Q&A: Running as rehab/muscle building/PHT race preparations

: On today's episode, I'm answering all of your Q&A questions. 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 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. Thanks for joining me. Hope your rehab is going well. I have posted onto a couple of Facebook groups. I'm looking for questions for to answer and I had a flood of questions coming in. Um, let me read out cause it's a long time, the Facebook group proximal hamstring tendinopathy help and support group. Um, I also put it out on the proximal hamstring and tendinopathy and avulsion group, um, but all the responses seem to come in from the first group. Um, And yeah, I think I might spread these out into about three different episodes over the upcoming months. The Q&A seem to be quite popular alongside the success stories. And so I have about 10 here to go through. And I think maybe about three or four per episode has that really nice balance. So let's get into it. We have a question from Rob Jones. He says, hi, I'm a marathon runner and I've been suffering with PhD for three years. I stopped running totally in lockdown and tried loading my tendons using progressive loading exercises. Nothing seemed to work. And I eventually gave in. with the questions of what exercises have you been doing and he mentioned glute bridges, squats, a single leg bridge, isometric, I think it was around 45 second holds for however many sets, Nordic dips and said he tried some deadlifts but I asked what his dosages were and what the weights were and he just mentioned the deadlifts and didn't mention the weights but nonetheless. Rob continues, I've now started running again and building up very slowly. I started with three rounds of one minute of running and one minute of walking between I can now run 3.5 miles pain free. Congratulations, Rob. That's, that's amazing. In your opinion, is this something that could continue to work for me as, and has anyone ever recovered from PhD in this way and he just remained. It's just talking about like, can we fully recover from PhD just building up the running slowly? And so my ideas, I did have an episode around running as rehab. Yes, running is just not the end goal. Running should be considered as part of your rehab, just like if you were to do strength training and you start off slowly and you progress. it would be wise to incorporate running or whatever cardio exercise you do have or want to return to, you do a little bit just enough so the tendon kind of gets used to it and doesn't flare up and then you continue building up. And so not only is the tendon getting stronger and adapting to strong stimulus from the strength training, but concurrently alongside that it is getting stronger with the running provider that's the right dosage. and a lot of people get go a bit awry with trying to find the right dosage to start with and then trying to figure out how do I progress to the next step what's the next stepping stone in my progression some people do it just way too quickly or their steps are too large or they just start off way too much I had an injury chat the other day with someone with PHT and their initial running attempt to see if running was successful was running for three miles. And that is nowhere near where I would get someone to start, but they flared up and they said, okay, I'm not ready for running, let me start doing something else. And so there's a lot of confusion or a lot of just like misunderstanding of where that starting point needs to be. But yes, this can happen concurrently. But when it comes to just doing the running and just incorporating this into the rehab, do I recommend it? I don't. I do think strength and running concurrently will yield the best results and give you the best results and more resilience. It gives you the best chance for success, in my opinion, and also increases your odds for the tendon just to be more resilient and more formidable when it comes to throwing different things at it, like say sitting and bending forward and all the stuff that the PHT will carry over into everyday life. And keep in mind that I've said this on the podcast before, the tendon has three strength buckets. You have your endurance bucket, you have your strength bucket, and you have your power and plyometric bucket. And yes, if you train slowly for running and you find a dosage the tendon can tolerate, and then you slowly build it up, then... you will get better. The tendon will adapt to running and you will be able to slowly return to greater distances. So yes, you're right in that Rob. But I believe that if there's any fluctuations in your training, down the track, if you want to introduce speed or hills or just an abrupt shift in something. Maybe it's recovery. Maybe you're getting lack of sleep and the tendons not able to adapt just as quickly in that moment. Or maybe you reach a certain mileage where it's just starts becoming a little bit irritated. Any sort of abrupt changes, it'll be a little bit more vulnerable if you just only do running as part of your rehab. Because we're only... tapping into one of those strength buckets, we're only tapping into the endurance bucket and not the absolute strength and not the power buckets. And so addressing all of those things and raising all of those things up at the same time would just allow a more formidable like fortified tendon that is just a little bit more unshakable when you have to test it out in different ways. So what you're doing is currently working. I'd recommend continuing with that because you've already had such success with it. But I would consider the strength and I haven't come across someone who said strength hasn't worked with me before. And I've really delved into the nitty gritty and found there was a lot of missing pieces in that strength. progression attempt that I have tried. And so that's why I decided to follow up with Robin ask like what exercises and what dosages weren't successful because he said nothing seemed to work and he eventually gave into the strength and the progressive loading. So I'm yet to find someone say that and then I delve into the real intrinsic parts and say and make suggestions because it seems like they've fallen apart and fallen astray with a few things. One of them being that bodyweight exercises bring on too much pain so they don't want to progress because they're scared it'll flare it up even more. But I've found if it's done so gradually that the pain itself actually tends to get better when you start introducing slow heavy stuff rather than just high rep bodyweight stuff. The other one being I have a episode purely based on deadlift progressions. Um, so if someone's in the same kind of situation as Rob, if progressive learning just hasn't worked for them in the past, have a listen to that deadlift progression exercise, uh, that podcast episode, and you can see just how incremental some steps can be. And yeah, you can, um, possibly try something out and see if that starts shifting things for you. Thanks Rob for your question. That was great. We have Andrea Camerillo, and Andrea asks, is there any technique to build lower limb muscle? to build on lower limb muscle with this tendinopathy. I've had PHT for three years. Finally, a year ago, I found a PT which made me work out through pain. She puts in brackets at no more than four out of five, four or five out of 10 with controlled movements, which has helped me being able to squat, deadlift, and some other movements at 75 to 85% of my one rep max. which has improved my body quite a lot. I'm still finding limits in what I can do and how much stress I can put in my workout. So please, some advice on this subject would be greatly appreciated. So Andrea starts by asking, is there any technique or any approach in order to build on muscle mass? with this tendinopathy. So quite a unique question. I don't often have some with PHT that's performing at such an end stage rehab already at 75, 85% of one rep max and asking how to put on muscle mass with this tendinopathy. So that's why I decided to include it in this episode. It's nice. Well, first of all, before I... Try and answer this question. I should say that I'm not a strength and conditioning PT, personal trainer or any of that. So they might have a different take, but I'll try my best based on the knowledge that I do have. When putting on muscle mass, I feel like there's a few components that help really well. One, yes, you need to be lifting heavy weights. That's pretty, it's a given. I'm not entirely sure the dosage, but I do know a lot of bodybuilders and those who are trying to put on muscle mash. They're in the gym maybe five or six times per week. So quite a lot. They also eat a lot. That seems to be a key to putting on muscle mass as well. If you don't eat a lot, or you're just eating the same amount you were when you weren't putting on muscle, it's gonna be very hard for your body to get the nutrients or get the requirements to put on muscle mass. And they also do little cardio. because the body prioritizes cardio when you do the two together throughout the week. And there is this interference effect where if an athlete decides to do strength training three or four times a week, but also runs three or four times a week, the body will adapt, will always prioritize cardio and adapt towards those cardio demands over strength. It seems just to be an evolutionary bias that the body wants to do. So, If you do have some cardio in there, it's going to be very hard to put on muscle mass because as soon as you do that cardio, the body's like, yes, I want to adapt to that. I want to be lean. I want to be efficient. I want to have a good aerobic capacity. Let's adapt to that, those particular traits. And so that's another particular element that I think. is crucial for putting on muscle mass. It's just like doing little cardio as possible. So not sure, Andrea, what the frequency and intensity of your workouts are. But I'm glad you've had such success with the BHT recovery with doing all this strength training. It's really nice to see. So my advice, I guess, would be you try and find which exercises you can tolerate more. So try and find which lower limb exercises that you can go quite heavy and the tendons not as hard with, I know calf raises, like that's minimal on the demands of the hamstring tendon and you can go quite heavy. You said maybe squats and dead lifts, but maybe you can reduce the range of movement. Maybe you can increase a lot of weight. sensibly and not go as deep into a range of movement and the tendon actually responds a lot easier and it's less aggravated. Step ups like you could do say a lot of different exercises where it's just less of a strain on the hamstring tendon. Yes squats and deadlifts are the big ones that will. Yes lunges like full range lunges or like a Bulgarian split squat they will definitely have. a fair bit of load on the hamstring tendon. But things like hip thrusts, bridges, like if you just do those weighted, if you just have a small step and you just do really heavy step ups, that should be less of a demand. So try and find those exercises and you can do more of those exercises, maybe three or four times a week. Whereas with the deadlifts and the squats, if it's still causing some flares, you may be doing those maybe twice a week. but I recommend trying maybe once in that week doing a reduced range of movement with those squats and deadlifts and heavier. And then if you want to do full range, then just go a bit lighter. So maybe you're just keeping the body guessing a little bit that way. But you can also try, I guess, greater rest breaks in between your sets. Again, not too sure what you're currently doing, but it might give the tendon a bit more time to recover. And so if you decide to do those squats and deadlifts, and it's a bit more of a challenging weight and you're not too sure how the tendon is going to respond. Maybe just leave five, seven minute break in between sets, give the tendon time to adapt or recover and then go again. So that may be something you can adjust. And then for the exercises that you are a bit apprehensive about or a bit cautious about, so full range squats and dead lifts, just be very slow, very patient. Um, with progressing them and then all the other exercises, you can have a bit more freedom with progressing. 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. Our last question coming in for the day is Arthi Raghu. Hopefully I pronounce that okay. Okay. I would love to hear more about rehabbing PHT while training for a race. I'm scheduled to run the Boston in April and have been rehabbing since December 3rd. I haven't yet introduced speed back into running and I'm just slowly building up my mileage. Not totally pain free yet but up to 8-9 miles and the pain has gone by the next morning. Fantastic, good to hear. Trying to decide if I should back out of the race. I've done Boston once before, or if I should run it and just take it easy, I don't want to jeopardize my progress. This is a good question and a good scenario that a lot of people seem to find themselves in. My suggestions is to write things down on paper to start with. So you would say, okay, where is my current long run? So you said it's around nine miles, probably by the time you listen to this, it's maybe 10. And then you can say how many weeks out until the race. So hypothetically, if it's like 10 weeks away, all right. So if I've got, um, 10 miles and I need to get to maybe about say 20, 22 miles before, um, before that let's slowly, that probably leaves me. building up to one mile every single week in my long run. So I'm building up my long run every single week by one mile. And then every now and then it probably, there's a two mile jump. So that's the slowest possible progression I could do. This is just considering the long runs, it's not considering all those other components within the week, but you just wanna say, this is my most gradual, patient, sensible approach possible based on the time that I have available. And you've written it down on paper, so you can look at the numbers and see if it makes sense. I wouldn't introduce speed work at all. I think that's a bit too risky and I don't think you have enough time to try and do a marathon like with speed involved. So I do recommend us do the slow pace that you have been currently doing your long runs with. Um, but once it's all written down, you can then start to look at. weighing up the risks versus rewards. And whether you're training for a race or not, whether you have an event coming up or not, I always like to have people consider this, whether it's, okay, should I progress my deadlifts? Should I progress my cross training? Should I start participating in yoga or start doing spin classes? Always start writing these things down and write down the risks versus rewards and how much of a jump it is, how much of a risk is it. because then you can really like make more of a justified decision, whether to continue doing it or not. And every goal, every event has risks. rewards associated with it, whether you're injured or not, they always have risks versus rewards and how much does the race mean to you. So if you progress gradually, maybe like you said, you've already done the Boston once before, so maybe it doesn't mean a lot to you. I can't put words in your mouth, but the thing with this process is because you're doing it in the most gradual. process available, like I said, you're doing one mile per week, you can't be more conservative than that because you've got limited time available. Then if you do reach a point where you do flare up, if it gets to the point, say by week six, where the tendons no longer agreeing with that amount of mileage, then you can just say, all right, I've tried the most sensible approach and it's not agreeing with me, let me pull out of the race. And because you've taken the most gradual step that you possibly could, then the flare up won't be as aggressive as if you were to take a more risky endeavor. And so the flare up maybe only lasts for a few days. And then you've realized within yourself, okay, that was too much of a jump. Um, I haven't lost any fitness. The flare up only lasts a few days. So I'm not too, um, annoyed at myself. This was the risk that I took on. This is what I signed up for. And so currently, Um, maybe I just live to fight another day. And this is another thing with when it comes to races, some people hold races, um, at a really high regard. They, for some reason, they just think it's going to be their last race ever. And they need to do it. It's, it's a must and it's. really tough to see people when they, um, back out of a race and they're really disappointing themselves. And you kind of just need to level with them and say, look, it's just a race. Like there's going to be so many races, um, coming up. There's always another race and it's, it's hard to pull people out of that mindset sometimes, but anyway, so take the more cautious approach. Um, and therefore if at any stage there is a flare up, then it's only a minor flare up, the most minor that it can be, I guess, in this scenario. So it settles a bit quickly and then you can reevaluate your goals after and say, all right, that wasn't for me. Let me pull out of the race. Let me focus on my next thing. And, um, like I said, if there is a flare up, That's what I've signed up for. That was the risk associated and the reward on the other side, if it is all successful, the reward is you successfully complete the marathon. So why all those things up? Um, and I've just, as we're signing off, those pain rules seem to be nice. Um, so. aren't exactly pain free, but the pain's gone by the next morning, provided the pain during is like hovering under maybe a four out of 10 pain seems to be like a successful, um, a successful behavior of the tendon. So if that's continuing, then I would say discontinue progressing forward and see how things go. But there's other podcast episodes that I've released in the past talking about the behavior, what's acceptable levels of pain or not. And if people want to know more about that, then they can just scroll back through the feed and have a listen to those. So thanks, Arthur. Thanks Andrea. And thanks Rob for submitting these questions. Next, I'll probably line up two more Q&A's. The next one, we're going to talk about recovery expectations, shockwave, PRP and surgery. A few questions are coming on those fronts. So I'll bring that to you next week. Good luck with your rehab this week and we'll catch you next time. 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.