the right side and they get a scan that shows no tears, but then they get a scan on the left side and it shows they've got hamstring tears. I'm totally asymptomatic side. That's never had any issues in the past. Um, I am one for just thinking that it's just an incidental finding and people just have these tears or splits or something of the collagen that just is ongoing, especially if it's longitudinal, like moving along the fiber of the tendon. Sometimes it can be some separation of little fascicles. I spoke to Miles Murphy a few weeks ago, put this episode on a previous episode and he was mentioning that about tears and yeah, how can something be torn if it's moving longitudinally down the tendon? Anyway, some baffled, I'm baffled by it. I'm confused by it all the time. And I think it's less and less relevant, the more and more I see. And that it could just be incidental. However, that's completely different to someone who has a traumatic onset, meaning someone's tripped slipped fell on ice or did the splits and all of a sudden they had this pop and this large pain sensation immediately after doing that traumatic event, then they get a scan, they show there's some sort of tear or a vulgen or something along those lines. I would heavily rely on those scan findings for that, but still use it as a piece of the puzzle. Usually when it comes to scans, we don't dismiss them. We just use them as a piece of the puzzle. And sometimes if it's just a gradual onset with you're training for a marathon or doing too much or doing some speed work and this is gradual onset. I would say tears on a scan is just a smaller puzzle piece that we put within to form that overall picture. So we do need to be careful, Michelle. When recovering from tendon tears, you ask how do we prevent future tears? I would say it is just about load management. It is about getting the tendon strong. with slow, heavy progressive load. And once you've got that foundation, it is avoiding abrupt changes, abrupt return to sport. If you do wanna return to running or cycling or team sports, just making sure that we are safe with our progressions. We are ready to tackle that next progression. And there's small steps in that rehab ladder. It's just a simple answer. It's an easy answer, but it's a safe answer. So... Like I say, it's usually and often the patients and the knowledge to build out that rehab ladder that people often miss. Okay, thank you, Michelle. We have Jason on next who says, do you think some people have a genetic predisposition to tendinopathies? I'm currently going through PHT and I've had various other tendinopathies throughout my life. I think we've all been in your position, Jason, Myself, I have had plantar fasciitis. I have had, I think the Achilles is one of the only tendons that I have been okay with. Plantar fasciitis, I've had some tibialis posterior pain. I've had some pes anserine tendinopathies. I've had patellar tendinopathy. I have had, what are those? Oh, shoulder. I've had a long head of biceps tendon tendinopathy. I've had a little bit of... lateral hip or glute medius tendinopathy. And some of those have been bilateral and I was once in that same way of thinking. I was one being like, man, am I just destined to get these every time I load and train and do all those sorts of things? Not to mention my proximal hamstring tendinopathy. How do I miss that one? Um, yes, it is one we can think that way. A lot of people think that way when they are injured. Often people have multiple injuries at once. But to answer your question, yes, we do think that there may be some genetic predispositions with some people. There is a, I'm not, this isn't my realm of science, but there was an article that showed that a certain gene type, it's called COL, C-O-L, COL 5A1. seems to be associated with Achilles tendinopathy for those who have a polymorphism, a gene polymorphism to that particular gene. I have no idea what that means, but they said that they query whether it plays a role in the regulation of CoL5A1 mRNA stability, and it says and by implication type V collagen production. So it may affect the type of collagen, which is the structure that makes up your tendons and other connective tissue collagen production. So maybe some people have some predisposition, I'll talk about gender and that sort of stuff in a second. But what I will say is, anyone who has a genetic predisposition will always have an environmental change and environmental influence that causes the tendinopathy. Say you're trading for a marathon, say your weekly mileage goes from 30 kilometers per week to 50 kilometers per week. If 10 people did that, if you didn't have that genetic predisposition, you might have a 10% likelihood of developing a tendinopathy if that you have that major swing in mileage, 10%. If you did have that genetic predisposition and you went from 30 Ks per hour, per week to 50 Ks per week, maybe it's 15%. So you've increased your odds of a tendinopathy by 5% because you have this genetic predisposition due to that environmental error. But if you train a bit more sensibly and go from 30 Ks per week to 35, to 40, to 45, to 50 over subsequent weeks, you won't develop that tendinopathy. And so... a roundabout way of saying if you do have, if you do think that there's a genetic predisposition, just take your time. Just make sure you're a little bit more patient with your training and your loading and any other changes to your body. If it's progressing deadlifts, be a little bit more sensible, be a little bit patient. But we do that for people who have multiple injuries anyway. If we do know that your likelihood of developing an overuse injury dramatically increases if you've had a history of previous injuries. And so if someone has in the past six to 12 months had three or four overuse injuries, and some of those might be tendinopathies, we would then be more patient and more sensible with their return. We would say, forget about races for the next 12 months, let's just focus on a building phase, let's focus on slowly building you up with sensible progressions and patience. So, matter if you have this genetic predisposition or not, I would say this approach is still the same. Thanks, Jason. Cyan says, I would love to hear your thoughts on whether some of us are at more risk of tendon issues than others. Sounds familiar, but she has a different take. I read that women are at higher risk of getting at higher risk when they get to peri slash benipause to thoughts. How can we prevent anymore? Okay, I did a another podcast episode on this. If you wanted to search, the title is gender differences with tendon adaptation. So you can type in Overcome proximal hamstring tendons the podcast and then type in gender differences. And then if you click on search that episode will pop up straight away. Because yes, I do discuss in that episode that it seems to be that Harry slash menopause does seem to affect tendon synthesis or tendon adaptation, meaning that they're, they're slower uptake or slower turnover processes, meaning that the tendon will take longer to adapt. But same with Jason's response, my response would be the same. Like you will still adapt to a stimulus, but it might take longer. So therefore rehab needs to be more cautious. Progressions need to be more sensible. Progressions need to be more patient. And when you return to training, that needs to be more gradual, more patient, more safe. Particularly if you've had a history of tendinopathies, a long history of tendinopathies. If you are pre or perimenopausal, let's just pump the brakes and let's just take things a little bit more sensible. If you are then 12 months injury free and you want to constu... keep pushing the limits and train for a marathon or something, maybe we might put a little bit of pressure on the accelerator, maybe we might see how you go getting away with a little bit more. But these decisions need to be justified. Okay, still working our way through. Patrick, anything about ischial bursitis slash swelling of the sit bone? The constant inflammation is driving me crazy. Sorry to hear that. Patrick, there is some data showing that PHT does can be associated or both can currently or coexist having a tendinopathy, but also having ischial bursitis, which if you're not familiar, bursa surround most tendons and joints to act as like a lubricant. They are just, as you would imagine, just like a little fluid-filled sack to, you know, assist with all of those things. And sometimes that sack of fluid can become inflamed, usually picked up with an ultrasound or some sort of imaging. And we do need to be careful. Like usually if you avoid whatever's irritating it to cause that inflammation in the first place, it usually settles down within a few days. Like it can be an acute thing. Like if you, like you can get like a bursitis around your elbow. Like if you fell and your elbow, impacted a hard surface and it swells up like a golf ball. We usually suspect it like, okay, the bursar has swell, swelled up. If you had a traumatic like fall, like if you sat on a hard surface and it was quite abrupt and it impacted the bursar, it can swell up. But usually if we avoid irritating it, maybe put some ice, maybe some anti-inflammation because it's an inflammatory process, that can calm down. And if it doesn't calm down, it's been several weeks and still really irritating, then a corticosteroid injection, usually a ultrasound guided corticosteroid injection would be really effective. So corticosteroids are designed to reduce inflammation. And unlike tendons, you may have heard in the past us talk about like corticosteroid injections are quite bad for. tendons might help in the short term but has ill effects or detrimental effects in the long term. We don't really want to inject anything into tendons, but the bursa completely fine. Like they respond really well to corticosteroids. And if it's ultrasound guided, they put an ultrasound on your probe on your skin so they can see exactly where the bursa is they can see exactly where the needle is they can see the needle go into the bursa and then inject the corticosteroid and then let the effects happen. That's different because some people like have a corticosteroid injection with it's not guided by ultrasound and they're kind of shooting in the dark a little bit and that still happens. So hopefully that helps Patrick, that's usually what we do. Maybe some ice, maybe some anti-inflammation for two or three days if it hasn't settled down. And we are certain or very confident that most of your symptoms are due to the bursa, then corticosteroid can be effective. Moving along, Louise asks, I have partial tears, but a surgeon said that it is my spine, not my hamstring. Three sports doctors don't agree. I'm just going around the circuit of physios, sports doctors, et cetera. And I'm about ready to go out of province or country for help. Any suggestions? Sorry to hear that Louise, that does sound very frustrating. My question would be. or question to the surgeon would be like, why do you think it's the spine and not the hamstring? Like what tests have you done? Or what imaging have you seen? Or what about my clinical presentation would lead you to have the hypothesis that it is my back and not the hamstring? And you can, you know, say the same things to the physios. Like why do you think it is the hamstring and not my lower back? What tests have you seen? What what pieces of the puzzle lead you to that conclusion? and sort of just get a general sense so that you can have a bit more of an informed decision of what to do and where to go. But sometimes if there are health professionals that aren't seeing eye to eye, or there might be the potential of a few different diagnoses going on, like I work as an online therapist, so I can't do hands-on tests or touch people or go through a rigorous diagnostic process. But... when we find ourselves in these particular situations, what I say is, okay, you can go see a local therapist if you want, but if there is still these two competing theories or ideas, we can use treatment and let treatment be a diagnostic tool or let treatment be one of these big pieces of our puzzle because we can treat the lower back and see if anything gets any better. If you treat the lower back, the lower back gets better and the hamstring also gets better. then that might increase our hypothesis that it is originating from the lower back. Conversely, if we treat it like PHT, and we strengthen up the hamstring and do all the healthy things that we should be doing, and it starts getting better, then let's double down on that. Let's continue treating it like PHT. So again, using treatment as a diagnostic tool to then gather more data, gather more information, because sometimes we can't determine where your symptoms are coming from or determine a particular diagnosis because, like we say, scans have incidental findings. We know that pain presentations and characteristics can overlap a little bit. Like we know that the lower back can refer into the glute region, can refer into the upper hamstring. We do know that piriformis syndrome or impingements like a ischiofemoral impingement can really mimic PhD symptoms. So yeah, we would let treatment be a diagnostic tool. Let's try it for a couple of weeks. Let's see how we find it. And can provide a bit more guidance, a bit more clarity. So that's what I would suggest for you, Louise. Okay. Fabian asks, how come my MRI shows severe tendonitis in the hamstring and but I've never had pain in Brexit until full evulsion. Well, again, I ask and I am puzzled and confused about MRI findings and scan findings, the more I look at. And tendons are interesting in the way that, yes, there could be incidental findings. Yes, we can have tears in healthy, asymptomatic, you know, perfectly functioning tendons. But there's a bit of a Venn diagram that goes on with tendons, because if you can imagine like a three-piece Venn diagram where one circle is pain, one is function or like strength, and the other is pathology, how much deterioration is going on. And you can get this weird overlap of all different types of these things. You can have a tendon that is actually painful. no pathology going on. It's just an acute, acute sensitive state, but there's no changes. There's nothing really going on within the tendon. It's perfectly healthy when you scan it, yet it's painful. We can have one that's really poor functioning, yet it'd be pain-free and it'd be pathology-free. It's just like a weak tendon. If you have a really weak tendon that's still healthy, it's poor function. But we can also have pathology. We can have a chronic, um, D degenerative tendon that doesn't have any symptoms that can exist. But then everything in between, like the mix and matches of all those sorts of things can happen. And so hard to say, but with Fabian, like a potential would be that the tendon that you're experiencing had a really severe pathology. So it developed became chronic, there has a chronic nature to it. It's a degenerative tendon, maybe a fair amount of portion, a fair portion of that became degenerative, but just not painful. And then there's a rupture that occurs. Like sometimes when people have Achilles tendon ruptures, there's no sign of pain dysfunction beforehand, but it just lurks in the background and then all of a sudden you do a sprint and then it ruptures. So, That could be the case, but we also know that a tendonitis can be an incidental finding and who knows maybe you just did a sprint or something that caused an avulsion even in a healthy tendon. Really hard to say, like I say, scans are puzzling, but good to know, it makes it confusing but it's good to know that it can be confusing rather than just using scans as the definitive piece of a puzzle, like the puzzle is only one piece and that is your scan findings. Doesn't work that way. Lastly we have Maria. Approximately how long does it take to get full strength of your tendon following tendinosis surgery? It depends on the surgery that's happened, depends on what things were like prior. So there's a lot of information I don't know. But what I would say is post surgery, follow your rehab protocols, hopefully your surgeon care team are good enough to give you a, this is what happens, week one, this is what happens, week two, week two to four, we're starting some loading, week four to six, we're starting some XYZ, like they're giving you that list. Once you've got to sort of this subacute phase, once you're like four to six weeks post surgery, I would say you'd obviously be starting to load the tendon. I would say from there, if you're loading and building strength, We're then following just general strength principles to which the researchers say for most normal tendons, somewhere in the three to six month range would be a good, would be a really good timeframe to develop strength and build a lot of strength. But then again, when it comes to getting full strength in your question, like what does that exactly mean? Do you mean full strength compared to the other side? Like do you mean equal strength compared to the other side? Because tendons can always get stronger. So I would say three to six months as a ballpark figure, as long as you have a good progressive management plan, I wouldn't just load the body and unload it or like just do body weight or low weight exercise and expect things to get better in three to six months. It needs to be good strength and conditioning, progressive. and working your way up through that provided at the same rate or following the guidelines of the surgery, but then also using symptoms and using how your body feels to progress and progress. Three to six months would be my general answer. Hope you liked this short fire rapid response when it comes to these questions. Madden is to cover a lot. Hopefully you've learned a lot when it comes to PHT, particularly scans, we've had a fair. stab at scans for this particular episode. I will try to do more of these Q and A's. So keep an eye out on those Facebook groups when I'm sending out the call and hopefully we can get some good responses like we have on this episode and help you out. So good luck with your PhD rehab this week and we'll catch you in the next episode. Thanks once again for listening and taking control of your rehab. If you are a runner and love learning through the podcast format, then go ahead and check out the Run Smarter podcast. hosted by me. I'll include the link along with all the other links mentioned today in the show notes. So open up your device, click on the show description, and all the links will be there waiting for you. Congratulations on paving your way forward towards an empowering, pain-free future. And remember, knowledge is power.