Q&A: Overlapping symptoms/sitting guidelines/hip weakness

: On today's Q&A episode, I'm answering all of your social media questions. 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. call out and got a ton of responses for questions that you, any PhD questions that you want me to answer. I've put it on my Run Smarter podcast, Facebook group and a few other. Facebook groups to do with PhD and thanks for submitting all your questions. Sorry, if I don't answer them all, I kind of have this process now where, um, for those questions that get asked, if there's an episode already specifically tailored to that, I'll try to direct people to that episode. Um, if the question itself is not really suitable or not really appropriate for, uh, the podcast itself, uh, may is just too irrelevant. I'll try my best to answer it for them. Just reply to their Facebook comment. And for those who, if there's too many, if it's a good question that I want to answer, but there's also too many responses, those who are a bit too late, I'll just carry it over into the next Q&A episode. And so thank you once again for submitting them. Chitra was the first one to submit her question and she asks, are there overlaps between gluteal, tendinopathy, adductor, tendinopathy and PHT? And so... For those who are unfamiliar, gluteal would be kind of lateral hip pain or pain around the glutes themselves. Ducted tendinopathy would be a little bit more inner thigh tendinopathies and obviously PhD. So do the second part of the question is how do we isolate what it is and is treatment is a treatment plan similar? So it's a very good question. If it comes to say widespread symptoms, widespread pain, sometimes it could be just more of a chronic nature. We do know that for particular injuries, muscular skeletal injuries, if it goes past the acute phase, sometimes the behavior of those symptoms tend to be a bit more vague and a bit more widespread rather than a focal, localized pinpoint type of focus. So sometimes it could just be the injury itself undergoing it's this chronic nature and becoming a bit more widespread. But then also we know that sometimes there are multiple injuries going on at once, there could be PHT mixed in with adducted tendinopathies. Or we do know that it's A PhD could be presented as well as say, a sciatic nerve involvement or piriformis involvement or, um, any other glute, glute made tendinopathies, which can produce pain higher up and even further down the leg. So there could be two things going on. why that would happen. Um, very rarely would two injuries arise at the same time. So at the very moment you develop the PhD, it's very rare that at that very moment, you also developed an adductor tendinopathy or sciatic nerve involvement. But over time, if you do develop PhD first, um, You may be moving differently because you're in pain. It might be uncomfortable sitting. So you might be sitting differently. You might be exercising differently. You might be compensating, um, with your walking or your running or your cycling. You might be compensating with doing your squats or lunges, and then that can carry over into another issue. And so that could carry over into a hip or glute type of pain, or it could carry over into say, low back pain. one that might be associated because you do start moving differently and the muscles have to be responsive to that and be like, oh, I'm not used to behaving like this in this particular position. I'm not used to sitting, you know, keeled over or sitting on my side with a side bend in my in my spine. And then those other symptoms can start presenting themselves in. Thinking of this question reminds me back to, it was a fairly recent, I was recently released on the PhD podcast, my episode with Alex Murray, talking about why one treatment doesn't necessarily apply to everyone with PhD and how every, how it just could be completely different. Um, because not often, more often than not, people don't sit on a particular diagnosis. We have we know the classic characteristics of PHT. We know say like bending forward would produce pain, deadlifts would produce pain, sitting for long periods of time would produce pain depending on the severity levels and depending where you fit on that pathology. But then we also know that direct like symptoms might not exactly correlate to classic PHT. Someone might get burning higher into their glutes. Someone might get a little bit of low back pain. Someone might get pain radiating into the hamstring, sometimes past the knee. PHT doesn't necessarily fit nor do any diagnosis fit in a very precise blanket of symptoms. There's sometimes some overlapping and sometimes some carryover. So it might be that in particular instances PhD does carry over into a ductus or glute type of soreness. And that's what makes it more complex. It's what makes it less, makes it more confusing for some people, because I also know that. when it comes to say sitting. People with PhD say, yep, I sit for long periods of time, especially on a hard surface. That's what really stirs me up. I know for me in the past, that's what happens for me. But then I also hear cases of harder surfaces actually help people with PhD in some circumstances. And so that's completely contradictory, conflicting. messages, but that's just why we're just different bodies, the pathology slightly different, the way the pathology of the particular tendon is slightly different, and so that's where we see those discrepancies. And whether there's two things going on, whether it's just the original diagnosis might be missed or not, or all of those complications, all of those interwoven, interlapping symptoms, Assurances. It might all of what I'm talking about might be a bit puzzling, a bit confusing and be like, well, what should we do? Well, there are some assurances to be had regarding treatment. And I did discuss this with Alex on the episode, but what you can be assured of and what can be quite empowering is you just treat a particular diagnosis, do it well, do it properly, do it. like the short term strategies, the long term strategies, do it really well and do it properly for probably three to four weeks. If there is no improvement, then you need to change the management. You need to change what you're currently doing because if you continue doing what you're doing, the likelihood of it not getting better is quite common because it's not getting better in four weeks, probably not going to get better in eight weeks if you've continued down that path. And a PhD experience that I've come across is people say, yeah, I've been doing my strength exercises for six months, it's not getting any better. And you ask what they're doing, and they're doing bodyweight bridges, maybe with a little bit of weight, they're doing single leg bridges, they're doing some hip exercises, and not progressing, not doing anything, they're stuck to those same strength exercises, and their same exercise routine, the same for six months. If you're not seeing any improvements, you need to change your management. That's the reassuring thing. But I, the caveat of that is you need to do it well. You need to make sure that you're following the right guidance with the right health professional to make sure that you are seeing improvements. Cause you could say, all right, let me try a progressive strength and conditioning program, but then also you're mismanaging it in say your exercise or you're mismanaging it with your running or your cycling or you're mismanaging it with sitting or those sort of things. And then it's not getting better. You say, okay, the strength exercises aren't working. I need to change. So you really need to put your scientific hat on and isolate one variable at a time to see if it really is truly ineffective or if it is making progress. Be very careful. Um, if you could still be, it could still be. the same diagnoses like it could still be PHT, but what you're currently doing isn't working therefore there's no point continuing. Hope that made sense. Not saying that you're better in three to four weeks, but there should be a small improvement because we do know for say chronic PHT it does take six to 12 months in most cases for that six to 12 month. six to 12 months of really good rehab for that period of time for it to make significant improvements. But in four weeks, if the management's correct, you should be seeing some small improvements in say pain, but maybe in your sleeping, maybe you're sleeping better, maybe you're sitting better, maybe your weight training is better, you're able to progress in the weight training. If you see those small improvements, then continue. If you notice If you keep continuing and you notice a plateau in that improvement, then needs a change. Hope that made sense. So thanks for your question Chitra. I have one coming in from Lauren. So Lauren asks, hi Brody, any tips on how to sit more comfortably when there is a flare up each time it gets sore? Should we start again with isometrics or push into slight pain with these exercises? And this comes off the back of Kirsten who also asks, is there anything that makes sitting more comfortable? So I do have sitting episodes earlier in the podcast. So if you haven't listened to those already, highly recommend to them but I do have a few other additional things to talk about to answer and help you with your questions. Perhaps keep in mind that when it comes to flare ups, I've talked about this in the past but not all flare ups are equal. So the advice for a flare up is very hard to come across because you can have a very major flare up or you could have a very minor flare up. an increase in pain beyond your natural kind of baseline symptoms. And if someone does have a severe flare up, a significant flare up, you could limit your sitting maybe for one to two days, um, people have resorted to sit stand desks or just. If they're at work, just taking regular walk breaks, um, trying to limit their driving if they can. We know sitting can't be avoided. Well, some people have, but in my eyes, day-to-day sort of stuff, sitting, absolute sitting can't be avoided, and probably shouldn't. If you get up and down regularly, that should be okay for the hamstring, but if you're just standing all day, it's a lot of pressure on your feet, it's a lot of pressure on your lower back as well, so not often recommended. Uh, so yeah, for one to two days, maybe limit or modify your sitting beyond what would you normally would tolerate some sitting modifications. Um, again, there was another, there's an episode on that, but putting more pressure on your mid thighs, I tend to have, um, say I sit all the way into the back of my chair, I raise my chair up so that it's at its highest point, I tuck my feet under the chair and then I just lean forward slightly to put all of my or most of the pressure on my mid thighs, almost at the front of the chair and then what that does just like a seesaw is kind of take pressure off my sitting bones. Still might be uncomfortable if you're experiencing a flare but it's less irritable. and will be more comfortable later on in the day. And so you can combine that with a pillow, you can combine that with a cushion, often helpful. I say often helpful because like I said, there's been other reports of people saying that hard door surfaces are better for their PHT. So keep that in mind. If you do the sit to stands like a sit to stand desk, like regular, I guess... So a starting dosage might be to sit for half an hour and then stand for 15 minutes to half an hour. And then you can just repeat that cycle. That can be quite nice as well, but just taking regular walk breaks as well. If you sit for half an hour, then go out and walk for two minutes and then come back, that can make all the difference as well. Um, regarding the isometrics, yeah, I think maybe just go back to the episode on flare-ups. Um, it talks about when to apply those isometrics and how to progress beyond the isometrics in those particular phases. So keep an eye out for that one. So thanks Lauren and thanks Kirsten for those questions. Um, we have two more coming in. Kelly said, I'd love to hear more about the likelihood of runners developing PHT if they have weak hips or hip impingement. So I guess we're talking about hip strength. Hip impingement is sometimes with the ball and socket joint which is the hip, sometimes the socket can be a little bit deeper and can pinch the thigh bone into the labrum or the cartilage or those particular structures and cause like say like a bit of a pinch. particularly with like hip flexion or certain rotation movements. And yeah, if there's a, I guess a link between the two. So my answer, the research seems to show, especially when it comes to runners that say strong runners get injured at the same rate that weak runners do. And doesn't make a whole lot of sense if you think about, you know, capacities and you think about, um, training errors, but Each runner seems, in my eyes anyway, each runner seems to flirt with their own limits. Like, no matter how strong you are, you might have a higher capacity to tolerate running loads, but that particular runner would still flirt with that same boundary line. of their maximum capacity until they get injured and are forced to do reduced amounts, or they're just constantly floating with that boundary line. Similar to someone who is quite weaker, their capacity is quite low, but they're still floating with that same line. I think just as runners and as humans in general. We like to do more, we like to push ourselves, we like to challenge ourselves and we like to see where our limits are. If we are pain free, we like to do as much as we can. Very self-driven, got a race that we need to prepare for or do the best we possibly can in that race. So we're constantly flirting with that. And so people break down, people get these overuse injuries or these training errors, these injuries leading to training errors. because we're constantly floating with that limitation. And so similar to running technique, similar to strength, similar to, I guess, mechanics, biomechanics, there's no right or wrong, provided that there's no. training errors. I guess if you have a low cadence, yes, we need to correct that. If you have an over stride pattern, yes, we need to correct that. Anything else like the body can adapt to the body should adapt to provided you offer that adaptation. You foster that right environment for adaptation. And there's no training errors present. So if you do have weak hips, Yes, you can train within your capabilities and then slowly build up from there and you shouldn't develop PhD. I had this analogy around a tightrope walker, which I've talked about on the Run Smarter podcast a couple of times, which I probably need practice with this analogy because I'm not too sure how this is, if it's really coming across the same way it is in my head, but imagine you have a tightrope walker. walking across a chasm, say at the Grand Canyon, a nice thin board that this tightrope walker needs to walk across. And they have that really long balance beam that they hold onto in the center of, and they have to walk across. And as they're walking across, there's certain winds, certain environmental conditions that can make it a bit challenging. In this scenario, this tightrope walker, the conditions, the wind that's blowing is kind of like your training, the training loads, the strengthening exercises that you have put upon yourself. And if you were to fall off this tightrope, this is signifying an injury or symptom flare ups. What we can do is just offer the body ideal environments that you don't fall off. But if your training levels this is like increasing the amount of wind that's blowing against that tightrope walker and can increase the likelihood of them falling off. But what about if we could increase the width of the rope? or the bar that they're walking across, if we can make it more of a plank rather than a really skinny rope, that would definitely help reduce our risk of falling off. Especially, well, even if there was higher winds, if the conditions weren't really that favorable, the wider plank would ensure, or not ensure, will reduce our likelihood of falling off. That plank is kind of like ideal mechanics. It's kind of like having your ideal cadence, your ideal step width, your ideal strength, say hip strength. It can contribute, but you still need to foster the right environment because you can have a thick, you can have a very wide beam. that you can walk across, but if the winds are a tornado, you're still gonna fall off regardless. But there are ways that we can slightly widen and slightly put that into our advantage. And so that comes with avoiding those training errors, you know, being quite strong, just being really sensible with your loads, having ideal recovery, making sure you're sleeping well, making sure your stress management is under control, all those sort of things. And so that's what I think about when it comes to the relationship between PHT and things like mechanics, things like running mechanics and hip weakness, that sort of thing. So yes, hip strength can help with widening that beam a little bit, but... And also I should say when it comes to rehab if you do have pht Strengthening your hamstrings, but also strengthening your glutes is highly recommended. So the combination of the two In regards to hip impingement, I think that's unlikely for runners usually hip impingements or like a ephemeral acetabular impingement, this FAI, is actually quite common for a lot of people, but just asymptomatic. I think I do have that a bit. My hips do get quite pinchy if I train inadequately. But for runners specifically, hip impingement isn't really that problematic because it's not producing a lot of hip flexion. We don't really put ourselves through a lot of range of movement when we do run. The hip extension is about 15 degrees and knee flexions maybe about 20, 25 degrees. So we're not going into high levels of knee flexion. We're not bringing our knee like really close to our chest, which is usually high hip flexion and sometimes hip rotations tend to stir up hip impingement. So maybe for like cyclists, maybe for dancers or martial arts athletes. those sort of things can be a bit problematic. Or if maybe you're sitting a bit, if it's being stirred up from sitting, maybe you sit in low chairs or something like that, and then you get up and run and it's a bit grumbly and you feel pain during the run, but it's not necessarily the run that's made it worse, it's the sitting or the cycling or something that's happened prior to that. So hopefully that made sense. This podcast episode is sponsored by the Run Smarter Physiotherapy Clinic, which is my own physio clinic where I help treat a wide range of PHT sufferers, both locally in person and all over the world with online physiotherapy packages. In the years I've been self-employed as a physio, close to 70% of my entire caseload has been helping people with proximal hamstring tendinopathy, which is why I decided to launch this podcast. So if you're building upon your own rehab knowledge through the podcast, but still require tailored assistance, I'd love to be on your rehab team. Whether you are a runner or not, head to runsmarter.online to see your available options for working together. If you're still unsure if physiotherapy is right for you, or if you need a rehab second opinion, you can always schedule a free 20-minute injury chat with me. Find the free injury chat button on my website or in the podcast show notes to be taken to my online calendar to book in a time. Let's move on to our last question. As I scroll down, it's from Edrick. Given a lot of treatments seem to be the same for any other differential diagnosis, so... like he says, build strength, mobility and resilience. Is there value in getting a more thorough diagnosis? Would it help with specificity of training and rehab? This is a really nice question because I think that I followed a very similar formula for a lot of different injuries. So in most cases, especially because I work with runners as well, There is the process of, okay, where is their current capacity? What's irritating their symptoms? Let's modify things to settle down those symptoms, but then introduce things to build up their capacity, especially for what their goals are. Maybe they want to return to sitting. Maybe they want to return to running. Maybe they want to return to swimming triathlons, what have you. And the process itself is very, very similar for shin splints, for Achilles tendinopathies, for plantar fasciitis and for PHT. And so Edrick's question is quite insightful and he's recognized that for treatments, the treatment plan is very, very similar. So it doesn't matter what the diagnosis is if we just follow those same things. And so very similar to Chitra, the diagnosis isn't extremely important if the rehab that you're doing is continuously becoming effective. If you're seeing benefits in that particular management plan, then it doesn't really matter what the diagnosis is. You can become more specific for a specific diagnosis. For example, like if we... assess a patient and we treat someone. First of all, we want to rule out red flags. So red flags are usually like serious medical pathology, like serious diseases that can masquerade as certain pains or can masquerade a certain pain patterns or pathologies and other sinister, I guess, events. So we do want to rule out a suspected say stress fracture, because that management would be extremely different if it came back as something else and not a stress fracture. So making sure we've ruled out those sort of things. Yes, we can specify specifically to PhD, like I said, sitting can be we can modify the sitting and we can avoid excessive static stretching. So stretch and hold type of stretching that you're not ready for, the tendon doesn't have capacity for, but... We'd pick that up already because if someone does have PHT, they would report that sitting is poor for them, like sitting for, I don't know, 15 minutes might be too much. And if they do a yoga session or a Pilates session, that flares them up as well. So we kind of just base it on the symptoms as well. And if someone came in with PHT, very mild form and sitting doesn't irritate them, which does happen. I do see these clients all the time. I wouldn't recommend not sitting or I wouldn't recommend modifications in their because they're tolerating sitting fine. And so it's based on the person, it's based on the symptoms. So we may not necessarily specify to the specific diagnosis, but we do specify for their current symptoms and also what their rehab requirements are. And an example would be Like I said, someone with pain, with pain sitting, we'd modify that. If they had pain squatting, like if they even just squatting to pick up their kids or to put on their socks, or if they're squatting in the gym with some high load, and that's causing irritability, then we would first of all see if those pain limits are within acceptable boundaries. But if they're not, then we would just modify things with, and then once we modify those things, we'd build them up. So we might start, for an example, squats but doing isometrics. We might reduce the range of movement of their squats, we might reduce the weight of their squats to create symptoms that are within acceptable boundaries and then build up from there. But then it just depends on what they want to return to because they just might want to return to sitting for their work and that's it. Maybe they want to return to cycling or triathlons or Iron Mans or sprinting. All of these things just depend on what the goals are, will depend on the actual management. And so, Really nice, Edric. I think, yes, we do follow a very similar process. We do, we do recommend building up strength, building up capacity, returning people back to what their goals are, but then trying to create resiliency in regards to once they've returned to their running or whatever goals they have, is building up that capacity so high with strength, but also power, resiliency so high that the odds of a flare up or odds of setting back are extremely low. And I hope that answered your question. Again, similar to Chitra's answer. we're just making sure that we apply something, seeing if there is improvement, seeing if there is continue on with that improvement, if you're not seeing improvement, it's worth modifying and changing. So as we recap, when it comes to say, Edrick's question and Chitra's question, always making sure that we're making, always making sure that the management is effective. And if it's not with really rigorous, I guess, methodical approaches to the rehab, change it. Make sure we change it for the better and observe once again, just like a scientist would. If they're not seeing the results, change the method, change the structure, and again, wait for results. And a lot of these success stories as well, they've tried so many things, but keep modifying, keep reiterating until they found something that actually worked for them, and then they stick to that and progress that. hope you guys have seen that very similar pattern. Continue with the rehab, yes. Continue with the recap, yes. Sitting, sitting modifications might be needed during a flare up. Make sure that you can take some walk breaks or some standing intervals, those sort of things. And then with hip weakness, with any injury in general, just think of that tight rope walker, trying to think of either narrowing, widening that beam. or being very gradual with your, the wind or the, the outdoor conditions that you give yourself. Keep that in mind. Hopefully that analogy has worked. Um, I'll do my best next time just to make sure that I am repeating it, um, in a way that makes sense for me and hopefully makes sense for you. If I didn't get to your question, I apologise. It will be in the next Q&A episode, which I'll do in about four to six weeks time and look forward to bringing you more Q&A's in the future. So if you do see a post either in my Facebook group or the other pht Facebook groups, feel free to reach out with any other questions. Alright guys, take care for now. 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.