Q&A: Scans / PRP / Diagnostic Tests / Diet

: On today's episode, I'm answering all of your PHT questions. Welcome to the podcast that gives you the most up-to-date, evidence-based information on PHT rehab. My name is Brodie. I am an online physio, but I've also managed to overcome my own battle with PHT in the past. And now I've made it my mission to give you all the resources you need to overcome this condition yourself. So with that, let's dive into today's episode. Okay, let's dive into these questions. I haven't done this for a while. Usually when I put this out on the Facebook groups and those sorts of things, I would expect, you know, five to 10 questions returned. And, you know, usually I try to split them up and see where I can allocate those into certain episodes. But this time I had 20 questions come in. So a lot more than I was anticipating. I like A handful of them weren't really relevant to the podcast. So I've reached out to those people individually and try to answer their questions. Um, so it's filtered down to 16, which is still a lot that I was a lot more than I was anticipating and wanted to break it into two episodes. I'm like, Oh, do I, you know, condense it to three episodes, but you know, with this episode, with this podcast. coming out to every two weeks. I'm like, well, you know, people are going to be waiting a long time for me to answer their questions when, if it's in the third episode. So I'm going to try my best to cover 16 questions in two episodes. So today we're going to go through eight questions. and see what we can do. I wanna thank everyone for submitting their questions. It definitely opened up a lot of threads and conversations on the Facebook groups as well, which is nice because I tend to think these days in Facebook groups, it's not getting a ton of reach like it is what I was used to. If you're a member of a group, it's the posts, even if you wanna see, it isn't reaching a lot of people. And like on Facebook, feeds these days, it seems to be a lot of ads, like my girlfriend and I were just talking about it. She opens up her Facebook app and scrolls through her feed and eight out of the 10 posts are ads and only like one or two will be someone who she actually knows who's actually posted something. I don't know if there's a slight shift in the algorithm throughout Facebook and the amount of reach that it's getting. I know on my Run Smarter Facebook group, the reach isn't as much as what it used to be, but glad that we got some questions in here and it was more than I expected. So, I don't wanna spend too much time rambling here. Let's dive into these eight questions that we wanna get through. The first one comes from Felicity who asks, Is it possible to still have PHT, although the tendons are now strong in brackets, according to my physio, and no longer provoke any pain during diagnostic tests? I still have daily pain at the insertion points and now, and now to about halfway down the tendon, I don't feel like it's cytokine. Okay. So a diagnostic test is done, uh, you know, by a health professional to try to. increase the likelihood of a diagnosis being made or, you know, yeah, the, uh, there's several different diagnostic tests that we like to use. We don't like to just say one because diagnostic tests do have some different accuracy measures. We call them specificity and sensitivity and very rarely does a test that produces a positive outcome. know, be 100% sure that you have this diagnosis. So we'd like to use a bunch of different tests. So Felicity with your, you know, going back to your question, yes, you can have a strong and painful tendon, you can also have a weak and painful tendon, like those two things will present differently. I've done a podcast episode on differentiating between the two. So it's good that you are strong and do have a good level of function. I think you have a good level of function. But if it's pain and we believe it's coming from the tendon, it's still considered a tendinopathy. I'm not too sure what diagnostic tests were used, how many were used, but when we do diagnostic tests, they aren't definitive. It increases likelihood one way or another, but not definitive. And we usually like to use a combination of diagnostic tests with your level of function, with your... history of presenting symptoms with your symptom characteristics, like all of these things, scans included as well, these are all things that we put together to increase the likelihood of a diagnosis. So for example, you could say, I got this pain six months ago because I increased my speed work too quickly and started getting buttock pain or high hamstring pain and we could do some diagnostic tests. And, you know, sometimes they don't really fit the pattern of what we would expect. Sometimes it's not a slam dunk. Sometimes not everything across the board is what we would hope. And if your history of presenting conditions, you say, yes, now I have this upper buttock pain, it's it hurts to sit. Um, if I extend my leg back, it hurts. If I try to do any speed work, that really hurts. Um, but then we go to do diagnostic tests and come up fine, you still could have PhD, it's still like something that's, we're not ruling it out. Because like I say, some of these tests have, you know, various degrees of accuracy, and you can have a negative test, but it's still be positive, it's you still have that condition. And so on the other side of things, you can have a diagnostic test, be positive, like it seems like you, your symptoms are produced, but it could be something else. And so that's why we want to be very careful with the accuracy and sort of combine these things. So it might seem with your Felicity just taking a guess, like you could still have PhD, but the diagnostic tests don't reveal anything because the tendon is getting so strong, but you still have a little way to go to, because you still have pain throughout the day. I would, however, encourage the physio to sort of broaden their scope. just to rule a few things out, maybe posterior hip impingement, maybe bursitis or bone stress reactions or any other condition that mimics PhD that's very similar to the presentation of being PhD, yet will have different diagnostic tests. So it's a confusing one, it's a complicated one. And that's why we like to say, we're only using these as pieces of a puzzle. And another piece of the puzzle would be your response to treatment. If you treat it like PHT and it starts getting better, that increases our accuracy that it is PHT. So that's another thing that we can follow as well. If we treat it like PHT and it doesn't get better, or if it gets worse or something along those lines, then again, we might broaden our scope and try to consider other things. But I would say if your function is improving Felicity, I would just continue with the plan. I wouldn't worry too much about the diagnostic tests because whatever you're doing, You're getting better. Okay, let's move on to Sue. I'm guessing that everyone's case is individual and may require different assessment and treatments. Can PHT be exacerbated by emotional stress slash tension? If so, how can this be overcome? Also, is pottering about a good exercise in itself? I had to ask what... pottering actually is English slang, she said it's slow walking around the house and gardening during the day doing light jobs of housework, etc. And so is pottering good for exercise in itself or a more targeted exercises essential for improving the chances of a full recovery? Thanks, Sue, let's talk about the emotional side of things emotional stress and pain and if that contributes to PhD. Absolutely it does. we know that pain is biopsychosocial. Bio meaning, biological meaning, activity, load, sitting, running, cycling, all that sort of stuff. But there's also this psychosocial component of pain, which is your thoughts, feelings, mood, interactions with others, your social life. All of this actually impacts how much pain you have, prolonging your recovery, or influencing your recovery timeframes. all that sort of stuff. And with PHT, it can be socially isolating, it can be very, a lot of people have a lot of fear and anxiety around day to day tasks with PHT. So very much influences your recovery. We know that pain is triggered by the brain and only by the brain. 100% of your pain experience is by the brain. And if that is present with fear, worry, anxiety, that ramps up the brains. importance of this pain and relevance and will therefore amplify pain. We also know that stress, there are certain stress hormones like cortisol and noradrenaline. These are considered as pain amplifiers. I've explained this a couple of times before but imagine like, you know, you're in a room that is slowly getting filled with gasoline. If you have room without gasoline and you light a match, you light a little spark, we can consider this like a little incidence of pain. The match flares, the match lights up, fades out, no biggie, just a little flash and it fizzles out. That's someone with none of these stress hormones circulating throughout their body. However, if you do have stress hormones circulating throughout the body, let's imagine that as gasoline slightly filling up the room. You don't see it there. But if there is a site of pain, i.e. lighting a match, you're gonna get a lot more bang for your buck. And so that's sort of how I like to imagine if someone's really stressed, really worried, really anxious, all of these stress hormones are circulating throughout their body, and then there's pain present, there's gonna be a pain amplification. So what can you do about this? Well, you know, manage stress in whatever way that helps you. I would say, you know, deep breathing, reassurance, journaling, meditation, yoga nidra, body scans, how you like just trying to be a bit more aware about your response to certain emotions like this is all outside the realm of my expertise. But I do know that certain strategies and techniques work best for some people but not well for others. So you need to sort of just gravitate more towards what helps you and your stress levels. and your tension, you know, you can try something like a cognitive behavioral therapy, trying to analyze why you're stressed, how are you stressed, trying to identify and unpack the thoughts and feelings and emotions behind it, and then strategies to help. If it is a big issue, then you can enlist help as well. You know, I've seen a lot of my, not a lot, but a handful of my clients have sought out, you know, therapists that can help with the social side of things and the emotional side of things. So that would be my advice for you Sue. Going to the new term that I've learned the pottering type of stuff, I would say definitely the more targeted exercise would highly increase your odds of full recovery. Pottering around doing some gardening, housework, chores, that sort of stuff could make things better. It could make things worse. It could make things indifferent. I don't know depends how much load goes through you throughout the day. and how much, if that's too much or not. I've said it before, I'll say it again, tendons love slow, heavy, progressive load. I don't think that's pottering around the house. I think pottering lacks like a defined dosage. You know, when we do our deadlifts, it's three sets of eight or four sets of eight. It is a hundred pounds, it is three quarters range of movement, we're very precise with the dosage and we are very precise with the progression. And so, next week, the week after, if able, we are slowly progressing those dosages because it needs to be slow, heavy, progressive load. And I don't think pottering ticks those boxes. So I would say that if you're looking for full recovery, which we know you are, more targeted exercise would be the way to go. It's kind of like my funny sort of pet peeve with gardening, especially because when I was working in clinics, I would have people with back pain, shoulder pain, neck pain, knee pain, all that sort of stuff. And you know, your middle aged adults and a bit older would, I don't know, it seems like gardening would always set them off, always flare things up only because, you know, they know their limitations, but they say, Oh, let me just do some gardening for 30 minutes. It is never 30 minutes. It turns into two and a half hours and they're kneeling, bending, straining themselves. And all of a sudden the next day they're really sore. it's kind of low load, but very high repetition, and they end up getting sore. So I keep seeing all these people after gardening, and it ends up being a pet peeve of mine. So just sharing that little story for you, so just be mindful. Next one, Alexandra says, Hi Brody, I know that you've covered PRP a little in episodes, I'm midway through the process and find it challenging getting information. I've spoken to surgeons, physios, patients, GPs, and still can't figure it out. I'm worried if I may need to redo if I haven't followed guidelines properly. I'm spending too much time and energy and concerned on its impact, and that's impacting my recovery too. I'm also ready to write a book about my experience. Thanks, I'd love to read that book, Alexandra, when you get around to that. Okay, PRP. I would say in general summary does not look great in the literature. doesn't not look great when compared to placebo or exercise therapies in the long term. There might be some papers that are, you know, low sample size or low poor quality that show that it's beneficial or high quality that shows it's beneficial when compared to other things like corticosteroid injections. So You know, we, you can have a big system systematic review or something and say, yes, PRP is the way to go when compared with, you know, corticosteroid injections. But we don't know what it's, but that only just answers part of the question. But I do follow people who are very well versed in this literature. Peter Maliaris being one of them I've had on the podcast before, and he doesn't think we should be injecting anything into tendons. there's not good research for it for the long term. Me on my side of things, I have a lot of clients that have had PRP and haven't had great success, but very well aware that the ones that do have success don't end up speaking to me. So I've got to buy a sample size there. I've spoken to surgeons a couple of episodes ago, I talked to Dr. Nick Hardy, who is a surgeon and I was very happy with his candid answers to these sorts of things and He was saying when it comes to PRP, yes, we know the research isn't great for PRP. But he said, we don't, we run out of options. If we have surgery, um, as an option, if someone doesn't want to go down the surgical route, or we think it's not a good, they're not a good candidate for surgery, we offer PRP because look, that's, that's what we've got running out of options there and so while aware that it doesn't look great with the research. Um, if For your case, Alexandra, if you've already had it once, and it hasn't really worked, I'd be skeptical to try it again. I'll look for other areas. I'll try to see if there's other areas of improvement with your rehab strength, sitting stress, as we've just talked about, like those sorts of things. Trying to see if we can get that under control and try to take that direction. I say tendons love slow, heavy progressive load, and PRPs aren't part of that. Like that doesn't change the structure of a tendon doesn't make it stronger. And so yeah, that's why I'm so skeptical on those sorts of things. Jason says Hi, Brody, do you have any thoughts on diet and nutrition, diet and hydration? Sorry, for tendon health and recovery? I'm wondering if a low carb anti inflammatory diet will be beneficial for a person with PhD? Good question. I'm not sure about hydration. I might just dismiss that sorry, Jason, but in terms of like the diet side of things, yes, a low carb diet might be beneficial, especially if it's like sort of chronic pain. I know there's research done with Rowena field, I've had her on the podcast, I've had her definitely on the run smarter podcast, not sure if it's on the PhD one. But she's been doing research on getting people with chronic pain, putting them on a low carb diet and seeing very promising results. If you are one, if you do have PHT, if it's chronic PHT, which is, you know, if you've had it for more than six months, if you are eating a lot of carbs, especially sugar, especially refined sugars, and you're also eating like, you know, throughout the day, you're not really giving the body a chance to rest. What you are doing is increasing your amount of insulin that circulates around the body. So when you eat, particularly when you eat carbs, there's glucose, so the carbs become digested, go into the bloodstream in the form of glucose, then the body registers this glucose, releases insulin so that they're combined and be stored in either the muscle or elsewhere. And if the body, like the body is used to having this spike and calming down, different if someone has like diabetes, process is a bit different. But if you are used to eating a lot of carbs and eating a lot throughout the day, the body doesn't have a lot of time to rest and calm down from those rise in insulin levels. Instead, the body is being in this constant state of low amounts of insulin, high amounts, low amounts and never really flushing it all out. That goes on for a long period of time, it can contribute to what we call insulin resistance. And It's believed and people on the podcast have told me that this insulin resistance and this circulating insulin that's constantly there contributes to what they call chronic low grade inflammation. And I was speaking directly from my interview with Dr. Peter Bruckner, who's a big proponent of low carb diets. And he is mentioned on the podcast as well, that he had a chronic grumbly Achilles issue. And as soon as he went to low carb that went away and he's seen that with his athletes as well that he's worked with. He's worked with national athletes and seen those responses. And so what I'd say for you, because everyone's different. I don't want to be the one saying this is the way to go. Cause I'm not entirely sure. I'm only just drawing evidence and conclusions and opinions on people I've talked to in the past. But Try it. Why not try a low carb diet for six weeks, six to eight weeks, I'd say. And if you feel significantly better, then lean a bit more into that. What does low carb look like for you? I am not sure. You would track your sort of macros if you want. There's good apps out there where you can just take a photo of your meal or scan barcodes and it'll tell you the amount of carbs that are in it. And then it will calculate and total up your score throughout the day. if someone's like keto or something like that, they might wanna restrict to like 30 grams of carbs per day or 20 grams of carbs per day, I think would be pretty low. And you know, that might be something that you try and can really like measure things down. And if you're feeling a lot better, that might be a direction you wanna take. The other thing on the topic of diet would be making sure you've got adequate protein. When you eat protein, it's broken down. and, you know, utilize throughout the body and your muscles, your tendons, ligaments, like all of that uses protein. And if you don't have sufficient protein, then we don't have a lot of turnover in terms of adaptation. And this is like quite new. I'm quite new to the world of learning more about protein and that sort of stuff. I have this new goal of trying to put on more muscle as I've got another high rocks race coming up in. four months time. And so I've recently bought some whey protein of we recently started taking these amino acid supplements and trying to really track how much protein I have. And, you know, if we are doing our deadlifts, and we're doing our rehab, and working hard, we do a good job to strain the body with our strength exercises. The next part is giving our body the right nutrients in order to bounce back, adapt, recover from that bout of exercise. And we need the right building blocks to do that. Hopefully we get enough protein. Not entirely sure I'd say like, you know, I tried to keep to two grams of protein per kilogram of my body weight, which is a bit more on the higher end. But, you know, I think again, you can give it a try if you think man I'm pretty I haven't really been tracking my protein maybe do that. Again, these apps are really easy to track and follow. If you want to try protein supplements, if you want to take some whey protein 30 grams before bed or after your workouts or whenever. Do that see if you feel better. See if you start this starts tracking you on the right putting you on the right track. I will try to do future episodes. I'm in conversation with one person at the moment talking about maybe doing an episode on nutrition and, uh, tendinopathies and those sorts of things. So thanks for your question, Jason. Uh, you know, I'm not a dietician or a nutritionist, so take it for what it is, but, um, they're just my thoughts and opinions on the topic. All right. Joanne says, hi Brody, how common slash rare statistically is the cause of PhD in non-runners or non-athletes? I'm a non-runner. and trying to solve why slash how I developed PHT. In brief, post-menopausal onset of insidious symptoms following a spinal epidural with in brackets, legs stretched. Could there be any correlation to these and the cause? Thanks in advance. Thanks, Joanne, for your question. Yes, I would say it is common, but, well, I guess not that common. to have PhD in the non athletic population, but I still see it. I have a handful of clients currently that aren't, uh, runners or that athletic. But you know, people go through day to day stuff. Like people I'd say like what strains the upper hamstring. Okay. Lunging, hinging, squatting, stretching, sitting, all of those stuff. You don't need to be athletic to do that. We just talked about gardening. I mean, someone can garden and. garden is on a slope or a hill and they're doing two hours of walking up and down, lunging, squatting, you know, hinging and doing all these sorts of things. And if it's been six months of winter and they haven't got out into their garden and then all of a sudden it's spring, they haven't done a lot of gardening and then they do three hours of gardening that could increase your risk of PhD. I would say it's common for it to be like in combination with sitting. Like if you were to do a lot of squatting, hinging, stretching, or like if say you've started joining a yoga class, you're doing a lot of stretching of the hamstring, and then you have a, I don't know, a three hour dinner on a hard stool, then, you know, the combination of those two things could irritate the tendon. I'm not too sure about the spinal epidural with the legs stretched. I'm not sure if you meant like during the operation or afterwards, but. Who knows, who knows if there was some sort of compression of the tendon going on at that stage, but I hope that answers your question. Like the tendon has a certain capacity, that capacity might be really, really low in the non-athletic population or the sedentary population and can be, you know, exceeded very easily with some lunging, squatting, hiking, or something that's outside the realm of your usual norm. Okay. We have one coming in from Lean who says, can sciatic pain caused by scar tissue be overcome by PHT or is surgery or shockwave therapy the only option? Does the presence of a tear and even the location of the tear make a difference in the chance or probability of success of PT? Okay, thanks for your question. I'll say like the tear. I've done a episode a couple of... couple of episodes ago about the surgery versus conservative. And the guidelines were if there's a tear impacting two or more tendons of the three proximal hamstring tendons with a retraction of more than two, with two centimeters or more and showing great level of dysfunction, we open up the conversation for surgery and we see whether you're a good candidate or not based on those. that criteria. So yes, I guess the location of the tear would be like, yes, is it impacting two or more tendons? And is it retracting away from the attachment point? If so, how far is it? Is it two or more centimeters? Let's start having a conversation. Because then it will come back to the what's your level of function? What goals are you wanting to return to? What level activity do you want to return to all of that with then, you know, move the conversation along around whether we do surgery or not. Regarding your first part about the Cytocar, Cytocar can initially be treated conservatively. I'm not sure if it's because of the PHT or whether we're suspecting it's something like concurrently that's going on, but it's hit miss like it's trial and error when it comes to Cytocar. You can try trigger point release, you can try neuro dynamics, which is like trying to mobilize the nerve within its groove. Uh, sometimes that can be effective. You can try dry needling or acupuncture. Not great research, but you know, individual response, relatively inexpensive, not a lot of risks associated with that. So why not give it a try? I don't think shockwave. Um, some people, I don't know. maybe say would say to you the shockwave helps break up scar tissue doesn't do any I've never seen any research that that's helping so if you have scar tissue and cytokine I wouldn't recommend shockwave therapy if anything like the shockwave therapy might really irritate the sciatic nerve we sort of want to stay away from the sciatic nerve when it comes to shockwave therapy and pht that's sort of one of the complications of getting shockwave with pht is trying to make sure we're away from the sciatic nerve because people can have a lot of pain after shockwave if that's been irritated. I'm guessing like you might have had scans done that has shown that there's presence of scar tissue from the PHT tendon tear. If there is a tear that's then started to create scar tissue that's then starting to impact the sciatic nerve. address it conservatively. But if it isn't, then maybe surgery might be an option. We might need to have that conversation. I know Dr. Nicholas Lefevre was with Dr. Nicardi and talked about the sciatic nerve scar tissue and release and those sorts of things. So if you haven't listened to that episode, you can go do that. But that, yeah, that's all I could pretty much say. We have Elizabeth who says, could you comment on hormone replacement therapy in perimenopausal women to improve tendinosis? Also, I know you recommend avoiding hills and sprints upon return to running. Any thoughts on treadmill versus land running? Okay, I haven't looked into hormone replacement therapy. I'd say kind of outside my realm, but I haven't really come across anything yet. What I would say is, okay, consult with your doctor. But my thoughts being, okay, if your estrogen and testosterone balance ratio is off, then you get hormone replacement therapy and that puts you back into a balance that leaves you more optimal and thriving with that balance. My guess is you're gonna have more energy, you're gonna be recovering faster, you're gonna be sleeping better, and you're gonna have more strength. So if you've got more energy, recovery, sleep, strength, that's pretty good, putting you in pretty good conditions when it comes to rehab. So that's just my general thoughts, but I have to say consult your doctor because I don't really know hormone replacement therapy and their costs and their risks and those sorts of things. So just bear that in mind. However, I will better answer your question about the treadmill and land that is within my wheelhouse. You did say in your question, I know you recommend avoiding hills and sprints upon return to running. Uh, yes, I would say we do need to be very cautious of hills and sprints upon returning to running. Um, but some people can take this and say, Oh, Brody says avoid hills and sprints with rehab. Um, I would say, you know, if it's a goal of yours, we want to introduce hills and sprints at some stage. We just need to make sure it's very gradual. But yes, in the early days, we want to remove as much variable as possible. One of those variables being hills and speed work. Let's just keep it slow, keep it flat and just work on the distance. Therefore we're keeping our variables at a minimum. What I will say is the treadmill versus land when it comes to PHT, indifferent. Usually the highest point of the strain for the hamstring. is during the swing phase, which is, well, if we're being really technical, it's like the late swing phase. So it doesn't matter if you're going over ground or not, everyone still goes through that same swing phase, no matter what terrain. And so that wouldn't matter. I would say with your treadmill, make sure it's at a 1% incline, which mimics over ground as much as possible. And I say that because we... You know, when you're on a treadmill, it's completely flat. You don't need to push off the ground. The belt just moves underneath you. All you need to do is just like lift your legs up and put them back down again. So you're not providing force or pushing off, but that 1% incline just leads you to push up a little bit and sort of mimics that. And why I say that is because you might want to eventually, or you might be exclusively on a treadmill, just doing that. But then all of a sudden, you know, your goals change, the weather changes, and you want to transition to. outdoor overground running, we want to be strong enough and have the capacity to make that transition and we can only make that transition or we it's a safer transition if we've practiced on the treadmill at a one percent incline. Next up we have Alice who says, Hi Brody, I have a four year injury symptoms of PHT, low level pain but massively restricted to movement and exercise Previously very active, not showing much on MRI ultrasound imaging. So no op, so no operation advised for last year, seen an excellent PT who diagnosed PhD and has done very focused strength training, similar to your podcast. He said the tendons now strong, but improving day to day. I'm not sure if this is a typo, tendons now strong or not strong. but improving day to day. I'll leave that. PT now suggests platelet rich plasma or PRP injection. Do you think this will help? Do you have any other suggestions? Any idea why not showing on imaging? Feels like I'm hitting a dead end, only 48 and not ready to stop being active. I would say you continue pursuing being active. This is definitely a goal that should be for yours. The PRP, like I mentioned before, There's not a lot of data to suggest that like we have good confidence that PRP is the right thing for you. What I will say is if you are seeing improvement, keep going, double down on that. You said that you are improving day to day, unless there is a typo there. So if what you're doing is working, then keep doing that. If you reach a plateau, I'd progress, like keep progressing what has been working because tendons love slow, heavy, progressive load. And so... there, just keep doubling down on that. I do have a bit to say on the imaging side of things because you mentioned that there's not showing much on an MRI slash ultrasound, and you're wondering why it's not showing up on imaging. Okay, there is a very poor correlation between scans, what people are seeing on imaging and your symptoms. I see this time and time again, someone will have really severe pain, really like, you know, years and years of dysfunction pain, they finally get an MRI and it shows mild tendinopathy. And they're like, are you kidding? mild tendinopathy, like they feel like their doctors have been very dismissive and to shoot them off because it's only a mild tendinopathy. And they're like, I have so much pain. And some people can have a lot of pain that shows nothing. But at the same time, someone can have no pain, no history. and have tears, have tears all over the place. So we do need to be very, very careful when interpreting scans and when correlating that with symptoms. Uh, I say this because people think the scans are the right answer and I need a diagnosis from a scan. You don't. Like I said, at the very start of this episode, we use a combination of things to diagnose someone. We use a combination of their history, diagnostic tests, their level of function. What's happened at the time of the injury, how pain has behaved and the characteristics throughout your rehab so far, what makes it worse? What makes it better? what your response to initial treatments are like, all those sorts of things, to then make an estimation or a guess as to what the diagnosis is most likely to be. The scans are useful, but is only one piece of a more complex puzzle. A lot of people like to place the scans as the puzzle. It is only a small piece that we need to correlate with everything else. So if you had a scan, And it showed nothing for PhD showed nothing on imaging yet. Your history, your care pain characteristics, diagnostic tests, response to treatments and all those sorts of things pointed towards PhD, you'd definitely be diagnosed as PhD in my books anyway. But we know about 15% of the healthy population have PhD. tendon tears in both sides bilateral hamstring tears in the healthy population who have never had any complaints of hamstring symptoms in 15% and that's on both sides at the same time. We need to be very, very careful because someone might have something else going on. They might have referral from the lower back and then they do scan and say, yeah, you have a tear in your hamstring tendon. So let's start treating you for PhD. And unbeknownst to them, it's something else that's going on that's mimicking PhD. So that's why we need to use all those other puzzle pieces. So a few things that we need is complex. I get it. It's confusing. It's hard to have one confident direction in these sort of things, but we do need to be aware that it is more complex than what's thought out to be. Thank you for everyone who submitted every one of those questions. We have eight. questions still to go that I'll answer next time. Looking forward to bring you that. In the meantime, hopefully you found this useful. Good luck with your rehab over the next couple of weeks and I'll catch you next time. If you are looking for more PhD resources, then check out my website link in the show notes. There you will find my free PhD five day course, other online content and ways you can personally connect with me, including a free 20 minute injury chat to discuss your current rehab. and any tweaks you might need to make. Well done for taking an active role in your rehab by listening to content like this, and together we can start ticking off all of your rehab goals and finally overcome your PHT.