Q&A: Recovery timeframes & your rehabilitation ladder

: today's Q&A, recovery timeframes and your rehabilitation ladder. 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. to apologize straight off the bat because it is very echoey in here. I have just moved house and I am, um, in my room, which will soon be my, um, physio clinic. I'm converting part of this new house into a physio clinic and At the moment, there is nothing on the walls and there are concrete tiles. And so everything, the sound waves are just bouncing off everywhere. Um, so while I get furniture and I get artwork and it's going to take some time, but we're going to have to manage with a little bit of echo at the moment. I had this idea of starting to do Q and a episodes. I've done Q and a episodes for the run smarter podcast. And I thought, why not just reach out on. um, PhD, like Facebook groups and on social media, ask around and see if anyone has any questions. I'll definitely be doing this, um, in future, in the future. So keep an eye out, um, jump onto say, um, like the running or like say not the running, the proximal hamstring, um, Facebook groups. I'm a part of two of them specifically. And I'm going to be a bit more active on there and start, um, making the Be bringing more awareness to the podcast itself, but I, um, I'll let you know the ones that I'm on at the moment. So proximal hanshering tendonopathy help and support group is one that I'm going to be quite active on. And the other one was the avulsion proximal hanshering tendonopathy and avulsion Facebook group. So keep an eye out if you want to submit some questions, but I've got some really nice ones coming in here. Let's dive in. So Jane asks, I am a chronic PHT sufferer I'm working with a trainer who is also an osteopath. Yesterday I did star lunges, I did isometric bridges, and isometric bridges on the bench, and also side planks with clamshells. Today I have domes in my quadriceps, which is fine, but my hamstring tendons are very sore as well. How can I progress? How can I progress after seven years of PHT and slow loading during those years and still get these flare ups that are quite intense? Okay, so we're looking at a scenario where Jane's had this PHT for several years now. It seems like has. been trying to implement some strength and conditioning, trying to progress her strength training but is still getting these random flare ups which... understandably is extremely frustrating. This is where I like to introduce, which is a part of the title, the rehab ladder. So when this sort of behavior occurs, when you try something out and you think you're going well, like management's going well, symptoms are going well, you're slowly building things up, then all of a sudden you try a new workout or try a new exercise or try a new progression and it flares things up. We often need to go back to the understanding of this rehab ladder. Now, the rehab ladder is say at the first couple of rungs is where your current capacity is, is where your current body capacity, but also PhD tendon capacity, that being strength, endurance, power, is where you're currently at. And as we work our way up the rungs of the ladder, we're progressing in a way that's just following normal progression protocols that still triggers adaptation but doesn't flare things up. Usually at the top of this rehab ladder is where your goals are. So running a marathon, getting back to cycling, sitting for two hours, whatever the goal is, that's what's at the top of the ladder. And what we need to do is find how many rungs within that ladder, how many rungs are required in order for you to get to that end goal? What minute kind of steps do we need to take? that doesn't flare up the tendon, but still stimulates it and adapts it enough so that we can slowly progress. And so we want to make sure that we're addressing these rungs, we're addressing the strength, we're addressing the endurance, we're addressing like speed, power, plyometrics, those sort of qualities that the tendon needs to have. An example that I, um, can come back to, like a personal example, I had years and years of, um, this pes anserinus tendinopathy. So it's like at the back of your knee, I had it for five or six years and it would constantly like flare up when I was running, but it wasn't that bad. I could still run. It didn't really hinder my running. Um, but running was not. healing it. It was staying there for years and years because of my running, but it never got to a point where it really flared up and hindered my running. So I was in that really tricky limbo of do I really rehab it or do I just continue doing what I'm doing and hopefully it goes away. But I decided to give running a rest and I tried a lot of strength training just in general strength training not necessarily rehab tried CrossFit did that a couple of times a week I did cycling couple times a week. I think I did some swimming as well. quite a long time ago now, I'm just trying to remember. However, the PES anserinus tendon pain totally went away. Didn't have it for like three or four months, totally pain free. I felt really strong because I was doing CrossFit couple of times a week and seeing progressions there. Definitely like the strongest I've ever felt. And then I went back to running. and the knee flared up straight away straight away it was like maybe a 5k run i thought i'd just take it easy and again that pain resurfaced and that was quite frustrating as well and looking back on it i didn't really I was getting strong, I was doing my slow heavy stuff, the pain subsided, but I never really worked my own rehab ladder towards running. Never really did that. If I was to take it sensible, yeah I might have a couple of weeks off and let pain really settle but I need the tendon to adapt to running in order for me to return to running pain free and that be like maybe... in my strength rehab conditions, trying to make sure that I'm stimulating the tendon very specifically to what it might mimic if I am running or use running as a component of my rehab and maybe do some really like 30 second runs then a two minute walk and doing repeats of that, seeing if that was enough for my tendon. That's what I ended up doing like a year later. That's the type of rehab that I ended up doing. And so this is the Jane's scenario of did, okay, star lunges. So they can be quite provocative. Isometric bridges on a bench. Yeah, it still works the tent a little bit. Side planks and clamshells works the glutes and the sides, not really much for the hamstring, but it could be the combination of all of those things that has produced this current flare up. And so I would. kind of go through this scenario and say, well, we know that the tendon hasn't liked it. We know that this workout, the tendon has, it's produced a flare up. So whatever we've done, we've exceeded that capacity. So maybe next time we take that as a bit of a learning curve. We now know, okay, that was too much. Next time, let's make sure we're doing a couple of rungs lower than what we tried and slowly build up. does take patience and it does, you know, take a lot of dedication. But, um, especially if you're trying something new, always best to, I'm not sure if this was a new exercise, Jane, but, um, if you are ever trying something new, best that we do it gradually and then slowly build up from there and pay attention to symptoms on the way. And I understand that this does require quite. a detailed understanding of how load, how the body responds to certain types of loads and certain exercises. And it does require a bit of an insight with some exercises regarding how much demand it requires of the tendon. It's quite tricky, but that's why health professionals should be a part of your rehab team if you are really struggling to make those progressions without flare ups occurring. Consider some variables as well. Like if there is an exercise that you are used to and you want to progress or if you're doing something new and you want to make sure you don't overload it, you need to consider a few variables. So sets and reps, obviously how many you do is often a variable that we need to consider. If you haven't done say what's an example we can use side planks, clamshell if you haven't done that for a while we're not going to do 50 on each side. Weight is another one so if you're going to do say lunges we're not going to pile on the weights if you haven't done those for a while but also the speed of the exercise let's just say if you're doing lunges and doing them slow, that's quite different than if you do lunges, same sets, reps, weights, but do it quite fast, the tendon has to work a lot harder. And the last variable for you to consider is the range of movement. So if you're doing a squat, if you're doing a deadlift, or if you're doing a lunge, you haven't done them for a while, or you're not sure how the tendon will respond, just go through half the range of movement of that exercise, see how the tendon responds for the next day or two, and if that's fine, then go more into range next time. But what I often see is people say, I feel quite strong, body weight exercises should be okay. And they're doing full range, say plyometric lunges, a lot of bounding exercise and they underestimate how much demand that requires of the tendon. Then they flare up the next day and it seems like it's come out of the blue, but unknowingly it's applied quite a high amount of demand for that tendon. So that's the... That's the bulk of that kind of scenario, but we also need to consider other things. We also need to consider pain science. We know that if a flare up does happen, sometimes it's not mechanical. Sometimes it's not an overload. Sometimes you might've under recovered or there might be an increase in amount of stress, or there might be, um, some social factors that have put into it. We know that pain is so multifactorial and it has this bio psychosocial interaction, say stress is another one. influence pain levels and so we also want to keep that in the back of our heads when we're talking about these sort of scenarios. Jane also asks, it's kind of like a part two, part of what plus, sorry she asked, plus what would be the best pain relief as I'm miserable with it? Again quite a hard question to directly answer or have one type of answer, but if you are experiencing a flare up and it's very irritable, quite severe. Oh, I think taking some sort of pain medication for two days is okay. Um, especially if it's an extreme flare up, but definitely not longer than that. Um, after that, you might want to do some isometrics, say some Isometric bridges or something, especially if you respond quite well to isometrics for a pain relief strategy That can get some pain under control. I know it's worked for me very well in the past with several different tendon issues in the short term You might say like for three or four days. You might want to limit sitting you might want to avoid Excessive stretching you might want to avoid other ags like say walking uphill or stairs or just limit those just be very mindful of those while you're in this particular flare-up state. I do have an episode on like a flare-up plan which was a couple of episodes ago if you want to go visit that for more details. Thank you very much Jane for submitting that answer I hope that helped. The second one we have here is Angela. She asks, I strengthen and can feel everything getting stronger, but don't seem to be able to get back to normal sport without causing huge flare ups. So my question is, how strong is strong enough to resume things like cycling? Or what exercises should I be doing in able to tolerate cycling? I've tried gradually introducing it, but it gets to, but I get to five minutes and don't seem to go beyond that without huge flare ups. So this actually ties in really well with what I was explaining with Jane. So, um, the rehab ladder could be implementing some sort of strength rehab exercises that mimic an exercise like cycling or it could be cycling itself. And so cycling might be, yeah, doing a couple of minutes here and there, seeing how things go, seeing how the tendon responds. But if in Angela's case, if you're not tolerating even really low levels of cycling, then it might not be something you're ready for and you need to mimic. that sort of scenario in your rehab exercises a little bit more before returning back to cycling. But there are some modifications you can do for cycling. I'm not sure Angela if you have tried these out but you also want to look at how First of all, the intensity of your pedal stroke, you want to make sure that when you're getting into it, it's really, really light. Want to make sure the variables of whether you're wearing cleats or not. If you are having cleats, which like the shoe clips into the pedal, you're working your hamstrings more as you pull up in the pedal stroke. Your position on the bike. So it might be that you're leaning quite far forward because the seat might be quite high, or you're just tucked into a bit more. of what we call like an arrow kind of position that puts a lot more compression on the tendon. You might also look at the type of seat so the seat might be quite wide and actually compressing the tendon against the sitting bone because the width of the seat is quite wide. So a few things there but if you've checked all those out and the tendon still flaring up after a couple of minutes of cycling then it's probably best we go back to rehab and mimic as much as we can. So I guess some tips on some exercises that I really like if someone were to be in this scenario would be to progress your single leg deadlifts. I think single leg deadlifts kind of mimic that hunched over compression. The hamstrings still working quite hard and into deeper levels of compression. If you can, Angela already do single leg deadlifts with say like a... maybe a 15 pound or like a 10 kilo sort of weight, then potentially do speed. So you're going slow down that single leg deadlift and then you're trying to come up quite quickly. Another exercise would be the Nordic kind of hip dips where you're doing kind of that Nordic exercise but you're only bending at the hips, which I've. described in the podcast several times. You could do like a prone hamstring curl, say with a band or with some weights, but you can also do that prone hamstring curl with into a little bit of hip flexion. So you might have like some pillows or you might have a step or something comfortable underneath your hips when you're lying on your stomach to do this curl. So your your hamstring is already in, or while your hips are already into a bit of flexion, your hamstring tendon is into a bit of compression, and then you're doing that hamstring curl. That kind of mimics that upward stroke pedal of your cycling pedal stroke. And then if you're doing quite well with that, then you can introduce speed. So curling that band or curling that weight quite quickly, and then releasing it quite slowly and doing repeats of that. If you are doing those sort of exercises and you're getting really good at them, I can't see a scenario where you get on a bike for five minutes and it still flies up, I just don't see that happening. So give that a try. See if you can progress and be a bit more creative to mimic the, the cycling pedal stroke, um, to see how things go with that. Angela also asks a bit a part two. She asks also when does pain actually go away? Does it ever go away? Um, so throwing on the tough questions here, I wouldn't say it's really time-based. You shouldn't really focus on, um, how long till it gets better because it's been. Like we see this on Facebook groups all the time or people ask me all the time. I've had it for six years and it's still there. So how long does it take to go away? Um, And I think they're hoping that I provide like a timed based answer like, oh, in two months time, I should be fine. But it only really depends like from when you have an optimal rehab plan in place. If you're currently doing something that's stirring up the tendon, you do that over and over and over again, it's never going to get better. Um, so not necessarily time-based, but, um, it's only once. you start implementing a really regimented, really effective, really optimized recovery plan. Um, that's when things can start turning around. And we know from previous episodes, the experts will say that from when you start, uh, your recovery, and that's with a good rehab plan, usually takes on average around about six months, but we also know it can sometimes take 12 months or sometimes more than that. So general frame of mind. But. can't, I can't highlight this more. It needs to be from good rehab. I know a lot of people say, yeah, but you always say strength, you should do strength and conditioning or strength rehab. I've done it for 12 months now. I'm still there, but they only ever do body weight exercises. They are still doing activities that flare up the tendon. They're not in building a lot of good management practices. So going back to this, does pain ever go away? We also know that chronic pain can be quite tricky as well. I've had chronic pain episodes on this podcast for a reason. It's because that pain can persist beyond tissue healing. So that tendon can get quite strong, the tendon can become, the capacity could be quite high. Physically based on what the tendon can tolerate, you go back to a lot more, but we still know for some people pain persists. And that's just the intricacies, the difficulties and yeah, the hard thing when it comes to chronic pain. That's why I have the chronic pain episodes in there. Have a look back to that if you are more interested in that sort of topic. The other point that I would add is that it says, does pain ever go away? Once it goes away... You should be expecting some mild flare ups here and there, which I'll delve a little bit more later in this episode, but just to complete this like well-rounded answer, that's something that we need to include. We need to have the expectations that there are some setbacks here and there if training errors were to ever occur, but it's just something that we need to learn, we need to deal with and overcome quite quickly. 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, on to our last. which is Jen who says, how do you know when rehab is over? Little bit more into her question or a bit more about her scenario. I have made a lot of progress and slowly increasing my mileage per week and speed. I am close to my 30 mile weekly mileage of the goal and next is to slowly introduce speed. Congratulations Jen on that progress, that's amazing. How and when can I go about just working out and training without constantly tracking my workouts and constantly tracking the hamstring tendon loading activities to ensure I don't overdo it. I know I'll always need to do some sort of strength routine but when will I get back? to when will I know that things are back to normal? For example, when can I know that I can go for a run at whatever distance and speed that I want within reason? Okay. So this is where I piggyback off my last answer and, um, just highlight the, the concept, the idea of the understanding that rehab is never really over and. However, it does become less of a concern and it becomes more kind of like a reassuring and just take myself as an example. I know that if I'm training quite well at the moment, I'm feeling quite strong. I know in my mind if I were to have a training error moving forward, my PHT would just, it probably be the first thing that comes back. Maybe my plantar fasciitis would be the second one in terms of likelihood of it resurfacing. And I know that if I went on a road trip earlier this year with my girlfriend and we did a lot of hiking, a lot of walking and my plantar fasciitis flared up, which I hadn't had for a couple of years because there was that abrupt shift. going to be there there's always this concern if it were to happen however because my plantar fascia my feet are quite strong it took a lot of hiking for it to ever start to arise but because it's also strong and quite robust that plantar fasciitis symptoms only lasted for two days and then I overcame that quite quickly well my puppies decided to have a sneeze And when it comes to say, PHT, if I were to do say sprint sessions beyond my capacity, if I were to run a marathon tomorrow, that would most likely, okay, I think she settled now, that would bring on my PHT symptoms. And so I guess when it comes to Jen and maybe your idea of being totally free and being able to run whatever distance and speed you want, I think you still need to have the considerations of overdoing things, if not for your PhD for any other injury as well. We want to make sure that we are training smart. We want to make sure we are making smart decisions and avoiding abrupt changes because that would increase your likelihood of any injury. However, when it comes to this PhD, You still need to remain quite strong with your rehab. Yes, you've highlighted that you've respected that a strength routine needs to still be in place. It can be more of just like the generic strength routine. So your squats, deadlifts, lunges, calf raises, doesn't have to be anything more complicated than that. But if you're building up that capacity, if you're making sure that your tendons are quite strong, if throughout that strength and throughout your running routine, You're slowly progressing the power of the tendon the strength of the tendon the endurance of the tendon It just becomes more resilient and while flare-ups occur flare-ups occur all the time You can have my Not guarantee but keep in mind that I see this all the time The bigger you build up your capacity and then you say become pain-free for six months If you continue to work on that capacity and then you have a training error and then things flare up, the stronger that tendon currently is, first of all there's a reduced likelihood that it will flare up, but if it does, it's very fleeting, so a couple of days, maybe a week tops, and the pain itself is very mild. It's not this huge flare up like you experience. back when the tendon was quite weak or back when it was a little bit more vulnerable. So when that starts to happen, I know I've had several flare ups for my proximal hamstrings in the last, say, 12 months, but it... when you realize that the flare ups aren't that bad, when it's only a two out of 10 instead of its usual six, well, the six has been in the past and you negotiated, you overcome it very quickly, all of a sudden you just have this. it becomes less of a concern. It's like, okay, that's, it's popped up. That's because I've done this over the last couple of days. I know based on the past flare ups, it's gonna be overcome quite quickly. Maybe I just need to implement a few different things here and there. Maybe I need to spend a couple of days being more conscious of my running or the loading that I'm applying to those tendons. And then it just... then you overcome it quite quickly. So have the reassurance and the confidence to know, but also the realistic expectations that rehab is never really over, but it does become less of concern if you do all the right things, which is why the podcast is here. It's why this resource is, contains all the strength sort of stuff and the return to running or the return to exercise and all those sort of components that you need to have that reassurance. Thank you Angela. Thank you Jane for submitting those questions. They're kind of tied in really well together and The general kind of concepts and answers float in really well So I definitely will be doing Q&A's a bit more in the future and hopefully you guys enjoy them So I look forward to bring you the next episode next week Thanks once