Q&A: Global PHT awareness/tendon strength assessment/rehab after recovery/mid-belly soreness

: 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 back. I apologize if my voice sounds a bit scratchy. I am putting in a lot of hours to narrate my own book, the Run Smarter book. If you're not familiar with the Run Smarter podcast, I have spent many a month writing and releasing, publishing the Run Smarter book and now just putting in hours of narrating it. So yeah, my voice is finite. And so I'm quickly learning that, but Would love to get through these questions. I've got four that I want to answer on today's episode and I should split them into two episodes because I've got four or five more questions that you've submitted that are excellent. All these questions are excellent. I'm really excited about the quality of questions that are coming in. I can tell that you've listened to these. past episodes before submitting these questions because sometimes I'll get a question like what's the best treatment for PhD and I usually just point them to an episode, an earlier episode that already answers it but yeah absolutely wrapped with the quality of questions that have come in so yeah I've got four to go through today and next episode I'll most likely cover the next four so if I didn't answer your question maybe a patient might answer it in the next one so Our first one comes in from Julia. Julia says, hi Brody, I have a general query about the fact that this condition is so difficult to treat within the physio-orthopedic community with seemingly only a handful of specialists, in brackets like yourself, who understand how to rehab it successfully. Is this a new 21st century condition that has been amplified by our sedentary lifestyles and long hours of sitting at work? It just seems strange that no one has this problem back in the 80s and 90s when jogging, running became so popular? Or did they have it and just give up running or dampen it with painkillers? So just talking about, I guess, the awareness around PhD and how it originated, I have no idea. I'll try my best to answer it. It is hard to answer because I've only been a physio for 10 years. So I only know. about this throughout my last the last 10 years of me being a physio. So I'll try my best. I will say I didn't learn about PhD when I was at university. Um, when at least here in Melbourne, we study physio both to be qualified to be a physio in hospitals as well as private practice. And a lot of the criteria were suited for getting us ready for hospitals, which wasn't really in the musculoskeletal realm. So we didn't have we didn't cover too much, but I had no idea what PhD was when I graduated university. And I guess just looking back on now, I can't find much informational research on PhD that's not. more than 10 years old. Uh, the research papers that I have put forth on this podcast have only been the last seven, five to seven years, I would say. And I know, I understand Julia, you might think that, um, you know, people are sitting in offices more and that might contribute to the pathology, like emerging more in the general population. Maybe now, like people are just more connected so they can know that a lot more people have this. We have Facebook groups with thousands of people with PhD. So it might seem like it is recently emerging, but we didn't have Facebook in the eighties and nineties to collectively come together to say, yes, I have this. Um, who knows? but I don't think it's a change in like our sedentary lifestyle because this condition's also well, it's more prevalent in the athletic population and Yes recreational running probably started ramping up in the 90s I believe but it's more popular now than it ever has before especially recreational like triathlons Triathlons are very popular now I'm pretty sure it's growing every year in terms of just recreational athletes giving it a go and PhD is very, very common in the triathlete scene, just based on the demands of the hamstring to perform at those feats and perform those tasks. So hard to say, potentially it may have been like a thing in the eighties and nineties and just misdiagnosed. A lot of these, a lot of you listening now would know that Or have experienced it being misdiagnosed as a glute issue, saying it's glute tightness, just do some release work, just do some strength exercises and do some stretching. And that was usually the, the management, I guess, if I was a physio, had no idea what PhD was, did some tests, saw like kind of the location. Just say if I was a physio 15 years ago, I probably would have prescribed that said, I'm not exactly sure what's going on. but seems to be a tendon issue, seems to be like a musculoskeletal mechanical thing going on. Let's just strengthen you up and monitor your training levels and just make sure that, you know, things aren't getting worse and send you away with that. And that might get them better. And then we just think none the wiser. That I guess might've been happening sporadically throughout the physio-orthopedic community and no one really... Took a stand to recognise it as an actual condition. Um, I do know that. Bruckner and Khan, these two authors, Bruckner and Khan, they released a book, or they had several editions called clinical sports medicine. And it was the Bible for those who were private practice physios, just graduating out of university and wanting to know more about treating. conditions that would appear in the private practice setting. So the book would just like work from head down all the different conditions. It'd be like tennis elbow, ankle sprains, Achilles, tendinopathies, um, whatever was very common within the sporting population. And I will say proximal hamstring tendinopathy wasn't in there when I graduated, uh, a new addition came out two years after I graduated and emerged a condition called FAI, femoral acetabular impingement, which is on in the hip. And that was just research that was emerging and wasn't really that recognized prior to that. So as I graduated, and as this new book came out, there was just a new consensus, a new merging information, understanding about this FAI condition, and so I guess PhD was just not there yet. Similar to that FAI. It was. probably going to just appear on the scene. But similar to PhD, like FAI would have been around. People might have just misdiagnosed and thought it was a labral tear or osteoarthritis or something. And yeah, just with emerging evidence, more understanding and consensus about this, then it just gets brought forth. And I'm not too sure about Bruckner and Kahn any latest additions if, you know. it has now come out, PhDs in there, I'm sure it would be if they are releasing additions. And then if it was, then people, physios, health professionals that pick up that book would then start learning more about it. And then it'd start trickling as to become, I guess, more of a common condition who knows how to treat it. But it's hard to say like some physios, health professionals don't pick up books and start reading or learning new things. So if a physio has been out more than 10 years, and isn't willing to, you know, improve their knowledge or see what new conditions are emerging that they would still be in the, in the dark. They would still fit what a normal physio practice or orthopedic health profession would do in the nineties. And that's probably why a lot of people these days and only a select few know how to treat it's cause they've gone out and looked at the recent evidence, looked at the recent research. And. this new understanding of PHT, but if you're not actively seeking it, then you're just going to continue treating like you've always treated. I've seen that in clinics working with really, I guess, older, more seasoned, more experienced, but just being out a lot longer, physios that just practice and treat the way they did 15 years ago. And what they do kind of works. And so they just keep doing it without any incentive to learn something new or improve. But yeah, just my take, just what I've witnessed, talking to physios and working with other physios. But as the research and understanding is still catching up, some people might be able to diagnose PhD, but their management is a bit backwards. Unfortunately, I still see PhD sufferers jump on injury chats and they haven't tried any strengthening rehab yet. Not what I would classify as strengthening and their- talking with their specialists about surgery, 100% backwards. And it's the diagnosis is there, but the treatment and management isn't, that's still backwards. That's still in the nineties, trying to approach a particular problem with a solution that was done in the nineties. So that's a bit unfortunate as well. But thanks for your question. Julie, that's made me think a lot. Um, I actually didn't really, I guess, have a, have an answer for you until I read your question and just had a thought myself. So Very insightful, thank you very much for that. Next we have Harvey who says, Hi Brody, maybe you could expand on how PhD sufferer assesses whether they have a relatively strong or relatively weak tendon. For example, a slight increase in a strength exercise or perhaps doing too much sitting in a given period of time will cause a flare up and will often take four to five days for the tendon to settle back down. Thanks, Harvey. Um, some people might be familiar. I did do an episode on, um, how to determine if your tendon is strong or if it's just weak and we know that, you know, a painful tendon doesn't necessarily mean that you're becoming weaker. It just means that it's just a bit more sensitive and it's to answer your question Harvey, like it's really hard to determine and provide a really objective measure. on how strong a tendon is and how weak a tendon is or how irritable it is. But the general premise is that if you do something, if you increase your rehab, if you increase your deadlifts, if you increase your lunges, if you sit a bit longer than what you can tolerate and there is a slight flare up, the level of irritation um, might determine how sensitive it is, might determine its irritability. Um, and so some people might think, oh, I'm just extremely weak because I do this and it flares me up, but then a day later they're totally fine. And it's not actually weakness. It's more just the tendon being quite sensitive. But how I like to, I guess, find a ballpark figure of how weak or strong a tendon is, is just current. base of strength, just talk to someone and say, okay, what level of fitness can you tolerate? How much running can you do? How much strength do you have? How heavy can you deadlift at the moment? How many lunges can you do? Can you jump? Can you do box jumps? How much sitting can you tolerate? How much walking? Can you walk uphill? All these sorts of questions would just help determine the level of strength. Because some people might say, yeah, it's really sore. My tendon's really sore. But... It's only after I run for an hour that it tends to ache and gets a bit achy the next day and sitting's a bit uncomfortable the next day, but they're still running 60 minutes. Compare that to someone who can't, who's unable to run 30 seconds. Huge difference in capacity. Someone can deadlift an empty bar of 30 pounds. Some people can successfully do deadlifts of 80 pounds. or 60 kilograms. And this, just gathering all this data will help determine how strong, how weak the tendon is. But then we also wanna know how much irritability there is. It's kind of like this second characteristic to determine the level. So irritability is just defined as, if you overdo things and it gets sore, how long does it remain sore for? Is it a couple of hours? Is it a day? Is it two days? Is it five? Is it more than seven days? And this can help just determine the level of irritability. Cause if someone increases their deadlift from 10 pounds to 15 pounds, and then they saw five days with every other variable being consistent, I would say that's a rel, it's a week, but also, uh, irritable tendon, someone who increases from 15 pounds to 20 pounds. and it flares them up, but their level of irritation lasts 45 minutes. I'd say it's still weak because we're only lifting a little bit and a flare up has occurred, but it's relatively stable, low level of irritability of only just 45 minutes. So looking at these characteristics, looking at how something behaves is a good, um, good measure, but does have its limitations because like I said, It's very hard to objectively measure strength, objectively measure irritation. Um, and mainly talking about the major limitation that I can think of is just the complex nature of pain. So pain is extremely complex and isn't just a mechanical, you overdone it. The tendon gets sore. It will recover when it starts feeling better. Pain doesn't work that way. There's so many different factors and the nerves themselves can just be really sensitized. You can have a strong tendon, it can be stable, you may not have done anything, but the nerves themselves are so sensitized and let's just say the psychological side of things just ramp up the sensitivity of the nerves and create high irritability or even masquerade as a weak tendon. but it's only just because of the high sensitivity. And usually in this case, if we're noticing, or if you fit in a category where most of the pain, most of the pain characteristics are due to highly hypersensitive nervous system, then over a longer period of time, just observing it, the pain patterns don't really make a mechanical sense. Like sometimes you can do a deadlift, 30 pounds, three sets of 10. and it feels fine. Other times you will do exactly the same and it flares you up. Sometimes you might have a day where you're feeling a bit stressed, maybe at work, maybe not a great night's sleep. Maybe you're just a bit more anxious, fearful on that day and pain levels just go through the roof. Maybe one day you go for a run and just are blessed to be out there and you just enjoy the day and you run a little bit further than usual and you feel fantastic and your pain has settled. This would... throw what I just talked about the level of irritability and the strength levels out of the water wouldn't make sense. And so that's why we have to consider the whole complex nature of pain and not just categorize someone as a irritable tendon, weak tendon, strong tendon, because it can be so complex. This podcast is sponsored by the Run Smarter series. If you want to 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. All right, I've had a drink of water. My voice seems to be holding up so far. Our next question comes in from Trina. Rehabilitation exercises are great, usually doing the job to strengthen and repair if following doctor's orders. However, once the hamstring and or tendon no longer cause pain, is it expected that someone would continue the exercises and if so, would it be less frequent, fewer reps, lower intensity or something else? In other words, what is the post recovery protocol? Thank you. Great question, Trina. Surprised I haven't thought of doing an episode on this in the past. Um, I guess it depends on the goals you have. I guess it depends on the level of activity you want to do afterwards. And like I said, the start of this episode, PhD affects the sedentary population, but also affects the athletic population. And within that athletic population, we all have different levels of competition that we want to strive for. Some people might be elite, want to run really fast, perform at you know, really strong feats. Others might just be more recreational, but yeah, I want to give a marathon a go here and there, maybe venturing into an iron man, like everyone and their goals just are totally different. So my advice would be very different. And for that reason, I've come up with two examples, one being like a sedentary option and the other being if you're say a runner, um, so let's just say You are on the sedentary side, just wanting not really a runner, a cyclist or anything, just wanting to get rid of PHT and just be able to sit, be able just to bend, to pick things up, do some gardening, that sort of stuff. If you have gone through your rehab and now you are symptom free, I would say you would still continue doing your rehab, not necessarily to progress, probably keep it in status quo. Keep the same reps, frequency, intensity that got you up to that point. Do it twice a week and then just maintain that. If down the track you develop a flare up, because flare ups might be common, you might go from, let's just take gardening for an example, because that's my pet peeve I think. I used to see a lot of people. injured or sore or develop an injury after gardening because people intend to be out in the garden for 20 minutes and then three hours later they're really sore and it's always repetitive stuff, it's always getting awkward angles and doing stuff you're not used to doing so that's why it's my pet peeve. But let's just say or let's have an example of you've been pain free for several months but then you have to do a long haul flight. You have to go across the world to visit your family and that long haul flight is just irritated symptoms a little bit, very common. You've been symptom free all this time only to sit for a very, very long time and then it's a little bit sore. In that case, in the moments of a flare up, you'd increase the frequency probably from two up to four to five, maybe just try and find a really nice zone. that made you really successful to overcome in the first place. And then once it settles back down, then you can drop back down to twice per week. And the rationale behind that is doing it twice a week at baseline, I guess, intensity and just keep things in status quo is that we're just preserving a lot of the strength and a lot of the capacity that you've made in your rehab to get you to symptom free. And so Your goals isn't really to push yourself to develop yourself. I guess if you really wanted to be extra careful and then you have planned in a few months time to do more gardening or do a long haul flight, then maybe you decide to increase and bump your rehab numbers up a little bit. But I don't really see that ever happening in the real world. But yeah, you know, just maintaining the strength that you've gained to get you to that point. On the other hand, we have a runner or like the athletic population. Let's just say they've increased their rehab and they've got to the point where they're now symptom free. I would still continue progressing their strength and conditioning, progressing their rehab about two to three times per week, because the job now is to maintain a capacity higher than their training, higher than your external loads. you have to try and keep chasing that tendon capacity and keep it above what athletic endeavors you have. And we know for the athletic population, for most of us anyway, we wanna continue striving. We wanna continue pushing ourselves. We wanna go from a half marathon to a marathon, then a faster marathon, then an ultra, then an ultra with hills and just do things faster, further, better than before. So our goal is to try and continue progressing our rehab, progressing our strength to try and continue meeting those demands. And in certain times of the year, if your training is consistent, so you don't have any races, you're just happy running four times a week, five to 10K at a low intensity, no real endeavor to push yourself for a couple of months until races start up again, then you can probably back off your rehab and just maintain the strength that you've gained. So pretty similar to what that sedentary population was. The overall training load will be, or the overall rehab load in terms of like the weights will be heavier for the athletic population, but it will still maintain. You won't need to progress the sets, reps, weights, and just maintain it at two or three times a week would probably suffice. But everyone's different. Every advice should be tailored to the symptoms, the history, the goals, the person themselves. A lot of factors go into place, but that's just a general advice, I guess you could say. Lastly, we have Jen who says, hi Brody, my question is, how common is it to have pain in the muscle belly, which is just sort of like the mid portion of the hamstring? Is it truly connected to this PHT injury? I occasionally have pain at the high tendon attachment, but it is rare. I have really stalled in my rehab and I'm wondering if it could be something else. I should clarify at the beginning, it was more prominent at the attachment, but not now. Thanks, Jen. Um, I'm unsure how common it is to have pain in the muscle belly. I take a wild guess and say with my clients, maybe about 20% have some symptoms in the muscle belly, not just isolated to the high hamstring area. So, um, I guess that makes it uncommon one in five, but in that population. the presentation still needs to kind of fit with the PHT diagnosis. It should like, I'd say in most cases when my clients do have mid belly hamstring stuff, they also in addition have pain higher up. And sometimes it can refer down. Like if you're sitting for a long period of time, yes, day to day sort of symptoms are high up, but then if you're sitting for a long period of time, sometimes it can radiate down into the hamstring belly. But as soon as you stand up and move around that sort of fades away. But research does show that there can be some sciatic nerve involvement. It can either be a just a total comorbidity or a co-condition that just fits alongside the PhD or they can kind of be linked. but that is when someone would fit being test testing positive for, I guess, a sciatic nerve irritation, because there's like straight leg raises and other nerve tests that someone can do a therapist can do to say, yes, there is some sciatic nerve involvement. There's also some tests that the physio can do to say, yes, it is PhD. So I guess it depends on what things are, how things are with testing with some. musculoskeletal testing because it could be other things. It could be a muscle belly soreness, tightness, tension. It could be referring from the lower back. It could be referring from the hip. But all these tests will help increase the accuracy and confidence of if it is involving one thing or another and that would be one thing. So the sciatic nerve could be involved. It could have been PHT that irritated the sciatic nerve and now there's mid-belly soreness, I'm not sure, just taking a wild guess. But two, based on like the rehab, the rehab might've just overworked the hamstring. And now the hamstring is the main complaint that is being overworked potentially, and probably needing more recovery time. And so you really need to make sure that your strength work, the rehab work, and the recovery is well balanced. because some people start their rehab, they do bridges daily, sometimes multiple times a day, then they progress those exercises and they then do hamstring curls, they do deadlifts, they do lunges, they do their bridges and they're still doing it multiple times a day and they're doing like five exercises twice a day and all of those exercises are tough work on the hamstrings and then overall, The hamstring just gets really overloaded because it's not getting enough recovery time. And so I think I just did an episode on the run smarter podcast about this, how the rehab itself, once you progress your exercises should become less frequent. And if you're following those particular, um, that particular formula, then you're still getting that balance of, uh, working, stimulating, adapting to a particular Um, exercise and then getting that recovery on the backend. So potentially psych nerve, potentially the hamstring itself, the hamstring muscle belly, just being overworked from the rehab itself, but I always say just to fit on the fence and sort of have a confidence in my response, I say, if it's a, if we suspect as PhD, like you said, you started with pain localized higher up in the the attachment, we treat it like PHT. But if you're not getting better with that PHT treatment, if we do everything that we should do and it's still not working, then that's when we need to consider something else. That's when we need to widen our gaze, look at the scope and say, okay, could it be something else? And then if we suspect something else, treat it like that and hopefully to see an improvement. If we don't see an improvement, then we need to consider other options, maybe run some more diagnostic tests. which would be like physical tests, like say testing the sciatic nerve, testing the hip, testing the lower back, these sorts of things. So hope that answers your question, Jen. Thank you once again. Thanks Trina, thanks Harvey. Thanks Julia for submitting your questions. If you had submitted questions, I have Jennifer, Rebecca, Brent and Rob. I'll be answering your questions in the next episode. So I look forward to bringing you that. Hopefully this helped bring more understanding or insight to PhD as you're listening, 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.