Q&A: PRPs, MRIs, Medications & Return to activity

: On today's episode, I'm answering all of your PHT 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. Thank you to everyone who has submitted their questions on social media, particularly through the PHT Facebook group. I've got a ton that have come in of haven't been able to answer all of your questions and I know some of you have. submitted multiple questions. I'll try my best to kind of group them into certain bundles. I know I've kind of combined a few questions in here to answer them at all once. And particularly those questions that some people have agreed with, like someone might have mentioned something about, you know, returning to sport and someone else comments after that being like, yeah, I really want to know about that as well. And I've tried my best to answer as many as possible in the time that we have and kind of group them in together. And so I've got a fair few questions coming in. So let's start from the top. I had Carla asked a whole bunch of questions and I've tried to pick the ones that are that I'm best suited for and what I can find answers for. So Carla asks, when can I apply heat? also asks, does ice and ibuprofen, which is an anti-inflammation pain reliever, does that impede healing? And can PRP help PhD? So we're talking about heat, we're talking about ice, we're talking about anti-inflammation, and we're talking about PRP. I've tried my best to, I guess, give my insights, give what the research shows, expert opinions. And we're going to start Um, I have, I think I've talked about this on the podcast before injury management. It used to be rice. Everyone used to remember the rice acronym rest ice compress elevate. So there was rest in there, which, you know, this podcast already shown is probably not the best ice, which, um, is now getting phased out, compressing elevator still in there. Um, that was a very old acronym for acute kind of injuries. If you roll your ankle or something. But they've now replaced that with a new updated acronym, which is Peace and Love. A lot of letters in there, but the Peace is more to do with the acute side of things. The Love is more to do with the after the one to two days of the acute phase, going into load, optimism, vascularisation, exercise, so getting out of that rest phase and starting to move around. But the Peace side of things is Protect, if needed. So if you roll your ankle, maybe don't go running on that ankle for a couple of days. So protect. Elevate is in there, but the A in peace is avoid anti-inflammation. And this goes along, I think the same borders of ice because for ice, there's no research to show that it is of benefit. And for anti-inflammation, there's shown to be of detriment. And then we've got C and E which is compress and educate. So compress, you can compress a injury if there is inflammation present. This isn't just for PHT, this is across the board for all injuries. And then there's educate, educate about the injury and how to get better. I did find a 2015 paper, it was titled Tendonopathy, an update on the pathophysiology. And it mentioned corticosteroids, which are still an anti-inflamm medication can impair local collagen synthesis. So just like the rebuilding of a tendon resulting in tendon atrophy, which just means tendon, um, just becoming less robust, more wasting away, uh, reduction of tensile strength and a decreased load to failure. Um, hence the decreased load to failure. And so corticosteroids, anti-inflamm, ibuprofen is kind of classed in that. just not good for tendons, especially if carried over beyond it's like three to five day intended purpose. It might reduce symptoms just because it does have a pain relieving kind of medication in there. So you might feel better. And there's also the potential of a placebo effect when you do take medication, but it's detrimental to tendons, especially when taken longterm. That same paper said also, local steroid injections in the vicinity of the Achilles and patellar tendon and in the presence of severe tendinosis or a tear are frequently discouraged due to the concerns with respect to rupture of heavily loaded tendons and or impairment of tissue repair where disruption is already present. So they've mentioned in here pretty much on the side of corticosteroids. It's not recommended just for in tendonopathies in general, just because we know it's discouraged because of the disruptions it has to the tendon. Same with ice. Ice might help decrease symptoms just because it numbs the area. So just because it decreases symptoms in the short term or the immediate term, I should say, doesn't mean it's doing much to heal the tendon. It's just dulling, numbing. pain signals. And so people can come quite reliant on ice because they do get that immediate symptom relief, but I don't think it's having too much of an effect. So it's kind of in the same way. I think for ice, it's kind of indifferent with healing. It's so immediate, like it cools the area, symptom relief, but within, I think, 10, 15 minutes after icing, it's back to its normal temperature. So it's not really doing a whole lot. I did interview Peter Maliaris. I think that was early days of this podcast. You can see that interview and he even mentioned he is like world renowned, like one of the top experts in tendinopathy management mentioned. He just doesn't like injecting anything into tendons. You shouldn't really be injecting things into tendons, maybe around the surrounding tissue, if there is inflammation or tendon sheath issues, that's something different entirely. If it's a tendinopathy. If you got PHT, you shouldn't really be injecting things directly into the tendon. Um, and he said just because PRP, um, steroid injections, all those sort of things, when it comes to the research, it just doesn't compare. Like there's no benefits when compared to a placebo or a sham therapy or those sorts. So, um, when can I apply heat? I guess you can apply heat whenever you want. Um, I don't think there's too much of detriment to heat because there's no inflammation present. Sometimes with an injury like a rolled ankle or something that has direct trauma, sometimes we might shy away from heat. The research is still debating whether heat or ice is best for those sorts of things, but heat can be okay. Heat increases blood flow, blood flow increases healing. So potentially that can be. success stories in the past. Todd Chinetsky who applied heat, started applying heat with his H-Wave I think it was called and noticed some profound benefits. So when can you actually apply it? You know when it starts feeling better I guess you can apply heat and if it's not, if you if it feels better then you can do that. I don't think there's any contraindications or warnings of when to actually apply heat. Okay so Carla's questions, when can I apply heat? Does ice or ibuprofen impede healing? Can PRP help PhD? Hopefully I've answered all of those and we can move on to Cristobal. Okay, chronic PhD sufferer, we're doing disciplined strengthening exercises, but still getting discomfort with sitting. However, MRI shows no issues with the tendon. Can this still be coming from the tendon if nothing is seen on MRI? It's an interesting question. I do think like something can some pathology, even if it's just a mild pathology within the tendon can happen without being seen on MRI, but you can also identify a tendinopathy on MRI. So it might be a false negative. Pretty much because you have a look every tendons different in terms of its pathology, whether you've had it for a couple of weeks, a couple of months, couple of years, they're still different parts of the tendon that are affected, the severity of the tendon can come into question. And so every tendinopathy is extremely different. I did find a 2014 review paper, it was titled drug induced tendinopathy, but it did mention scans on it and what scans might show. And so it said that ultrasounds and x-rays, chronic tendinopathy may be seen as a thickening like a thickened tendon with blurred images instead of just like this well-defined kind of tendon that can be seen on ultrasound and x-ray and those two things can also identify tendon calcification. So just like they're starting to be well calcified calcifications like bone they can start to produce some like calcification within the tendon which those But they do say a ultrasonography is the recommended scan of choice, pretty much based on like weighing up the cost as well because we know that MRIs are quite expensive. But that particular scan can find a loss of parallel fibre alignment. So it's from what I gather quite high powered and can actually look at the fibre alignments of the tendon. And can also test it dynamically. do a particular movement, do a particular test, and it continuously assesses the tendon, whereas with an MRI, if anyone's ever had an MRI, you have to stay completely still, and while they scan it, so they get a static image rather than the ultrasonography that can do it during dynamic movements. And that ultrasonography has become the cornerstone of the investigation of tendon abnormalities. They do mention MRI, they say that it can find local tendinopathies as seen as a focal tendon like misshapen, like the spindles within the tendon start to become a little bit like the shape starts to change and become more rounded rather than straight. And for global tendinopathies, like I say, the edges on the outside of the tendons start to undergo some changes. And produce more of a global spindle shape in the sagittal plane and an ovoid shape in the axial plane. So these scans can pick up on tendinopathies. I reckon there might be some room of a false negative just because if there's a small or focal pathology but it's in the middle of the tendon, it's not on the outside because you can have, it's kind of like they The whole of the donut can be tendon pathology, but all around the outside of the tendon can be healthy tendon. And so sometimes scans like the edges look fine, there's no thickening, there's no like changes but it's the inside structure of the tendinopathy, of the tendon that can have that dysfunction that can definitely pose and present as a chronic tendinopathy. So crystal in your case that might be. might be what's going on. Okay, I've got a couple of ones that I've bundled together here. So Benjamin, how do I reintroduce compression activities? He said as an example return to cycling. Alicia, along the same lines, when can I return back to hobbies such as gardening and roller skating? Norma said I had a PRP and it's now developed into a chronic I had a PRP and a few other injections and is now a chronic PHT. Will I ever get back to hill walking? All of these I can kind of answer in the same way because without going into individual unique circumstances, which I'd need more information to answer every single one of these, but broadly speaking, we want to do what we call focusing on your rehab ladder. So Even though no matter how severe your tendon is, how long you've had it for, how strong you are, you have a certain starting point, you have a certain baseline, like that first rung of the ladder, that withholds a certain capacity that you can tolerate. That might be walking for five minutes, that might be sitting for ten minutes, that might be running only for five minutes, it might be cycling at a certain wattage for ten minutes, like everything. your tendon will have a certain capacity that it can currently tolerate. So that's your starting point. Then what you want to do is have at the top of that ladder, where do I want to return to? You need to be specific. Okay, is it gardening? Okay, for gardening, I need to bend over, pick some things up, maybe carry up to 10 kilos and maybe do that for 15, 20 minutes. that can be the top of your ladder. If it's cycling, it might be 20 minutes at, on average, 180 watts. And for hill walking, it might be 30 minutes of hill walking at an incline of, you know, 8%. If that's at the top of your rehab ladder, we then need to develop some sort of rungs in between that ladder to bridge the gap and start building up the capacity. And exactly how you do that, that's where the rehab comes into it. That's where strengthening and trying to become more specific to that tailored goal becomes. So if we use cycling as an example, again, depending on what you can currently tolerate, but we might do weighted step ups, we might do lunges, we might do those sort of activities that involve like a single leg push down, which is kind of like a pedal stroke. we might do something a little bit more powerful or a little bit more speed work because cycling at a particular cadence can be quite fast at times so you're ticking your legs over quite a lot. So that might be doing very fast theraband hamstring curls, it might be doing plyometric lunges. But then also with cycling we need to consider sitting, we need to consider the compression of the pelvis on the seat. So maybe getting, depending on the sitting tolerance, building up that sitting tolerance and sort of combining all these things, all these things become rungs on the ladder to achieve your goal at the top of the ladder. And we become more specific each time. And so if you can build up sitting tolerance and you're getting better with speed work and you're getting better with the slow heavy stuff, then we might try cycling, but we only do it for five minutes and we do it at 150 watts. We see how that goes, we use it as a test. And if that's successful, the next time we do a little bit more with a little bit more wattage and eventually bridge the gap, continue bridging the gap to the top of your rehab ladder. If you reach a snag, if in between rungs, if it's a jump from five minutes on the bike at 150 watts to 10 minutes on the bike at 150 watts, and that's too much of a jump and it flares things up, we learn from that. and we build more rungs in between those existing phases. And so it might go from five minutes to six minutes to seven minutes to eight minutes, and we just work within those particular phases. And this is done no matter what the task. Could be gardening, could be roller skating, could be hill walking. We're just slowly building upon that. That might take experience. It might take... expertise might take a little bit of inside knowledge about how the body works and what the demands are. But that's why having a health professional or a coach or someone to guide you can be a really, really good thing and help provide a lot of clarity, especially if you keep falling short of that particular goal, then you need to maybe have some inside knowledge. So understand the concept of that rehab ladder and it'll set you on that trajectory and if you get to the top of that ladder which is 20 minutes of cycling at 180 watts That goal then becomes the bottom of your next rehab ladder because you might set sights now on a race You might want to ride, you know a hundred kilometers and do that as an event and it might have hills involved it might have speed involved and We've now set your first rung, and then we're working up the next rehab ladder. 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 PhD 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 caselo 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. Okay, got three or four more questions to tick off. Jen asks, what core exercises can I incorporate that won't irritate the PhD? Jen, I'm assuming you've tried some core exercises in the past, and it's flared you up. I'm not sure what they are. But based on your question, it's sort of leading that that's happened to you in the past. But like my thing is, Every it requires trial and error because every tendon is different. Um, I've mentioned this on the podcast before, but I've seen so many tendons that, you know, sitting is fine. Sitting is not fine. Um, deadlifts are fine. Running's fine, but cycling isn't. And there's, there's so many things that chop and change and so many aggravating factors, but also things that can easily be tolerated and all depends on the pathology, all depends on what that tendon can tolerate. Um, if you've. gone without sitting for two years because you're fearful of it or stretching, introducing those things once again can be quite a challenge, but someone who has the same PHT but has maintained their sitting or maintained their tolerance to stretch, building up those particular phases would be a lot easier for them. And so you'll have to try a few different core exercises and you can just see based on symptoms. what irritates, what doesn't irritate, then you can formulate that yourself. So you can put your scientist hat on, say, all right, let me isolate two or three exercises and let me see how my tendon feels afterwards. You let the tendon symptoms guide your decision-making process. But I guess for a few ideas, Swiss ball ab crunches should be okay for core-based exercises. So just sitting on those big, those big balls that you then just put your feet against a wall, you're sitting on the ball facing the wall and then you just do some ab crunches, that should be okay. Side planks and just planks in general, they can be okay in most cases. Things that might, a core exercise that might aggravate the tendon, I guess, reverse planks. If people are familiar with those, that can load the tendon. tendon tolerance, it may aggravate, may not aggravate, depends how strong your tendon is, but reverse planks in the past, like just purely by its design and the position that you're in can activate that specific proximal hamstring tendon and therefore if it exceeds the capacity it might get sore. I guess sit ups from the floor, if you ever thought of doing that, might have a little bit too much compression under tension. just that direct kind of rubbing, kind of like sitting but on a harder surface so that might irritate things so just be careful with that but hopefully that gives you a few ideas to play around with. Grace asks, should I be stretching foam rolling my glutes? Also how often should I be incorporating heavier exercises? The stretching is fine, I guess it's just depending on... how it feels, like just again, trial and error. You can stretch the piriformis, the glutes, you can do that kind of pretzel stretch. It definitely won't make things worse, particularly if the dosages are relatively innocent. So if you wanna stretch, let's just say for an example, if you stretch your piriformis, you stretch your glutes, you do kind of like that pretzel stretch, and you do it for 45 seconds only once, and you do that about three times a day. if that's enough to alleviate symptoms and you notice a direct benefit from doing those stretches, you keep that in. You don't, that should be totally fine. Where people become apprehensive with stretching is if they're constantly stretching and that irritates the tendon. But I also know some people who stretch their glutes and foam roll their glutes and they don't really feel much better. They feel indifferent with their symptoms. And in that case, I'd say it's probably not worth it. it's probably not, doesn't have enough bang for your buck. You should notice a profound benefit, even if it's just in the short term, might be a benefit for 10, 15 minutes after doing that. And that's it. But maybe that's clinically justified if you do it for, if those 10, 15 minutes symptom reduction you use to do your exercises, to do your strength exercises, then that could be justified. Grace, you also ask how long or how often should you be doing your heavier exercises? It depends, it depends how heavy you actually are doing them. What I say for rehab is initially you start with light exercises or exercises you can tolerate. And for some people that are quite irritable, quite severe tendons, that level that you can tolerate might be quite low. So you might have to start with bodyweight exercises or really light banded exercises, you might say. In those cases, we can do them every day, simply because the body doesn't need time or much time to recover. So we do them daily, sometimes more than once a day. And as you get stronger, you start to tolerate heavier loads, we then progress their exercises so that you can, we progress them to heavier and heavier stuff. But then as you go heavier, you also need to start doing it less often. So we increase the weights, decrease the frequency throughout the week. And so that might eventually simmer down to about twice a week. So a Tuesday and a Friday, so there's like three to four days apart. And we do that purely so that there's enough time to recover from that exercise. because we'll eventually get to the point where the exercise is so challenging, so heavy, so demanding that there's a bit of soreness the next day, just generic muscle soreness, but you need that one or two days to recover, have another rest day, then get back into it. So it would depend where in your particular rehab you find yourself and just make that justification. Your body will tell you, if you start doing heavy deadlifts, and lunges and you're doing that every day. Your symptoms and the rest of the body, they're just getting a stiff sore and you'll probably know within yourself that you need more time to recover. Lastly, we have another one from Alicia. I'm currently reading the book, The Body Keeps Score, Brain, Mind and Body in Healing of Trauma. Are there any other books that you recommend? I have this book right here. It is by Kerry Jackson Cheadle and Cindy Kuzma. And the book is titled Rebound. And I guess the subtitle, Train Your Mind to Bounce Back Stronger From Sports Injuries. And I've read this book, I've interviewed Kerry Cheadle before, highly recommended this book. If you have chronic PHT and you are struggling with returning to your sport or activity of choice, and you're really feeling at a loss. You're really feeling like you're not getting anywhere. You're getting frustrated. You constantly, your returns back to that sport keeps experiencing flare ups. I would definitely get this if you're really mentally struggling and need a particular strategy. It's called train your mind to bounce back stronger from sports injuries, has a really big focus on the psychological process, the frustrations, the... anger sometimes about being injured, the blame that you give yourself and how to heal your mind, heal your body, you know, change your, your ways of thinking to get back to the sport of choice. So the book is called Rebound. You can get it. I'm assuming you can get it wherever you find your normal books and that would be what I recommend. And so as a bit of recap, heat can be applied whenever shy away or stay away from ice and ibuprofen anti-inflamm medications. When it comes to returning to sport, it's all usually about that rehab ladder, finding your current capacity, finding your end goal, be specific with that end goal and then just develop rungs on the ladder in order to get you there. It doesn't have to be a sport. It can be just... bending down and picking up your kids, it could be gardening, it could be anything that you want that you want to return back to. Do some core exercises and stretches if it feels good in the moment, just trial and error and if it doesn't irritate then it's fine and like I say, get the rebound book because I find that really beneficial. So hopefully you enjoyed, I have my list of episodes that are coming out fortnightly, what do we have coming up? I do have a success story on the horizon, we'll see how that goes. I've also got a couple more posts from Facebook members that I wanted to convert into a total solo episode entirely. I do have on the list how to rehab your tendons without a gym membership. I've got another PHT scientific paper that I want to discuss. It's all about expert opinions on diagnosis management and prevention of PHT. So I've got a ton of things on the horizon and hope you're looking forward to them. I hope you enjoyed this episode. 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.