Q&A: Pain Behind Knee/Max Deadlift Calculations/Cross Training/Pain Guidelines

: On today's episode, I'm answering all of your questions with another Q&A. 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 of course, bust the widespread misconceptions. My name is Brodie Sharp. I'm an online physiotherapist, recreational athlete, creator of the Run Smarter series and a chronic proximal hamstring tendinopathy battler. Whether you are an athlete or not, this podcast will educate and empower you in taking the right steps to overcome this horrible condition. you the right knowledge along with practical takeaways in today's lesson. Let's get stuck into it. Hopefully you are enjoying this format because this is, I guess, the third Q&A that we've done in a row and gives me a chance to kind of rant, but also gives me a chance to answer your questions because most often if you have the same question, a lot of the audience, a lot of people listening to this will have the same question and You know, we sort of go off on tangents here and there, and hopefully those tangents helps you learn as well. I've got four questions for today's episode, and the first one comes in from Shastri and says, My hamstring pain is right behind the knee towards more attachment. Should I go through the same exercise and recovery regime as PHT? Okay, so I know you say that it's hamstring pain. PhD is proximal hamstring tendinopathy. Hopefully most people know that, but it stands for like proximal means closer to the midline or proximal would be closer to the origin, which in this case for the hamstring would be the sitting bone. So that's why it's proximal hamstring tendinopathy with it where it attaches describing where it attaches or where the location of the tendinopathy is. And so Yes, it's the same muscle. It might be the same muscle, but because it's in a different location, those tendons will have different demands and different requirements, and therefore should be rehabbed slightly differently. And it only needs to be slightly differently because if you can get the hamstring really strong in whatever domain, that be hamstring curls, deadlifts, running, cycling, if you can just build up the strength. you are concurrently building up the tendon and all of its tendons. The overall unit, the capacity of that overall unit being the muscle and the tendons will slightly start to rise. And so that's always a good thing because that gives us a better chance to exercise without breaking down, builds our resilience. But we can adjust and tailor the rehab to meet certain conditions. So what we talk about with the proximal hamstring tendon is we want to tolerate certain levels of compression. We want to, if it's quite irritable, we want to start exercising it outside of compression, that being with say hamstring curls, and then we slowly want to build up its tolerance to tolerate compression, that being You know, we need the tendon to tolerate compression everyday life. When you run, when you sit, when you bend over all those sorts of things. But the tendon that's distally so towards the knee and sort of attaches behind the knee that doesn't need to go through compression. So those stages, and if you aren't familiar with the stages, it's one of the earliest episodes I've done on this podcast talking about the three stages, stages of rehab. Um, you won't need to do that and you can maybe suit the conditions to better tailor for the tendon more distally. So some things that I could recommend for you would be, uh, hamstring curls. And if you can start, I guess, depending on your symptoms, if you can tolerate that end of range hamstring curl. And I'm talking about a hamstring curl either at the gym. where you do a prone hamstring curl with a weighted machine or with like a resistance band. I don't really recommend ankle weights. Ankle weights sort of, what you wanna do when you apply tension is you want it to be tough throughout the entire range of movement. So it is tough through the entire range of movement with a machine when you have like a cable or a pulley or something that just has weight behind it. It'll be that same resistance the entire time. for a resistance band, it's kind of easier to start and then harder to the more you pull just because it creates more and more tension. So that's less than ideal, which is why I always have the hamstring curl machine as like the number one priority. But the ankle weights, it's sort of like, it's tough at the start, but because you curl, And the more you curl, the more you sort of become perpendicular to gravity. Like the 90 degree angle is kind of like at its easiest. And so we do want to keep those in mind, but if you do have, again, I'm trailing off, if you have your distal hamstring and you apply tension, do a hamstring curl, if you have that with the resistance band, make sure that you're already applying resistance, make sure it's already under resistance. before you start that action, because we wanna apply the most tension at the start of that. So you might only curl maybe half range of movement or even a quarter range of movement, but the entire range is under a lot of tension that would sort of bias the distal part of the hamstring. You can also do long lever bridges and sometimes even bridges with completely straight legs. You can put a weight on your hips and move up into a bridge with almost the legs completely straight. That would also put a lot of tension on the distal part of the hamstring. So slight adjustments you can make. And so to answer your question, yes, you want to increase the strength of the entire hamstring complex, but some slight adjustments you can make depending on what tendon you're sort of after. I'd also want to make sure that it is the tendon itself. If you've got pain behind the knee. and you believe it's the hamstring, you wanna make sure that diagnosis is correct because it could be a few things. It could be a popliteus muscle, could be a pes anserine tendon or bursa, could be ITB, could be a Baker's cyst. There's a few things that can happen around and behind the knee. So the treatment for each one of those is completely different. So just make sure that you're on the right track with that. Next we have the lovely Alicia who asks kind of a two-phased question. Number one, how do you determine the max weight you should use for a specific exercise? Is there a calculation or formula? And part two, once you're in the maintenance phase, can you reduce the weight used and it still be effective? For example, if I have over several months progressed to 70 pound deadlifts, can I reduce the weight to 60 pounds and it still be effective? Thanks Alicia, good to hear from you. Let's go back to part one of your question, which is, is there a formula or calculation to work out how heavy your exercises should get? We're gonna use deadlifts as an example, because that was in your example. And it's a solid question. I get asked it a couple of times. How... much should I progress? Because I always am in the mind to always progress, get heavier, lift heavier, get the tender to adapt to slow heavy load, I say it all the time, but is there a limit? I think determining your limit, first of all there is no calculation or formula, because everyone's completely different, but I would sort of keep three things in mind to determine your own tailored calculation. One, Um, you want to continue progressing if you're still experiencing symptoms. That's in my opinion. Um, if you're getting better, the heavier you go, but you still have symptoms, let's keep going heavier. So continue progressing based on symptoms, but also the demands because everyone's a little bit different. So Alicia, I know you're not running marathons. Um, I know you have. a bit more of a sedentary goal to have maybe around sitting and just bending, gardening, just doing, you know, day to day sort of manual labor if required. So those sorts of things are your goals and your demands. And we don't have any marathon or trail running, sprinting sort of ambitions. That will be different demands and also future goals. So The demands would be kind of what type of athlete or what type of person are you? But the future goals are once you're better, what do you wanna strive for? So that might be marathons or sprinting, or even just sitting. If someone's not a runner, their future goals might be to sit during a long haul flight, or I wanna go on a road trip in a year's time and I wanna be able to sit in the car throughout that time. That might be a future goal. And... So if your demands are different, if we look at a sedentary individual compared to a triathlete, their demands are completely different. And so what, how many, how heavy their deadlifts need to be is probably completely different because we need to challenge, um, different aspects. And when it comes to future goals, so we can have two, five K runners. One has a goal to run the fastest five K they can possibly do. The other wants to do 5Ks and eventually go to a slow 10K, then a slow marathon, and then maybe some ultras. That's two different scenarios and we need to prepare the tendon differently for those two scenarios. And so this is where we need to say, okay, how heavy do those deadlifts need to be? How much do we need to train? How explosive do we need to be? And base our assessment on that. because the idea is to sort of raise the capacity in your tendon and your hamstring further than any goal or any future goal that you have. That is like, it's easy to say, it's just got that theory that if you wanted to, if you want to get to running a marathon, let's get your hamstring strong enough to tolerate double a marathon. If you want to run 42km, let's try and get your hamstring to tolerate 50km. If it's 100k ultra, let's get it to tolerate 150k ultra. That way you're not exceeding your capacity and you've got this big, robust, resilient tendon where the capacity is so high that you couldn't possibly surpass it in your training. doesn't happen in real life, but that's the desired goal that we want to have. And so if we then go back to your goals and say, I just want to sit for two hours. That's my goal. That deadlift requirement or, you know, the progression of those weights is completely different to someone who wants to run a fast marathon. So yes, that's sort of what I think about the other was once you are in the maintenance phase can you reduce the weight used and still and it still be effective. So let's just say Alicia has a goal to sit for two hours and do some housework, clean the house, vacuum, sweep, do some gardening, maybe go to a movie and spend some time with her family, pick up her grandkids and just wants a tendon to tolerate all those things. Let's just picture that. She's built up to 70 pound deadlifts and now has no symptoms. I would say that in that scenario, you could probably try reducing it down to 60 pounds if you want. You can keep to 70 pounds, nothing wrong with that. If you want to reduce to 60 pounds, that's fine as well. But just keep in mind that the capacity of the hamstring and the tendon will slowly reduce over time if you drop it down to 60. It's not going to reduce by a lot. It's going to reduce very gradually, but it will happen. Is that 60 pounds enough for you to maintain the goals that you have? Probably. There's no formula. It's impossible to determine if, you know, that's the right amount. But I would say most likely. And when it does come to rehab, I will say that it is hard to gain, easy to maintain. I've said a couple of times on this podcast, hard to gain, easy to maintain. So building up the strength and tolerance and resilience does take work. It takes several months building up your dead lifts, building up that strength, getting stronger and stronger and stronger. It takes several weeks, a couple of months. Um, but then once you've achieved that, it's really hard to lose. If you just keep a maintenance phase of like once a week, doing the same weights and that's it, then it's gonna take a really long time for that tolerance, that resilience and capacity to start dwindling. But it will do it gradually. If you completely rest and completely stop, depends what else you're doing throughout the week. If you're bedridden for two weeks, then you will lose some strength. But if you're just active, moving around, doing some weights here and there, doing some gardening, then the strength itself will be maintained quite easily. So a few things to keep in mind. I hope you are satisfied with that answer, Alicia. 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. Okay, moving on to our final two questions. We have coming in from Kimber who says, I love running long distances in brackets, marathons and 50Ks and am willing to take a break. while I focus on recovery for my PHT. Do you have any suggestions on other cardio that wouldn't aggravate it? Thanks, Kimba. I have a couple of recommendations for you. And I would say that you can just dial back the running if that's what you love, because we don't want to take away something you love if we don't have to. And particularly if you aren't... that fond of other cardio options. Like if I have a triathlete that I am working with and running's the only thing that flares them up, then we can easily back them off running or dial it back because they love doing these other things like swimming and cycling and maybe strength training. But we wanna make sure that your rehab experience is a positive one because if you just theoretically, if you hate doing any other cardio and you have to stop running and you hate not running, then it's not a great experience and that's those emotions are going to impact and hinder your recovery as well. So, tier number one, or I guess, you know, stage number one would just be doing less running, maybe less intense, or dropping the speed or dropping the heels or doing something to modify so you can still keep running and still be proactive with that. Um, and then, you know, solely focus on your PhD and build up and let symptoms be your guide. Um, but that doesn't really entirely answer your question. So I do have a few other suggestions. If any sort of running aggravates the hamstring, then let's fall back to the next tier of some sort of cardio options. It's sort of look like running because you still want to maintain a high tolerance for running because. Otherwise, it's going to be a bit more of a struggle returning back. If you've spent some time off, the body's going to sort of decondition itself and. The return back to marathons and 50 Ks are going to be, um, hindered. There's going to be a lot of resistance there if you haven't done it for a while. So if any sort of running flares you up, our next fallback is let's try and find some cardio options that actually look like running or challenge you similar to running so that, you know, we preserve a lot of that stuff. So my ideas would be. like fast walking or hiking, definitely like it looks like the running action, can get quite a workout with hiking, walking uphill, those sorts of things. The elliptical trainer is another one, very much looking like a running action but none of that pounding or eccentric demands because the leg isn't swinging in free space so the hamstring doesn't need to that's sort of like the next tier. It's walking, hiking, and elliptical. If that all aggravates things, if that still aggravates things, we've got the next tier, which is you can try cycling. Cycling is a big sort of leg workout, which is why we put that in there. But cycling's hit and miss. I do have some cyclists that I see, I have triathletes that I see, and I have runners who enjoy cycling. And some people with PHT can cycle a lot. Some... not so much. For whatever reason, whether that be the seat or the angles of the bike or what part of the tension has been affected, a fair few variables, but for some reason some can tolerate it, some can't and that just comes with trial and error. And so that would be my next tier is to, if you haven't done any cycling before, you're not sure if the hamstring will tolerate it, try it out a little bit, see how it goes, maybe try 10 to 15 minutes. If that's fine, maybe go to 20 to 25. If that's fine, 45 to 60. And along the way, just if symptoms allow, then you can just do more. And if you can do that, then you're getting a good cardio workout, you're pumping the legs and the transition back to running will be have less friction. But if cycling aggravates it, I've got another tier, which would be things like jump rope. and just other cardio, like create your own cardio circuit. That's what I like to do because we're picking stages that, um, aid enjoyment. So I've done this with a couple of clients in the past. Jump rope is just, you know, jumping on the spot, preserves a lot of calf strength, a lot of hip strength and is a tough cardio workout, but that can be included with other stages, like we can pick four or five, um, stages and do our own circuit class. So that might require push-ups or tricep dips or star jumps or burpees. Those sorts of things that you spend like 90 seconds at each stage then move to the next stage and do four rounds of that. Everyone's going to be it's going to be tailored different. The level of intensity, the numbers, the duration, they'll all be tailored based on your fitness levels and what we think that the hamstring can tolerate. that could be a nice option as well and we're tailoring it to you based on what you can tolerate. The other one, I'll mention swimming as a cardio option because definitely a good cardiovascular alternative but some again some people tolerate swimming really well, others not so much and the straight leg kicking action can aggravate some people with phd and for my rehab, I guess ethos or philosophy, I have people do a resistance band like a standing hip extension. So standing on one leg, the floating leg stays straight but then kicks back against resistance. If that's painful, then perhaps some fast kicking in the pool will aggravate the tendon. So we either, you know, keep to very light kicking. or put a floaty in between your legs and do no kicking, but can still be a good option. But I've had people with PHT that can't tolerate much running, but they can kick all day long in the pool. So again, we can trial those. Kimber, hope that helped answer your questions. So we've got just dialing back the running, option one. Option two, you can use like an elliptical, walking or hiking. Option three, try some cycling. Option four, some... cardio circuit that you can just create yourself. And option five, you can try some swimming if symptoms allow. Julia is our last question for today and asks, should I be pain free post exercise to progress or is low level but stable pain okay to cautiously progress? Definitely. want to progress if there's still a little bit of pain. I'd say not to try to focus on being pain free, try to focus on baseline, baseline symptoms. Your symptoms, your baseline symptoms may not be pain free. Your baseline symptoms may be a one or a two, maybe a two or a three, but recognise where that baseline symptoms are in the last couple of weeks, when is it the most settled? When have you not irritated, aggravated, and it's just there in the background? That would be your baseline. Some people do have pain-free baseline levels, but then we need to follow our pain rules from here. So pain during, for most cases, should be less than a roundabout of four out of 10, and return to baseline in less than 24 hours. It's pretty good guidelines to follow. If... elevated. If you do say your deadlifts and squats and lunges and pain is elevated afterwards, try to see how long it takes before symptoms settle. Is it two hours? Is it 12 hours? Is it 12? 24? 48 hours? This will help create sort of reasoning for whether to progress or not. The reason we don't aim for pain free is tendons like slow heavy load And there's tons of studies to show that even doing it through a bit of discomfort, the tendon adapts really well. And if we aim for pain free, we run the risk of not progressing quick enough. I have seen this time and time again. People do body weight bridges and they've been told by their PT to do these body weight bridges and it's a little bit painful. It's a two or three out of 10 during, returns back to baseline pretty quickly, but they're scared to progress because they have pain of two to three and they think that progressing the exercise that two or three will get to a four or five. And so therefore with that justification, they just keep to body weight bridges for six to 12 months and they don't see any progression. And Like I say, it's a pattern that I've seen quite often. People don't like being in pain. I get it. If you haven't been told these lessons, I can see how you're naturally gonna gravitate towards lesser pain, but we need to sort of pass a sort of a threshold. You're in a bit of pain, but you're also at the same time, not giving the tendons the right environment to get better because like I said, they like slow, heavy load. bridges, bodyweight bridges doesn't do anything. And so when I see a client with that particular history, we try slow, heavy deadlifts. It might not be that heavy to start with. And the range of movement might be quite restricted. Might be a quarter to a half range of movement deadlifts. But at least it's something to start fostering that adaptation. Enough. wait to sort of trigger a response to get better. And yes, that might be a two or three out of 10, but if it returns in less than 24 hours back to baseline, we then progress. Keep that in mind, hope that is okay. But I will say on top of that, I do change these pain rules depending on the person. Everyone's completely different and there have been some people and I said where I change these rules and say, look for you, maybe a pain of less than two out of 10. is what we need to aim for. And maybe it needs to return to baseline in less than 12 hours rather than 24. And... we might've tried the earlier lesson for returning 24 hours in the past and maybe we're just not seeing the improvements we're making or maybe is this really sensitive and yeah, we're just not seeing the right progression that we wanna see. And so we have justification or, you know, the method to sort of change those parameters. But I recognize that it's not all pain's not just from the tendon. Pain is biopsychosocial, which I have pain episodes that you might want to listen to if that doesn't make a whole lot of sense. But you could have the tendons really enjoying the weight or the exercises, but pain really spark and be flared up for 48 hours because psychologically or socially it could trigger pain or trigger sensitivity. And so as an example, you could do deadlifts and the tendons really love that weight. really love that environment to get stronger. They said, yes, finally, we have the right conditions for strength, but the whole entire time you're thinking, will this tear my tendon? I mean, a lot of pain during this deadlift, is this wrong? Maybe I need surgery after all, like these sort of catastrophizing thoughts during the deadlift can spark a lot of pain and create a lot of pain afterwards because the brain feeds forward a lot of these thoughts and said, and says to itself, this is a big deal. We need to produce pain because we're doing something wrong. Because you've convinced yourself that it's probably the wrong thing to do. And so you might flare up for a couple of days and we might assume or tell ourselves that was the wrong weight when in fact it was right. So pain is extremely complex and we need to recognise all of those patterns, the bio, the psycho and the social elements, which is why I have all those. different episodes to discuss all those elements. But just to let you know that the pain rules, those pain guidelines might fluctuate from person to person. But also Julia, last but not least, my final pain rule is that pain and symptoms need to improve for the most part, if all goes well, week by week. Week by week, you should notice a noticeable improvement. So, If you're not pain free and progressing, we don't want the trend to slowly get worse week by week because that means our management plan is not finding the right balance. But if you do have pain during your deadlifts, if it does settle back down to baseline in 24 hours, and you're seeing that long-term trend of improvement week by week, then we know we're on the right track. So hope that answers your question. I... I'm more than happy for people to ask questions that have already been answered on the podcast, because I know I have a ton of episodes and sort of trying to review them all is a bit daunting. Um, so thanks for submitting your questions. I'll come back in the, um, next episode. I think I might have another success story on the horizon, which I know you all love. And I'll be doing some solo episodes in the next couple. And I don't know, maybe every couple of months, we do another Q and A and look forward to hearing, reading and responding to your submissions. And until our next episode, good luck with your PHT rehab and take care. 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.