Q&A: Managing Multiple Injuries/ Preventing PHT/ Sit Bone Stress/ Marathon Ambitions

: On today's episode, we have another PHT Q&A. 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... 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 everyone. Always loved doing these episodes. Love doing some Q and A's and I haven't done one for a while just because I've had so many, um, other ideas and I just get put into my run sheet and, you know, before I know it, I'm like, I've done all those success stories and book reviews and other things and haven't really caught up with doing too many Q and A's. So, uh, a couple of days ago. across socials on Facebook groups and my Instagram accounts. What questions do you have? And so I've got a fair few coming in. I will, this episode I'll talk through the Instagram answers or questions and next episode we'll do the Facebook ones. So thanks for everyone who's submitted their questions. Let's start off with on Instagram, we had Anna who chimed in and said, I have high hamstring tendinopathy preceded by Achilles tendinopathy on the same side. Is this related? Um, I'm assuming, I dunno, it took me a while staring at this question for a while. A high hamstring tendinopathy preceded by Achilles tendinopathy. So I think you've had the, the PhD first and then developed the Achilles tendinopathy second. I think, I don't know, I don't know why I'm struggling to interpret that, but let's just assume we've had the PhD and then developed Achilles tendinopathy. Okay. Could this be related? It could be related, but it doesn't have to be related. And I know if you go to health professionals or coaches and those sorts of, you know, health professionals, they are one to try and link the two because They look for answers. They like answers. They get a lot of buy-in when they say, Oh, you have Achilles tendinopathy because your hamstrings not activating properly, glutes aren't activating properly, your rehab is inadequate. And this is putting more strain on the Achilles and those sorts of things. And that could happen. But it also could not like, you know, injuries can happen. Injuries happen all the time. Not sure about your situation, Anna, if you're a runner or a, um, you know, an athlete of any kind, not too sure about your background to sort of pull these strings together and pieces to the puzzle, but, um, it doesn't have to be, they don't have to be linked because what we know about injuries is injuries are a simple equation of load versus capacity. Every tendon, muscle, ligament holds a certain capacity. And if you train, if the load that you place on that structure exceeds its capacity, it's going to start getting sore if you mismanage it and then, um, spirals out of control. And it's also training load versus recovery as well. If you train and have inadequate recovery after that training, things start breaking down rather than building up. And then, you know, that can slowly develop into an injury. So the same reason you can have. PhD because of load versus capacity, because of inadequate recovery. You can also develop something else that pops up in your body as well. So when someone comes to me and says, okay, I've got this and I've also got this second injury, is it related? I like to. dive into their training history. Okay. What was happening at the time of the PhD, what was developing or what was your training like around the time of the Achilles coming on, it might've been after a heel session, it might've been after, uh, you know, cross training session or strength training session, we can sort of see if anything fits a pattern. Um, And also just get what's your training philosophy? How do you like to train? What's your intensities? How hard are you working? What's your, what we call intensity distribution? How do you like to spread your different intensities across your week? That might be a little bit skewed and you might be slightly over training or doing something too much. The link with PHT, um, it's very closely related to running like speed. I've said this on the podcast a couple of times, but very correlated the faster you run the exponential increase in demand that goes through the hamstring but also the faster you run places a lot of load on the achilles and so maybe there is an intensity issue um i hate sort of trying to make guesses because i don't know a lot about your situation and up it these are the things i think about um Looking at your overall training philosophy, looking at your overall recovery methods, because you could just be training without intensity, but you know, you're lacking sleep. There's increased stress, hydration, nutrition isn't necessarily adequate, and you can easily develop overload injuries in multiple areas, just because globally speaking, your body is under recovering. It's very easy to overload structures in the body. So globally speaking, that could happen. They don't have to be related, but like I said, they could be related. There could be compensations and those sorts of things that do develop. Uh, if there is a compensation, perhaps there is a lack of a rehab from one injury, which then carries over to overload another injury. So in this example, or in this hypothetical, we could say that they're the return back to running may have been too quick or the rehab. may have been inadequate and the hamstring itself has lacked strength, lacked power, or maybe you yourself have lacked confidence to run stride out, activate the hamstring, use the hamstring to its full capacity, and maybe that lack of confidence is leading you to be a bit more ginger when running on that leg. Therefore, other things have to pick up slack, therefore... the Achilles might be pushing off and producing a bit more force than what it's used to, and therefore it may become overloaded. I can't say that definitively, I can say that there's a possibility. Daily modifications is also something that, like when people are injured they just move differently. All of a sudden they start sitting differently, they start walking differently, they start going up and down stairs differently, and that can place a load, different load on people's bodies. I've seen people develop PhD on one side and then get PhD on the other side just because of the sitting, because they spend so much time leaning over and taking pressure off one sit bone that they put too much pressure on the other sit bone. Or people develop plantar fasciitis because they're avoiding sitting all together and they're just standing all day and their plantar fascia isn't used to that really abrupt swing to standing all day. Maybe there's something to be said for that for the Achilles. Maybe you're sitting less, standing more or walking more, and that's putting more daily load on the Achilles. Yes, standing and walking isn't a lot of load on the Achilles, but let's say you go for a run, then you're standing all day and the Achilles isn't really getting that recovery. Next day, you'd probably do the same. Achilles isn't getting that recovery, and then it can become overloaded. So that's probably my best response with the limited information I know. Possibilities are all out there. All those hypotheticals, they're out there as well. Hopefully that maybe brings some understanding or one of those hypotheticals and are sort of like, um, light bulbs turning on for you and maybe. Fitting some pieces of the puzzle, but you also ask, uh, what's the best way to rehab or heal slash prevent PhD. So this was kind of like a two-parter with your Instagram submission. So you say, what's the best strength and rehab work to heal or prevent PHT? I've got my favorites, plus or minus a few others that I might add in there based on the unique circumstances of the client in front of me. So deadlifts, I almost always put deadlifts in there. Of what starting point? It might be 10 pounds, it might be... one quarter range of movement, it might be, you know, really, really low level stuff based on the person in front of me. But I usually start off with some form of deadlifts and progress from there. Prone curls, which lying on your stomach, doing some hamstring curls with a machine that you find at the gym. Well, I'm also quite surprised at how many gyms don't have a prone hamstring curl machine, but you can get away with a seated hamstring curl machine if... you can tolerate sitting and you can tolerate that particular exercise. Or you could do a prone hamstring curl with a band. Usually don't prefer the band, but you can also do it with a cable where you get the pulley system and there's like this Velcro weight, uh, this Velcro attachment that you put around your leg and then, or your ankle, and then you can curl that pulley system and then you can adjust the weights accordingly, which I really like cause you can progress quite well when you have that weight rack. handy. So deadlifts, prone hamstring curls, step ups, weighted step ups, finding something that's about mid shin height and holding on to dumbbells or a kettlebell or weighted vest or something that's stepping up and down is my other go-to. Again, everyone has a different starting point. And then everything else after that is probably just adding in based on the person in You know, I have triathletes, I have runners, I have sedentary people, I have, um, pickleball players, you know, there's, there's a whole bunch of people that we need to consider for. And so we need to tailor these exercises. If they're running and wanting to introduce some sort of bounding, running sport-based exercises, I would put some eccentric exercises in there. We could do an eccentric. Hamstring curl where you're curling up with two legs. and then releasing one leg and slowly releasing that weight with one leg. I would do resisted standing hip extension with some people who are really struggling with that particular movement. I think I'll get to that next week with a question that we have. Hip thrusts are an exercise that you could do. You could do Swiss ball. Swiss ball rollouts where you sort of bridge with your feet up onto a ball and you're curling the ball back and forth. I usually gravitate towards the slow heavy stuff, the things that can be progressed with weights rather than Swiss ball exercises and glute bridges and those sorts of things. But they're my go tos. And so, Anna, you asked to heal. What are the best exercises to heal and prevent PHT? Well, they're the same exercises to heal PHT. we need to get the hamstring and the tendon stronger. And to prevent PHT, we need to get everything that unit stronger as well, because it's harder and harder to exceed the capacity when it's so robust. And so those same exercises do apply. But I thought I would add on to that particular question because Rachel also asked, I have not had PHT, how can I avoid it? My first point with that is just keep your hamstrings strong. Keep the capacity high. Try and make sure the hamstring can tolerate the demands that you want to put through it. Because like I say, injuries are just load versus capacity. If your capacity is really high and your training load is below that capacity, it's very, very hard to get injured. Very, very hard to get an overload injury, which is what this is. and you're setting yourself up for success. And if you do manage to develop PhD, the stronger the foundation, the easier it is to get rid of. And so that would be a particular focus of mine, keep the hamstrings really, really strong. The next point would be just to monitor your training loads. So we're covering both the capacity side of things and the load side of that equation. So the load side is just making sure that we are, you know, writing down your training plan, writing down your intensities, writing down your speeds and making sure nothing is too abrupt. Because a lot of times people get injured, just running to feel, or based on they've got a race coming up and they're really extremely motivated and they get an injury and then they look back in retrospect and say, Oh, look at all this mileage that I did last week compared to the week before. Wow, that was a big jump. I've obviously overdone things. And so if we can forecast and plan. to avoid getting into that situation. You're significantly reducing your risk of PHT and any other running related injury. Also, I will say just be very, very conscious of speed, the speed element of your training cycle if you do interval sessions, or if you do hills, running uphill tends to put a little bit more strain, but I would say speed work on the flats, doing interval stuff. 200s, 400s, 1K intervals, anything that involves speed work is fine and is actually encouraged because doing it in the right way increases your capacity, increases your eccentric strength, increases your overall capacity to tolerate load, but it just needs to be done sensibly and needs to be progressed in a systematic fashion to which not a lot of people do. So bear that in mind, keep the hamstring strong, monitor your training loads. In particular, a very conscious awareness towards speed. And then I would say if we're looking at how to prevent PHT, I would say scenarios where you're combining long or hard training sessions, races with sitting. Just a combination of the two doesn't really go too well. Like very common, someone will have a marathon that they have to run. on a particular day, but they also have to drive to that event. I'll have to drive to a race. And so it's a two hour drive there. They'll run, they'll do their event. They'll run hard, they'll race hard, and then they have to drive two hours back. That's a scenario that we want to be particularly aware of. People travel for flight, uh, fly for marathons. They go, they jump on a, you know, 12 hour flight run. a marathon a couple of days later, and then they're flying back the next day. That's another thing that you might start getting a bit uncomfortable in your sit bones if you've never had it before. And that's fine, like we can't not avoid doing those things. You just need to be conscious of doing those things. And then if symptoms arise, this is my next point, if symptoms ever arise, you need to do the right things early on to then mitigate it really quickly. And a lot of people struggle to pick up on PHT symptoms, because sometimes it can creep up on you. And you don't really notice it. But if you are cognizant and act accordingly, it turns into a three day, you know, annoyance rather than a six month injury. And so what I will say is, always when people ask me, what can I do to avoid injury? I say, if you have races that you wanna run, if you love running, you wanna run fast, and you have all these athletic endeavors and goals and achievements that you want to do, you need to push your capabilities. And to push your capabilities is always gonna be a risk of a running-related injury. It's a part of life. Injuries are a part of life. We can't totally avoid or prevent injuries. We can do the right things to reduce your injury risk. but we can't get that risk down to zero, unfortunately. If that were the case, I'd probably be out of business, but we can do the right things to minimize that risk. However, because that risk cannot get to zero, symptoms might arise, early symptoms might pop up here and there. Achilles might get tight, planifacial might get tight, sitting might become uncomfortable. Like all these sorts of things are just early signs and it's picking up on those early signs and doing the right things. that will, like I say, lead into a three day injury or a three day awareness rather than an injury. And so Rachel, good question to prevent PhD, keep your hamstring strong, monitor your training loads, be conscious of speed, be conscious of doing something quite challenging and then sitting, if you have a long meeting or hard, if you have to watch your children play sport in those really hard surfaces. and you had a long run that morning, stand up, move around, just be conscious of that. And then if slash when symptoms do arise, do the right things early. Thanks for your question, Anna and Rachel. Let's move on to Jordan. Jordan says, I have imaging that has shown PHT plus bone stress reaction at the ischial tuberosity, which is your sit bones where the hamstring attaches onto. Is this common? I don't think it's very common, but it can happen. I have seen it. Um, but I do work a lot with PhD and I don't see it that often, but perhaps. There is a lot of, maybe there is a lot of bone stress reactions that aren't picked up just because they do present like PhD. And, um, you know, you just continue treating it like PhD and maybe it gets better. Um, so it can. B-linked like those two things can happen purely based on the mechanics. So what happens with a bone stress reaction? Um, it's sort of like the precursor or the very, very early stages of a bone. A bone stress fracture. So the bone undergoes some sort of breakdown, some sort of overload and. Develops eventually if ignored and doing the wrong things, the bone will eventually get worse and worse and worse, develop into a bone stress reaction where there's a little bit of edema or swelling or thickening around the outside layer of the bone. Again, if it's still ignored and not managed appropriately, that can start to affect the inner parts of the bone and it becomes fragile, it becomes sore, it becomes tender to touch. Then again, if still ignored, that pathology just continues until it... fracture appears and we call that a stress fracture, which is particularly like it's just an overload injury just done over a longer period of time to the bone structure. And bone stress can come from tendon pulling on the bone. So when you run, when you sprint, when you play team sports, the hamstring is pulling on that tibial tuberosity, the sit bones. It has to, it's what it does. And if that is too much, then the bone itself can start becoming overloaded, undergoing a little bit of a stress reaction and can also fit very similar symptoms to PhD. I did an episode, a couple of episodes back about other things that, other diagnoses that PhD could be. And you know, bone stress reaction was on that list. And Um, so yeah, the same reason that you could develop PhD, you could also develop a bone stress reaction of the issue of tuberosity. And in some unfortunate, unlucky circumstances, you can develop both at the same time or one than the other, just cause it's so related. Not only is the structure very close in proximity, but the mechanism of injury is similar in both. So you want to be very careful and hopefully don't overload both structures at the same time. But I would say for you Jordan, as well as other people who've had bone stress reaction, we always want to delve into your history and seeing if there is anything to do with bone health as to why a bone stress reaction has occurred as well as the tendon issues, because most of the time the bones are pretty strong and more resilient than the tendons. And so that's why people develop the tendinopathy and not the bone stress reaction. So we want to look. to see if there's something in your overall picture, overall history, overall generic health as to is there something to do with bone health that might be an influence? So, disordered eating, under-fueling, malnourished, previous history of stress fractures, anything to do with recovery, anything to do with, yeah, just general things. relative energy deficiency in sport, which is a condition of, you know, your younger athletes typically training too much and not feeling themselves adequately and their bones don't develop or their bones don't become strong and robust. And they are just setting themselves up for a lot of stress fractures in their early years, but also in their future years, because you... It's the early adolescence, 20s, early 20s, those sort of years is where you build up the biggest bone mass. And then after that, it's a real struggle to hold on to that bone mass. And so you really want to bank a lot of the strength in the early days, a lot of bone mass in the early days. And if you're under fueling yourself, that's very, very hard to occur. So yeah, I'd see what that would be like in your general health scenario and see if there's a link there. Okay, thanks for your question, Jordan. Let's go on to our final question, which is Sue, who asks or says, I am 60 years old now. I used to run more than a hundred kilometers per week. I've had recurrent PHT and can't run more than 10Ks every second day. Is it okay? This is okay, but I want to run the last two of the six Abbott majors, which I had to look up, which are Marathons, marathon distance. I've been doing all the exercises for my glutes directed by my physio and running coach. Is there any hope for me? And she also adds, I've ran 25, more than 25 marathons and trail marathons. Thanks for your question Sue. I reached out to you when you submitted this question on Instagram, I put it into the thread and also put it, I sent you a message. a direct message asking like specifics, cause you said you're doing all the exercises for my glutes. I just wanted to know what they were like, what exercises are you doing? Cause that would be great for me to sort of add onto, but unfortunately haven't replied yet, so I'll just go off something generic. I hope it's not just glute work because we need to strengthen the hamstrings as well as the glutes. And I've seen a lot of people, like I jump on free injury chats with people with PhD all the time and very common are people doing bridges, crab walks, monster walks, like body weight, easy light resistance stuff for the glutes. And doesn't get them anywhere. Maybe it gets them a little bit better in the initial days, but like I've said on this episode already multiple times, we need the slow heavy stuff. So I hope you're doing the slow heavy stuff. I hope you're doing some sort of deadlifts or step-ups or prone curls and all that sort of stuff that really builds up the robustness, is that if that's a word, to the hamstring, to the tendon and reaping those rewards. I hope that's the case. If not, then make a start, make a start on those exercises I've listed already. And there's... The question, okay, is there hope for me to start to do these marathons? Um, I don't know when these are, but I will say don't rush into marathons. You can't fight your physiology. You can't fight your capacity. You can't fight how quickly this thing heals. And so my guess, if your symptoms are adequate, if your symptoms are acceptable with doing 10k every second day, which seems to be tolerated, I guess. Maybe you can make a start. Maybe you can turn that 10k into 11, 12, and then slowly progress that as you would do in a normal training, marathon training cycle. I'd give it a little bit more time. Like I say, I hope this is like maybe four to six months away. I suppose you're building up, if you're doing 10k every second day, I suppose that's a good base. So maybe three months, four months. But that if you start increasing that 10k and symptoms increase, I would say you're not ready for a marathon, I'd say take some time, work on your weak links, work on your little kinks that might be strength training. And then once the ramp once you do that build up, and your symptoms are responding well. then we can talk about, okay, let's prepare for a marathon. Might be a slow one, but it can be achieved. If you want to work on speed, that's a different story. It might take a bit more time. But we wanna sort of work on the things that are working well. You have said that you have recurrent PhD. So not sure how long you've had it for, how many episodes, how many PhD episodes you've had, what's led to those. But if you've had it multiple times, and you're struggling to increase or build upon more mileage, but you also have a marathon that you really want to hold on to. I'd say that's a recipe for disaster. And it's only just because I talk with people all the time. A lot of people, uh, drawn to compelled. To towards races and it brings them undone. It leads to a lot of chronic injuries, a lot of injury recurrence, a lot of stuff, just because they're just so, their passion is races. And I'm so like emotionally detached from any of that decision making. And so I get frustrated because I'm like, just don't do the marathon. Just like do some proper rehab. And then next year you'll be running marathons without any issues and you'd be feeling happy, but people rarely look at the big picture. Um, You may recall my success story with Ashley, who was just doing marathon after marathon fine performing well, but just kept having like PhD injury flare up, uh, had it now had it for like several years only just because she was so compelled. She loved doing marathon so much that she was just going marathon after marathon after marathon, like in the sensible timeframes, but just the PhD just wasn't getting better. It was stubborn. It was a sticking around. And it wasn't until we had a, you know, chat had a good discussion about, let's talk about your training philosophy. Let's talk about your mindset, your attitude and, um, what you think about marathons and we have to really peg back. And say, look, let's think, let's look long game. Let's look two years from now. Do you still want to be running marathons? How about running marathons and getting PBs and running fast without any symptoms? How about we? not try to push this next marathon and actually work on your rehab, make rehab, prioritize your rehab first and foremost above everything else. And if the marathon's, if we need to forgo the marathon, so be it. If marathon looks likely, we'll do it, but it'll be slow. And let's then use that as momentum to the next marathon. It's actually good timing because I had a talk with Ashley recently and she, well, first of all, she did that marathon. We actually were, she built up her rehab well enough that she could do that marathon. She had to do it really slow, which she didn't like. She had to train really slow, which she didn't like, but her symptoms improved dramatically. So instead of going from marathon to marathon to marathon with symptoms, she actually did a marathon slow, but without symptoms or very, very minimal. And then at the time of recording, just as a couple of weeks ago, She ran another marathon, she ran a PB and didn't have any symptoms. And so this is where we sort of need to look big game. Um, I know Sue, like you're 60 years old, which, um, I'm. Inspired and motivated that you're, uh, you'd love doing marathons and you're getting back to it, but you can still look big picture. There's still a lot of marathons on the horizon in two years, five years, 10 years. And let's do that. Let's not rush. Let's not rush these things. Um. That's just my, like I say, I'm emotionally detached from a lot of these. And when people say I have PhD, I want to do everything I can to possibly get it better. I'm sick of this injury. I'm sick of it recurring, but I also have a marathon in two months and I need to do that as well. That's where I get a little bit. Okay. We need to prioritize things here. Um, don't want to kind of finish on a downer, but, uh, hope that helps everyone. Hope that helps even just like the philosophy, like just thinking of it, having a different mindset, different. changing our attitudes towards thinking big picture. No matter what your goals are, I think that's always a good thing and might be a good topic to finish on. So got four questions there done and dusted. Next time we have some Facebook questions and yeah, looking forward to answering those. Hopefully this helped in today's episode and we'll catch you in the next one. 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.