Q&A: Flare-up Confusion/Measuring Progress/Chronic Pain Susceptibility/Preventing PHT

: On today's episode, I'm answering all of your PHT questions. 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 bust the widespread misconceptions. My name is Brody 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. Welcome. Thanks for joining me on today's episode. I have posted onto social media, let me know your PhD questions and I've had a ton come in of selected 12. They are very good questions and I might answer about four per episode and do these Q and A's over the next three because really, really great questions. I couldn't really knock any of them out or discard any and It's come at a good time as well because I'll be going on annual leave in two weeks time and traveling for a couple of weeks. So batching these episodes and scheduling them out helps me. And I'll do the same for the Run Smarter podcast. But yeah, I've had some great questions come in. So looking forward to diving into them. Let's cover four in this episode. I think four questions is a really nice, I guess, length of time. Really good. We don't want to cover. like an hour's worth of going through questions and, you know, kind of being overwhelmed. I want some really good takeaways. And even these questions, they get a little bit complex. So we're going into, I guess, different tangents within one question. So hopefully you liked the length and quality and value of each episode. So the first one we have is from Karen. Thanks for submitting a question, Karen. I know you've been a very avid listener and very engaged with a lot of the posts and things. So thank you for your commitment. I hope you're well. Karen asks, what makes the PHT pain come back? Seemly out of nowhere. Is the treatment different for a recurrence? Thanks Brody. So Karen's asking, okay, what makes the pain come back if there is like a flare up of sorts, especially if it just comes out of nowhere, if it comes out of the blue, what's happening there? What's making it come back out of the blue? And if we do have a flare up, pop up out of the blue? Should we treat it different to something that was a little bit more predictable or something that made a little bit more sense? I thought I'd break this question into a few different things. One, what makes the pain come back? I want to start with the obvious ones before we dive into Karen's, I guess, little topic around seemingly out of nowhere. Because if you're a new listener, I think it's good to start with the basics, start with the foundation then. move into something a little bit more complex. So what makes it come back? Or what makes it come? Well, the, the obvious ones, the sort of make it come back. Also the sort of variables that make it occur in the first place. So let's dive into those. Any sort of changes in routine, that being within training or that being outside of training, that sort of, I guess, puts more load on the PhD, more load on the tendon. So. Obvious changes in training will be. If you are doing rehab for your PHT, if that changes at all, any changes in load, if you increase the weight of your exercises or the duration of your exercises, if you reduce the rest between sets of those exercises, if you increase the range of movement within those exercises, for example, squats or lunges or deadlifts, if you have been doing half range of movement for those exercises, and then all of a sudden you go to full range of movement, that would put more strain on that tendon. Those elements within your rehab or within your just general strength training, if you don't have PHT, any abrupt changes that exceed the capacity of the tendon, whether it's been injured before or hasn't been injured before, if it exceeds that capacity, it's gonna increase the likelihood of symptoms turning up or at least initial signs of it letting you know that we've done too much. Other things outside of rehab and strength training, something that involves repetition, particularly repetitive bending forward. Gardening is a perfect example because you're squatting down, you're kneeling, you're lunging, you're sort of bending over to pick things up constantly, lunging forward to rake or sweep, those sorts of things. So if you've spent two or three hours in the garden and then the next day you wake up and you've got a sore, you've upper hamstring soreness, it will make sense because it might seem like I didn't go for a run that day, I didn't bike ride, I didn't do any strength training, what's going on here, but it might seem low load, but it's the repetition that might increase that level of irritation or cause that irritation. So keep in mind for repetition. Another obvious one that most of you listeners would be familiar with is just changes in sitting, sitting habits. long haul flights, car trips, a firm seat, even if it's just for a few hours, sporting events that have those really hard seats. That can be in combination with some of the things we've previously discussed. So you might do your strength and conditioning, where you've increased your deadlifts or increase the range of movement of your deadlifts, but done it within sensible limits. It's only just been a slight increase that's safe. But then after that slight challenging session, you've then sat in a really hard seat for a couple of hours watching sport or gone on a long car trip. That can cause it. I know when I had PhD a few years ago and I had maybe 12 months of it being pain free, symptom free, I went on a trail run. I competed in a trail run and it was about an hour and a half away from my And so I sat for an hour and a half on the way there. I ran and tried to run in my fastest time. Like I tried to put in my best effort and then driving an hour and a half on the way back. And then later on that day, my hamstring was sore. The race itself seemed within limits. I trained for it. I prepared for it. It did all the right things, but didn't train to do that plus three hours of sitting. And especially driving for some reason, like it was my right hand side and putting my foot on the gas pedal sort of put more strain on that tendon. So, you know, these things happen combination of things. The other thing I didn't mention was stretching. So we're still on this conversation of what can make it come back. And all of these things aren't bad. I've sort of highlighted this in the past. Stretching is fine, as long as it doesn't exceed your capacity. Deadlifts are fine, as long as it doesn't exceed your capacity. Sitting is fine as long as it doesn't exceed your capacity. But what we're seeing with a lot of these things is either a combination of a few things or one has exceeded their capacity, a long haul flight, you know, sitting for 12 hours, people don't usually do that. And then a lot of people get a bit worried about those things and totally avoid them altogether. And that makes it worse because that deconditions the tendon to tolerate future bouts of whatever the activity is. So we need to be really careful and sort of balance it out. So the obvious things, what makes it come back changes in routine, changes in your strength and conditioning and your rehab that either be load, range of movement, um, repetitions, bending forward, gardening, those examples, sitting and stretching. That's what I had, but I've got two other categories to sort of answer Karen's question around what makes it come back seemingly out of nowhere, because there might be some parameters where. you may not have thought about it. You might even, it might even be the gardening that I was talking about before. Like it's just come out of nowhere, but you haven't realized the load or the repetition or the range actually plays a factor in it returning. So keep that in mind, but I do have these other things. One is increasing in pain sensitivity because as we know, pain signals are sent from the brain. It's not sent from the tendon itself. It's the brain trying to organize the relevance and distribute the pain signals accordingly. And sometimes the body is in a state where it becomes more sensitive, becomes more sensitized to pain signals. So you might have a 0.1 out of 10 pain one day. It's still pain signals that are being sent. There's still something going on there that causes this borderline, I guess, awareness or dullness or ache. that you can pretty much ignore. But in certain circumstances where the sensitivity increases, that 0.1 can turn into a four out of 10, seemingly out of nowhere. You haven't changed your routine. All that's happened is your body has become more sensitized. So what increases sensitivity? We have decreased amounts of sleep. If you decrease your sleep, that increases the hormones of the body. It's not really recovering. we have noradrenaline and cortisol that circulate throughout the body, and that is a pain amplifier. So sleep, stress is another one. So if you have high levels of stress throughout the day, you can have a funeral, or you could be a moving house or a newborn baby, and this increases your stress, decreases your sleep, increases the cortisol and noradrenaline in your body. Nothing has changed in terms of loading of the PHT, but all of a sudden, pain increases. Another one would be thoughts. If you have negative thoughts, pessimism, catastrophisation, fear of movement, all of these sorts of things can increase the sensitivity because it raises the level of urgency in the brain. So the brain has to prioritise all these things and distribute accordingly what it sees to be the safest decision for you. But sometimes it gets it wrong. And if you're constantly worried, stress, anxious, hypervigilant, and constantly thinking about catastrophizing of this condition, the brain says, oh wow, we really need to treat this with urgency. This is a really big deal. And it sort of has this feed forward loop that increases pain sensitivity. And unfortunately, when pain sensitivity increases, this pain seemingly comes out of nowhere. and feeds forward that anxious, stress, anxiety, provoking symptoms. And so it sort of perpetuates those things. So be very careful with thoughts. Attention is another one. So sometimes distraction can be really nice. People can go for a run and listen to something and not think about their PhD. Whereas others might not listen to something and constantly think, how's my hamstring? How's my hamstring? Every single step that they take. And... that attention increases the pain sensitivity because you're giving more relevance to that area. Lastly, when it comes to pain sensitivity, we're looking at diet. I've sort of become more of an advocate over the last, even just the last couple of months, talking to Peter Bruckner and Rowena Fields on this particular topic about how carbs, sugars, increase chronic inflammation in the body and increase pain sensitivity. So... load might be the same, stress, sleep, all might be consistent. The only thing is you've just had something that's a bit more high carb diets and like these sugars and that sort of thing can create a bit more of a inflammatory state, something to think about. And the other one is under recovery. So when it comes to recovery and rehab and getting better, we kind of want to find this really nice balance between training load and recovery. So you can overtrain and tip the scales and pain can increase or you can overload yourself or you can have your training load consistent but your recovery strategies become suboptimal and that can tip the scale. So the best recovery we have is sleep, other recovery states, a decreased amount of stress and nutrition. Nutrition just provides the building blocks for recovery. So we want to make sure they're all in check. So what makes it come back? We've got the obvious things, the training load side of things, but we also have the pain sensitivity side of things, sleep, stress, thoughts, attention, and diet. And along the same lines of, well, in the same category, sleep, stress, nutrition actually impacts your recovery. So very important to keep in mind. The next part of Karen's question was to work out, okay, is treatment different if there is a recurrence? And I guess my answer would be, I guess it depends on what you identify to be the cause. If you have gone back and looked at what we were just discussing, the changes in load, the pain sensitivity, the under recovery, if now you can identify something that caused the increase in pain, then we want to intervene. We want to be proactive with what we've just uncovered and um hopefully get that under control. So for example, if we realize came out of nowhere, but now I realized I'm actually being quite stressed the last couple of days, you know, dramas at work and that treatment being proactive with that might include interventions to decrease stress. It might be doing some meditation, might just be being mindful of that stress process. It might be decreasing your training load while you are in stressed. out situations and so trying to get everything back under control. If a flare up does make sense, you would treat it similarly. Like you treat it like the treatment would be just like every other. Episode of sort of recommended on this podcast, just be going back to the rehab exercises, building up strength, building up tolerance, modifying your sitting, if that's what's causing irritation, don't avoid sitting altogether. Try and modify it and keep within acceptable limits. And The most key important part is just to learn from every flare up. If you are doing something and it's come out of nowhere, do your research, do a deep dive to try and find out what the cause is. Once you identify the cause, make sure you're proactive enough to reduce the risk of a flare up in the future. If it was a mistake, if it was a change in circumstances, change in lifestyle, identify it. change it, reduce the risk of a flare up happening in those same circumstances next time. So I wanna make sure that we learn from every particular flare up. Jennifer asks with the second question, with this being such a slow healing injury, how do you measure week by week progress? Do you need to look at it across a bigger scope of time? Are there markers to progress besides a reduction in day to day pain levels? Great question, Jen. Thanks for. asking this one, I guess I should start off by saying so Jen says, with this being such a slow healing injury, I will say that not everyone has a slow healing timeframe, but it is common. Usually the longer you've had the condition for the longer it will take to get better. That's across that's just a very broad statement across multiple injuries, not just PhD, but the most part. The longer you've had it for, the more complex the pain sort of gets and the harder it is to overcome because we're sort of working out other complexities. It's not just as simple as a load capacity, strengthen what's weak, loosen what's tight, like those sorts of things. It's becomes a little bit more complicated, especially if you've mismanaged it early. And that's, I guess that's why this particular condition is so... chronic for some people and like Jen suggests, so slow to heal. I think it's mainly because the condition itself, it's very hard to find accurate information about it. And because that's so hard, it gets mismanaged in the early days. And also because it's a very gradual onset. Well, for most, it's a very gradual onset. It might just be tightness. It might just be an ache. It might just be like uncomfortable sitting and sort of shifting around in your chair for several weeks. And you're not too sure what it is, you think it might be your glutes, you think it might be your lower back and you go to a health professional and they say, oh yeah, it's your piriformis, just do some stretches, do some body weight bridges. And it just doesn't, it's just the effectiveness of the strategies that you implement is just not enough. It's not what the condition needs. And so those early days of mismanagement can then lead to a prolonged recovery. So that's sort of my ideas. I do have some insights about Jen's question about should we use, is there anything else we can use as a marker to measure progress besides just a reduction in pain levels day to day? I do think that you do need a longer, a bigger scope the longer you've had it for. If you've had it for several months, let's just say if you've had it for less than six months we can look at a time schedule week by week to see if there is improvement. If you've had it more than 12 months, it might be a fortnight or two weeks that you might see that slow trend, but there might be hiccups along the way. Definitely month by month. If someone's had it for several years, we wanna check it out month by month, there should be a significant difference. Even though there's little bumps and blips, you might have a couple of bad days, you might have a bad week, but generally speaking, you should see a trend on the improve. But when it comes to how to measure this progress and not just using pain. There can be other things. So I've got one, two, three, four, five things written down. One is sitting tolerance. We know that for most this condition sitting can be quite uncomfortable. The ability to sit for long periods of time or on hard surfaces can be uncomfortable. But just measure what your tolerance is and try to measure week by week or fortnight by fortnight. Is that tolerance getting better? So in a systematic world, let's just say someone can't tolerate sitting for more than 30 minutes. If it's under 30 minutes, everything's relatively under controlled, no aggravation the next day. But if it's over 30 minutes, you start to squirm a little bit, pain starts to increase. Then when you stand up and walk around, you can notice a little bit of sensitivity there. And then when you sit down after that, maybe it's increased its sensitivity to like 15 minutes. So we know that it's been irritated. So that's what the current tolerance is. You might find week by week, if your strategy is effective, if you're doing the right things, and it's recovering, you know, day to day pain might be the same, but your sitting tolerance might increase, you might go from 30 minutes to 40 minutes. And then you might think to yourself, you know what, I've just sat in a meeting here for 45 minutes, and I haven't felt the need to squirm around in my seat, or I can sit on a firm surface. for 15 minutes, whereas before I could only take five. And that can be something for you that you can use to measure. The other thing is like morning symptoms. So it might not necessarily be day-to-day stuff. It might be morning stiffness. You might wake up and say, you know what, this hamstring symptom, this stiffness that I get in the morning hangs around for about 10 minutes before I'm feeling loose again and feeling like I can like move around. And then... in three weeks time, you say, you know what, that 10 minutes of symptoms or stiffness is now only two minutes. The pain is still the same. I wake up still with a four out of 10, but the duration that it lasts for is significantly reduced. That's a big sign of improvement. The other one is any sort of reproducible self-assessment, usually a test or a movement or an exercise that triggers some sort of discomfort, which you can retest over and over and over again. Sometimes maybe once a day, not more frequently than that, maybe once every three days. An example, when I was doing Tom Goombs, who's a Physio in England, his online course and looking at stuff, he was talking about a PHT client that he saw, they had the Moisturizer Test because that particular client notice the hamstring in the morning most when she put her foot on the sink bent forward to moisturize her legs. That stretch would cause say like a three or four out of ten tightness and it's not irritating but that's when she can notice that sensation. So Tom Goom said okay let's call this your moisturizer test. Every every couple of days I want you to do the moisturizer severity to see if we're heading in the right direction, because you might do deadlifts one day, the next day you wake up and the moisturiser test is worse. And you say, okay, maybe I over did it the day before. Or week by week, you're saying, you know what, this moisturiser test is now down to a two out of 10 to show that you're in the right direction. So some other exercises could be just a hamstring stretch, it could be a deadlift, it could be a single leg bridge, it could be a long lever single leg bridge where your foot is just further away from your hips as you come up into that bridge action. Just come up with your own thing. It might be getting into the car. It might be sitting for 10 minutes. Just find your own reproducible self assessment and you can use that to document to see if there's signs of improvement week by week or month by month. The other one that I have written down is an increased capacity without an increase in pain. So if you're running twice a week for 15 minutes, you're also doing cross training for 20 minutes, twice a week. If you are cycling, or if you're doing your strength and conditioning with a certain level of pain, if you're sitting at your desk job, Monday to Friday, this is all seeing what your capacity is throughout the week. And then you're measuring your symptoms, pain severity. If we then fast forward to four weeks down the track and instead of running twice a week, you're running four times a week and doing double the amount. And you're also cross training, double the amount and you're deadlifting heavier, you're doing lunges now, which you weren't doing before. All of this is an increased capacity. And if your pain levels are still the same, it's like, yeah, well, I'm not pain free, I still have a four out of 10 pain. It irritates for about 20 minutes after my exercise and then fades away. And you can say, yeah, but four weeks ago, you were still at a four out of, a four out of 10. and it had the same lingering symptoms. So you have the exact same symptoms, but you're doing twice as much. That's a good sign that you're increasing your capacity. So it doesn't necessarily need to be about pain, it can be your activity levels. The last one that I have to sort of measure, which isn't really that tangible, but it's just something that I've seen people self-report, is just a reduced hypervigilance or reduced awareness. which is a really good sign of recovery. So what that might look like is someone say, hey, you know what, I just ran for 10 minutes. I didn't think about my hamstring once. Whereas two weeks ago, I was thinking about it every single step. Or like I said, for that meeting, you might've sat down at a meeting for 45 minutes and say, you know what, I didn't need to squirm in my chair like I did before. Usually I'm squirming every 10 minutes, but I didn't think about it once. And so it's that reduced hypervigilance, which is a really good sign of recovery. You kind of don't notice it until retrospectively, but is a good sign. So back to recap Jen's question. Measuring progress can be pain week by week can also be sitting tolerance, can be morning symptoms, particularly how long those morning symptoms last for. Some sort of reproducible self-assessment that you want to do, like the moisturiser test, a sign of increasing capacity without increasing in pain symptoms. and a reduced awareness or hypervigilance. 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. Joey has been a super fan of the podcast and has submitted his question. Thanks for submitting this, Joey. What makes a chronic sufferer? Is it body type and genetics, or is it the level of initial injury that causes it to come back forever and the best a person with chronic PhD can hope for is to manage the level of pain through varying exercises? Great question, Joey. Let's start with defining what I guess chronic. chronic sufferer actually is. I guess the definition would depend. If you go to the literature, most people will suggest or the literature mainly says that if you've had this pain for more than six months, it can be categorized as chronic. They usually have that definition in there just so they can pick the right criteria. They try and set a criteria for what is chronic, what isn't chronic so that, you know, they can put people into their study and label them a chronic sufferer. just so you know they have association, a difference between the two. You mentioned genetics. There may be some genetics that leave people predisposed to soft tissue injuries and to tendon injuries, but not necessarily that same, that genetic sequence wouldn't increase the likelihood of them turning into a chronic sufferer. I found some research about certain genes one is col 5a1 and it seems that people with this certain segment or encoding of these proteins can have like their genes just change the way the tendons are structured and it seems that people with this particular gene variant seem to get more musculoskeletal injuries can increase the likelihood but also needs to be combined with environmental exposure. That's what the paper suggested. So you still need to have a training error, you still need to have an abrupt change in your circumstances. It won't just spontaneously happen. There needs to be an increase in mileage, speed, heavy lifting, sitting too long, you know, those usual abrupt changes. But those who seem to have environmental exposure is there, is present. But like I said, wouldn't lead someone to increase the likelihood of it developing into a chronic injury. I know I did a episode on gender and how female tendons respond differently to rehab, to synthesizing, to pain, like all those sorts of things. You can go back to that episode, it wasn't too long ago, to work out the differences there. Body type, Joey, I am unsure. I have a lot of non-runners who are just sedentary and just sat for too long or just did too much stretching and developed PhD. I mainly see a lot of runners. And so, you know, their body type is usually lean, but we know that PhD is very prevalent in gym goers, people lifting heavy. And I don't think it's their body type. I think it's what they're putting their body through that's causing the PhD and wouldn't necessarily have their body type predisposed to developing PhD, especially becoming chronic. However, one pattern I have seen that might lead someone to become a chronic sufferer or maybe predisposed to having chronic pain would be personality or traits behavioral traits, history of depression, anxiety, just how your thoughts process things. This ties in well with the first question that we had talking about the relevance of thoughts, feelings, stress, anxiety, emotions, how that increases pain sensitivity, and increases the importance and relevance for the brain to say this is an issue, we need to really focus on this. And can't think about anything else because this is so important. Nothing else matters. Sometimes people can get in these thought loops and really catastrophize things, you know, become really sensitive to loading attendant or stretching attendant or sit. These things are fine, but the thoughts that you attribute to those things, again, changes the structure of the brain, changes the structure of the neural networks, changes how pain is perceived. I have seen quite a strong pattern just in my experiences of those who can't seem to get better have also had a link to depression, anxiety in the past. And it makes sense, makes sense to me. That's why I have these pain science episodes in the podcast to illustrate that it's not just about tendon damage. it is about you as a whole. And maybe there's some other strategies that we can do to help your experience, your rehab experience, but also help dampen pain and get you recovering when we start considering all these other elements. You know, the other most important part is just, like I said before, PhD has a bit of a lack of understanding around effective treatment. And it is... We have like a lot of misinformation out there and people unsure of how to overcome it effectively. That's why I designed the podcast. But if you do have PhD and you're not sure what to do, or if you led down the wrong path and you mismanage it in the early days, that can really develop into something chronic because you're just not sure how to get rid of it. And it is something that you do need to know what to do to get rid of it. Um, but also just in its general nature, like I said before, kind of has a very gradual onset. plantar fascia, plantar fasciitis is another one where it almost seems like the very first time you start to take relevance of it, you sort of had it for three months already. Um, it can develop as a really benign, like non-important stiffness in the morning or just, you know, uncomfortable when you've spent the whole day on your feet. And then all of a sudden you're like, Oh wow, this is actually turning into a pain. Let me take action. And then you go to a physio and they say, how long you've had it for? You know what? I think I recognise this about four months ago. And then all of a sudden you've had it for four months without you really realising. PHT is very similar. And so the likelihood of it developing into something chronic is just purely based on the nature of the condition, sets people up for that. I hope that makes sense, but sort of these are the things I think about. Um, and also people are quite stubborn. They run through an injury, people prepare for a marathon and they're upper hamstring gets a bit tight and they're like, I need to run this marathon. So they just run through it. They do the wrong things. Um, and that can easily develop into something quite chronic, or they just don't progress their rehab. Again, one of the main messages of this podcast. And hopefully if you listen to all of these success stories, you will recognize that body weight exercises just won't suffice and people have been doing body weight exercises for 12 months. And. it's not until they start trying something heavier that they get better. And so you might think to yourself, Oh, why am I in this category of a chronic sufferer? But you know, you think you're doing all the right things, but maybe there's something, some elements that makes your rehab a bit more effective. Thanks, Joey hope that helps. Um, it's a very tough question to ask, but this is just the things I think about. Hope that made sense. Next one we have Rachel, another very loyal listener of the podcast. Uh, she asks, how can we prevent. PhD. I do have a bit of a spiel about people, um, about on the topic of, can we get our risk down to zero with most injuries? Um, I usually have this on the side of running related injuries, but I know some of you listening aren't runners, but. I will say. My belief is you can't get your risk of injury down to zero. Therefore, when it comes to preventing PHT, we can't necessarily say, we can't get that risk down to zero, but you can implement things that can significantly reduce that risk of it appearing. And so I've got five things here that you might want to consider paying attention to, to reduce that risk. It might be you haven't had PhD before, you don't want it to happen. Or it could be that you have had PhD and you've overcome it. You're back to exercising, doing what you love, but you don't want to come back. Number one, have a good foundation of strength. You can't build a house if the foundation is flimsy. You build a good foundation by building upon your strength, building upon your power. and just overall endurance. So a good foundation strength might be that you can tolerate 60 minutes of slow running. That's very good. You might be able to deadlift 80% of your body weight, three sets of 10. That's good strength. That's good heavy strength. Power, you might be able to successfully do hill sprints or kettlebell swings or plyo lunges. these things with speed that's involved that your hamster can tolerate. So we have endurance, heavy, slow load and power. If you can build up that foundation, the risk of you overloading yourself through training is very low, but we know that it can still potentially happen. But that takes me to my next point, which is good training, making sure that outside of the strength, what you're doing. in terms of running, cycling, just cardio, just all those things. We want to make sure that we have a, we control those variables very well. We progress those variables very well, methodically, sensibly, and consider that, okay, let's make this progression. Should, am I able to handle it or what's the risk of my PhD flaring up if I do this training session? Let's say you haven't done box jumps in 12 months. and then all of a sudden you participate in a class that's full of box jumps. That's a bit of a higher risk, but some people might wanna take on that risk. It's all about what can we do to reduce that risk of injury? And then if there are some risks, then recognise and take that on board. So number one is a good foundation of strength. Number two is just making sure you're systematically documenting and controlling the variables in the rest of your training. Number three is just good rehab. You can do your deadlifts and get to the point where you're better, back to the point where you're running pain free and you say, thank you, thank God, it's not coming back. Let me just go back into my running and just reduce my amount of rehab. Even after injury, you still wanna have some sort of rehab there. Sort of comes hand in hand with that foundation strength, but you just wanna maintain that strength with good rehab. Um, want to make sure that that's still consistently in there. Might be once or twice a week, focusing on maintaining the strength of your tendons, but needs to be implemented. Number four is a good understanding of the condition. You're listening to this podcast. This is right up your alley. Cause like I said, you can contain, you can control your strength, your training, your rehab, everything's under control, but you might run a race like I did, and then have to drive an hour and a half back and then think, what did I do? Like my running was fine, my training was fine, but it's just the combination and understanding that combination might lead to soreness. It's the, it's just recognising, okay, I know that sitting, you know, can challenge the tendon with compression. I know that running, speed, hills, and all of that was combined in one morning. You know, it's no surprise it's a bit sore. But now I know what to do about it. This is what I do for day one, day two, day three, just a big control of, you know, a big understanding of the condition and knowing what to do about it. Cause I say on the run smarter podcast all the time, you can't get your risk down to zero and I say it in the run smarter book, you can't get your risk down to zero, but my definition of true injury resilience or injury prevention is once symptoms do arise because we can't get it to zero, but once they do arise. knowing what to do to swiftly overcome it without losing fitness. That's my definition of injury prevention. So we need to understand the condition, understand what to do, overcome that little blimp in symptoms effectively. And then away we go. So in my example, a couple of years ago, when I did that run trail run, hills, speed drove home, bits all that afternoon. I thought, okay, let me just see how tomorrow goes. If I am still a bit sore tomorrow, I'm going to do. my slow heavy load, that's going to be my strength day because I know for myself, if I do slow heavy load, my tendons feel so much better. So that's what I do. I won't run the next day. Um, I do my strength work and then reassess the day after that. And if I'm back to baseline on back to final pain free, then I'll try a run and it will be at 75% of my usual intensity. And if that's fine, then I'm back to a hundred percent of training, haven't lost fitness, um, done the sensible things and yeah. Moving on to the next chapter. The last one I'll say is, we're still on the topic of reducing PHT. We've talked about strength, rehab, training, understanding the condition. The last one is just good recovery. I've mentioned the importance already. Sleep, stress, nutrition, making sure all of those are ticked. And if all of those aren't ticked and subpar, then we need to reduce the amount of training because we need to find that balance between training load and recovery. So it's a very, very smart decision when you recognise that your recovery methods aren't ideal. And then even before symptoms arrive, you back off your training because you're like, this isn't time for me to push the envelope. I need to enhance my recovery. Once my training, once my recovery enhances, then I can go back to full training, pushing myself, pushing the envelope. That's not to say you do zero training. You might say, okay, I'm not sleeping that well, but I can still run. Let me just back it off and really low intensity, that might be a good decision. So thank you, Rachel. Let me do a quick recap. Covered a lot today. Karen's question about when pain comes back, what do we do about it? Or when it comes back out of nowhere, talking about pain sensitivity, under recovery, just monitoring things in your training that might make sense if a flare up does happen, recognize and identify why that's happened. change something in your training for the future so it doesn't happen again. Monitoring your pain week by week to see if there's a if there is monitoring if there's an improvement, we can use sitting tolerance, we can use morning symptoms, we can use a home test to reproduce those. A chronic sufferer. I don't like maybe a little bit of genetics, maybe a little bit of gender, but most of it is just. Poor management in the early days, poor understanding of the condition, and then maybe those who develop real chronic sort of pain, there might be a link to your thoughts, emotions, feelings, hypervigilance, that sort of mental side of recovery, and reducing your risk or preventing PHT as much as possible. Get a really good foundation of strength, good rehab plan, maintain your rehab even after this injury. good training, making sure that everything outside of your strength works. So whatever cardio that you do has the right parameters and you're progressing sensibly understand the condition. You're hitting the mark there with listening to this podcast and good recovery. I hope that all made sense. I'll do some Q and A's for the next two episodes. So look forward to bring you that. And I'll be after that going on annual leave. So I'll have some nice time off, but In the meantime, good luck with your rehab and we'll catch you next time. 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.