Q&A: Tendon Swelling, Squats vs Deadlifts, Aggravating Tasks, Give Up Running?

: On today's episode, I am 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. Welcome back everyone. We are finishing off answering the questions that were given through Facebook groups and various social media accounts. I've been spending the last couple of episodes going through them and I think I've left myself some doozies. I think, yeah, just as I go through a list of, you know, 15 different questions, I sort of left the tricky ones to last, but nonetheless, I endeavour to answer all of these questions. The first one comes in from Patrick, which, you know, had to get me thinking a little bit. He asks, what are your thoughts on inflammation during rehab? For examples, on rehab days, I have a little bit of a swollen, but not painful tendon. Does this mean it's getting blood flow and healing? And that was his question. Okay, so I'm guessing after doing some rehab exercises, Patrick, you're sort of feeling the high hamstring area and feeling like the tendon is a bit swollen. And like you've mentioned, not painful, just swollen. Hard for me to imagine exactly what's going on there. First of all, this is my current understanding of tendons and tendinopathies subject to changes. you know, new research and investigations trickle out, but tendons don't really get swollen. They thicken chronically over time. There's you some people may have scans MRIs and it shows tendon thickening. And classically, we can see that with the Achilles if someone has a really chronic Achilles tendinopathy, you look at the width of the Achilles on the affected side compared to the non affected side and sometimes it looks a bit thicker. But that is a slow gradual process that happens over time with a chronic tendinopathy. It's not something that just, it thickens and then goes down and thickens and goes down, which it seems for you, Patrick, seems to be the case. It seems to be responsive to rehab where you feel like it's swollen and then it comes back down, then it's swollen and it comes back down. So for an acute inflammation, it's hard to imagine the tendon itself getting inflamed. This is why we've moved away from the term tendonitis. We don't really use that term anymore because the ITIS part means that the primary influence of this pathology is inflammation. ITIS means inflammation and tendonitis means tendon gets inflamed but We know since the primary driver of pain and dysfunction isn't really inflammation, there's more other processes that are going on. Sure. There might be a little bit of inflammation there, but it's not the primary driver. So we've moved away from tendonitis and start calling it a tendinosis or a tendinopathy. They're sort of interchangeable that are more common these days. Um, so either, I'm trying my best to answer this question. either your perception of the swelling or maybe hypervigilance is there maybe after rehab there is more awareness of that tendon and therefore you feel it and it's might you might have the perception of it feeling more inflamed yet it's not exactly an accurate case or if you do feel like there is some significant swelling maybe it's something else maybe there's other structures that are going on. the bursa is probably something else that some people report. Some people feel that like, they feel like they're sitting on a peanut or they're sitting on something that's like a bulge or something that feels a little bit inflamed. Often that can be an inflamed bursa high in the hamstring that can, like if it's swollen, it usually can be painful. So it's like... that the bursa are just like these fluid filled sacks of fluid and they are responsible for lubricating things structures that sort of cross over and pass over one another. And you do have several bursa around the high hamstring region. And sometimes if it gets irritated, sometimes with blunt sort of trauma, like if you fall onto your sit bones or that sort of trauma, get inflamed. Classically, like it can happen to the elbow, some people fall, they fall on their elbow. It like irritates one of the bursa and then just swells up sometimes to like the size of a golf ball in like the worst circumstances. But then if it persists, they can like put a corticosteroid into the bursa and it helps calm it down significantly. And that would usually, a bursa would usually stay inflamed for several days until it calms down. But like I said, if it still remains irritated, then you can use those interventions. Potentially that could be what's happening with you, Patrick. Potentially there might be some other swollen structures around that gets irritated with rehab. Hard to believe it's blood flow and healing. I don't necessarily think that would be the case. I know you've just question marked, does this mean it's getting more blood flow and that for it's more healing? I would be pretty... confident to say no. Blood flow, well yes, blood flow can increase as with rehab as you're, you know, working certain muscles, more blood flow will go to a muscle. And yes, we do know that blood flow contributes to healing. We do know that certain parts of the body that have a rich blood supply do heal quicker muscle will heal quicker than cartilage. Um, and certain parts of cartilage and certain parts of the meniscus that are more, um, Deprived of blood flow, if there's an injury in that area, it takes longer to heal. So yes, there is a correlation there. There isn't a lot of blood flow that goes through tendons, but the situation that you have where you feel like things are getting more swollen, then calm down, swollen, calm down, wouldn't be blood flow. Blood flow doesn't swell things up. It's more other types of fluid that do that. However, my advice would be, um, not to focus on the swelling per se. I would follow pain and function and see if that those symptoms are on the trend, on the improve. So rather than focusing on, okay, how much swelling am I getting? How long does it take to, you know, settle down and using that as a guideline to whether you're hitting the right mark or not. I would just, um, focus more on pain being How sensitive is the pain? How severe is the pain? How irritated is it after the workouts? And function. Am I improving? Am I lifting heavier? Am I running further? Am I cycling? Am I sitting better over the long term? So look at those trends, the pain and function, those two things over the long term, week by week, month by month, to know if you're heading in the right direction, rather than focusing too much on the swelling and try and interpret what's going on. Hope that helps, Patrick. Okay, another one comes in from Brian, which I've probably answered your question, Brian, because I know we jumped on a call several weeks ago, but thought your question was insightful enough to address the rest of the podcast audience. So Brian asks, squats versus deadlifts. I understand deadlifts are important to PHT recovery since they load the proximal hamstring tendon the best. However, Could you please comment on squats in relation to deadlifts? Do they also work the proximal tendon? I recently added Bulgarian split squats to my otherwise stable deadlift routine and they have flared me up and I'm not sure why. I think a lot of people have this same question. So yes, squats are different from deadlifts. My best interpretation, let's start with the deadlifts. So... The deadlifts do a great job because they are solely responsible for loading the upper hamstring. Other exercises like a hamstring curl, they might load, primarily load sort of the mid-belly of the hamstring, but the deadlifts do a great job of targeting the upper hamstring, the proximal hamstring where that tendon is located. And not only does it target that upper area, but it also compresses the tendon. It sort of loads and compresses the tendon in a certain way that if you can get the right sweet spot, it will trigger a nice adaptation, increase function, increase capacity, decrease pain, and follow that trend. It's hard to find that sweet spot though for a lot of people. We might need to really adjust the range of movement, the tempo, the weight, the sets, the reps, and all those sorts of things to find that sweet spot, but that's why they work so well. When we talk about compression, we're talking about kind of the tendon wrapping around and behind the sit bone so that when you hinge forward, it kind of squashes the tendon around that bone like a physical kind of compression. It's kind of hard for me to illustrate or depict exactly what's happening without certain diagrams and videos and that sort of stuff. But we like compression because we need compression for day to day life. We need. the tendon to tolerate compression when we climb stairs, bend over, pick something up off the floor when we sit and all those sorts of things. And so adapting your tendon to tolerate more compression is obviously going to carry over into better function, which is why again, deadlifts are so good for that. I'm not entirely sure how squats are different. My best interpretation, my best understanding currently is that squats do a... pretty good job of compressing the tendon, but not really like pulling on the tendon. There's not a lot of load going through the hamstring itself, but it just squashes the tendon. It's kind of like sitting, but under higher loads, I guess you could call it. So it doesn't really, it'd probably do a good job of irritating if too much without adaptation, because we're not getting the necessarily, we're not getting the necessary load to adapt. So load, just compression without the load, deadlifts have the load and the compression. Like if we do squats, most people would feel domes in the quads and the glutes. Not necessarily, I don't really find too many people that have domes in their hamstrings after doing squats. So that's a fairly good indication that you are working your quads in your glutes when you squat, but you know because you go into that sitting action, you're essentially you know squashing that tendon. under load. Like I say, it's hard to describe and that's probably my best understanding. I'm probably wrong. I don't know. But based on the mechanics and based on how I know these type of movements influence the body, that's my best understanding. And so, yes, we do. Squats are totally fine. Like I want you to still do squats if you do have PHT, but just be careful. Just know that it's not a direct... rehab exercise per se, it's an exercise that you can do when having PHT, but you just need to try to find the right sweet spot for you. And often that is, if we're looking at settling down the PHT or not irritating or not aggravating the PHT, probably modify that range of movement of the exercise because the further and deeper you go into the squat, the more likely you are to compress the tendon and therefore irritate the tendon. So, If you've never done squats before and you wanna give it a try, sure, start with some lighter weights, but also start with a reduced range of movement. Find yourself a box that if you squat and you just touch that box and your hips stay above your knees so your thighs don't go below parallel, then that could be a good starting point. Try it out, try three sets of 10, three sets of eight if you want to. See if there's any irritation afterwards. If not, then we can add in some weight. keep the range of movement the same. With, I've been trying to get through this answer with my dog barking and it's kind of hard to concentrate at the same time. I feel like she's settled down now, so I feel like we can continue, but for now I'm just gonna pause whenever Jasmine starts finding another dog that's walking past or something like that. All right, let's refocus. Back to Brian's scenario of the Bulgarian split squats. So if someone isn't familiar, Bulgarian split squat is kind of like a static lunge but you have your rear foot elevated up on a box or a bench or something and then you squat do a single leg lunge kind of action straight down and then back up again. People might know it as a rear foot elevated squat or something to that effect. This is a bit tougher because it's single leg it's kind of mimicking the pressures and the strain of a squat. but just doing it single leg. So that's a lot more load through that one area. For some reason, like if we're talking about squats, like back squats, and most people get their doms in their glutes and their quads. When I do split squats or these Bulgarian split squats, I sometimes get doms in my upper hamstring. So yes, there's probably some sort of load going through there, maybe some eccentric load high in the hamstring. the movement slightly different. It's kind of like a lunge, which lunges do a little bit more load in the upper hamstring. So we do need to be careful because there is a lot of compression. It is single leg. There is a lot of tension on the glutes and the quads and the hamstrings. It's a good bang for your buck exercise. Like when I talk about advice for runners, if they don't really want to spend a lot of time in the gym or doing a lot of... spending a lot of energy doing these exercises, I just give them the Bulgarian split squat because it ticks off so many muscle groups and it's a very efficient exercise. But we do need to be careful with it if you've never done it before. And to Brian's point, like I said, had a stable deadlift routine and then just introduced Bulgarian split squats and flared things up. That's a fairly good indication that we do need to be careful with these sort of exercises. So if you did want to start doing them, that's fine. Start with body weight, reduce the range of movement. So maybe have like a foam roller or a Pilates block or a yoga block or something that's about, you know, three, four inches high. And then when you drop your knee down to the floor, it only just touches that item, whatever you wanna put underneath and then come back up. So you've reduced the range of movement of that exercise. That could be a useful start. Yeah, and just be careful with the initial load. And you can do three sets of six on each side as a good starting point, and then build up from there once you know that falls within your adaptation sweet spot. Next one comes in from Jen, who says, are there activities that tend to aggravate PHT more than others? Activities of daily living or particular sports like walking versus running, quick movements, cycling, et cetera. Okay, thanks for your question, Jen. My initial response is, okay, everyone's a little bit different when it comes to what really aggravates their own PhD. It could be because there are three different tendons that attach onto the hamstrings. So, you know, if it affects one, two, three, or any individual tendon, symptoms may vary. But also like if we're focusing on just one tendon, A certain portion of that tendon has the tendinopathy. So it could be the front surface, it could be the side, it could be somewhere in the middle, it could be behind, like depending where that tendon weight within that one tendon, the pathology exists might influence or change symptoms slightly as well. Um, but also people have different vulnerabilities with their symptoms. Like some people can tolerate compression, but not load. Some people can tolerate power, but not compression. Some people can tolerate the endurance stuff, but as soon as they do any speed work that sets them off. There's, um, this is just based on what, uh, load and experience and exposure the tendon has had to then develop its own strengths and weaknesses. And so it will vary and be different, slightly different for everyone, but follow your symptoms. Like if Jen, if you're asking what activities really aggravate PhD more than others, Give them a try. Do you find that walking irritates more than running? Do you find that cycling irritates more than running? Vice versa, like we wanna put on our own scientific hat and we wanna conduct our own little experiments. Sure, we wanna be safe about it. If we wanna see if running irritates more than cycling, then just do like five minutes of slow running, then do five to 10 minutes of easy cycling and see. Judge your own symptoms to see what. what's different for you. For example, like I've seen people do very, very well with cycling. Let's just say I've seen people that can ride, cycle for two hours, but they can't run for two minutes. I've seen some people that can swim for five minutes and irritate. I've seen people that can swim for two hours and not irritate and vice versa. And so it really depends. But typically let's... try to answer your question Jen with a good blanket kind of statement. What irritates? Running, particularly speed work. Often I'll see a runner who says yes I've had PhD for six months. It sort of happened around the time that I was introducing more speed work than usual or I was just getting slightly faster. I was preparing for a race and like my long runs were getting slightly faster, my easy runs were getting slightly faster, or I was incorporating more structured speed workouts. And we know this because as running speed increases linearly, hamstring demand increases exponentially. And so that's why we need to be very careful. So that would typically be activity that irritates, aggravates BHT more than others. Typically, if we're running, sometimes uphill running can be an influence, sometimes not. Hit classes like high intensity interval training classes usually incorporate a lot of jumping, a lot of lunges, a lot of squats, a lot of deadlifts, a lot of kettlebell swings, all those sorts of things. So if people aren't used to it, a lot of people get like health kicks around this time of the year. People have these goals that they want to attend. the getting fitter, losing weight, getting stronger, pairing for races, all that sort of stuff is very high on people's motivation. And so they attend classes and they attend like gym challenges. This is a big thing these days and people sign up for a gym membership and then they attend all of a sudden five classes a week without, you know, the prior week doing none of this stuff. Then all of a sudden they're doing a lot of deadlifts, a lot of lunges, a lot of squats, a lot of kettlebell swings, and that's too much. especially kettlebell swings. It's power-based, speed-based work on the upper hamstring when you do kettlebell swings. And so that does have the ability to irritate PHT more than others. If we're looking at daily activities, most people know sitting is one that can irritate more than others. Sitting on hard surfaces, something that irritates more than others. But other things moving around, I would say like, Housework, I would say sweeping, vacuuming, anything that has like this little lunge that's being done over and over, this little like hinge pattern. That yeah, is just done, you know, hundreds of times if you're, depending how big your house is, if you're sweeping. I would say gardening can be something that irritates more than others, but it just depends what you do when you do garden. This is something I've seen quite often. Typically, because there's a lot of crouching. a lot of kneeling, a lot of compression, a lot of like, innocent movements just done a lot. And a lot of people, I would say most people that go out gardening for a 30 minute task usually ends up two and a half hours. And I typically when I was working in clinics would loathe gardening because it would cause flare ups and cause injuries the most like someone like. when you see enough times your clients come in, be like, yeah, I was gonna do some gardening for 30 minutes and then I was out there for three hours and now I've got really bad neck pain, shoulder pain, low back pain, you know, when you start hearing that enough times, you start, you know, loathing gardening. And that's why I sort of have that potential trigger. But hopefully that helps answer your question, Jen. But. I think anything to fall back on for anyone who's listening is just to try a few different things, try some experiments and then to see what you are prone to, what are you vulnerable to, what are your strengths and just use your own symptoms as guidelines. But I do want to suggest that we don't avoid these things. If we've found something that really irritates and aggravates, but something, but it means a lot to you. Don't shy away from it. Just find where your tolerance is and then build upon it. I've seen people say, you know, I have found that sitting on hard surfaces is a really aggravating factor. So now I just stop sitting altogether, period. And they just stand all the time and lie down all the time. And then, but sitting is something that really means a lot to them. Takes away a lot of their quality of life if they're not sitting. And so that's where we're. we sort of don't want to do those things. If you really want to run, there will be a way to get back into running. You just need to find your tolerance, you need to find where that is and then slowly build upon it. So just a closing bit of advice for that question. Okay, lastly, we have one that comes in from Betty, who says, I'm returning to a running program two times per week after doing PRP three times on one side. after PHT and partial thickness tear in the hamstring. One physio is saying to me, if I get PHT one more time to stop running, another one saying nothing. I've had PHT for a couple of years. I can either give up running or swim, but have to do strength work on my legs for the rest of my life, whatever happens. Do I get a physio to write me a program? It's looking like a lot of time and money. I'm really scared. what to do, thanks. Okay, hopefully I can help you out here, Betty, because we don't want anyone being scared about the scenario that they're being presented with. So, let's start with the non-running side of things. I am yet to find someone who has to give up running. I'm yet to find someone and I've seen a lot of PhD clients, a lot of them gravitate towards me. Usually it's someone who's been through the ring, I've seen a ton of in-person. health professionals before they eventually get to me, sometimes 10 plus years of tendinopathies. And I'm yet to see someone who I say, you know what, maybe we can't return to running. Yet to see that. Remember, if you have a chronic tendinopathy and it's really painful, there's a lot of dysfunction there, the vast, vast majority of that tendon is going to be a healthy tendon. it's only gonna be five to 10% of that particular tendon that has the tendinopathy that's deriving all of that pain and all that dysfunction. It's only like a small percentage of that entire tendon. So what we do is we treat the healthy portions of that tendon. We increase the capacity of the healthy fibers of that tendon to help build up your capacity. And that capacity can increase to the point where you can return back to the things that you wanna return back to. If you can't tolerate a lot of running right now, then yes, some cross-training options might be helpful. You can do swimming, you can do cycling, you could do elliptical. Jump rope is something that I often prescribe. I often prescribe like cardio circuits, getting someone to like find five or six stations of push-ups, star jumps, you know, maybe the bike or maybe a rower or maybe the elliptical or a ski erg. Just finding a whole bunch of different things that don't irritate the PHT, but. still get your cardio going. But you know running can be done, just needs to be done sensibly just yes you're back to running following and running programs that's nice two times a week that's a good start. But just follow your symptoms from there just keep it slow keep it flat and when I say flat I mean the terrain and then slowly build things up from there. You can do it. This is my bread and butter. This is me working. I work with runners all the time. And we just follow that and just use symptoms as our guideline. And there's a lot of episodes here to instruct you on how to follow those symptoms and how to respond to those symptoms. In regards to the strength training, you say that, okay, do I need to do strength work on my legs for the rest of my life? I would say probably, but. For strength in general, like for strength and capacity, if you wanna continue running, if you wanna continue being fit and healthy, you'd wanna do strength training anyway. But it doesn't need to be too disruptive. We should eventually get to a point in your rehab where you're lifting somewhat heavy and only doing that twice a week. That's a good stable rehab strength training plan for most. Like work one muscle group twice a week is a good way to build upon your strength. But then if you want to maintain that strength, you probably only need to work that muscle group once a week, just for maintenance. Once you've reached the capacity that you want to reach. And Betty did mention, it sounds like a lot of time, a lot of energy, a lot of money. I would say probably hiring someone initially to teach you the basics if you're a bit uncertain of the decisions you should be making. That's my bread and butter. If you want to jump on a... a call, we can like offer these free injury chats to people. And you can book in for that and then we can discuss if there's online options that might suit you. But this is what I do. I jump on calls with people. I build out programs for people. I talk them through usually a one month package is the most popular. So we have a month of us working together to build out and learn as much as possible about your particular injury and your particular strengths and vulnerabilities and how to work towards your goals. But then by the end of the month, hopefully you've collected enough data and you've got enough wisdom to know how to progress things, to know when to progress things and what that plan roughly looks like. And then you've got those skills. You've got that for the rest of your life. It's just one sort of small investment that then you have those principles to take away and move forward with. In regards to like gym memberships and weights and equipment and those sorts of things like. I just recommend for most people, if they don't wanna get a gym membership, just buy some adjustable dumbbells just for home. With adjustable dumbbells, you can do deadlifts, you can do calf raises, you can do squats, you can do lunges, there's plenty of things that you can do. You can buy them secondhand off Facebook marketplace. Just those dumbbells, you just got the different arrangements of weighted plates that you can just put on. as you get stronger. And then as you get stronger, yet again, you can go buy more plates and buying them secondhand, you can get them super cheap. And the quality of the weights never diminish. It's always, 10 pounds is always ever gonna be 10 pounds. It's always gonna be something you hold onto. So like, you know, you're not limiting your quality there, but you can get them super cheap. Another option for you, Betty, is I do have the PhD online workshop, which... sort of walks you through. It's a little bit more affordable. You're not getting this one-on-one tailored thing as you would if we do work together, but it is, has a series of videos and it's my best attempt to teach people the principles, how to build running programs, how to build cross-training programs, cardio circuits, how to develop the right strength training program, how many times per week, what those progressions look like, how to interpret your symptoms to progress, all those sorts of things. It's probably equivalent to jumping on about three one-on-one calls with me, but for a more affordable price and you can just watch it at your own leisure. You can go back and revisit videos and there's instructions there to build your own plan. It's off a Google spreadsheet that you can copy and paste and do all these sorts of things and do it all yourself. So that's an option for you as well if you're concerned about where to go, what direction, what am I doing? Sounds like a lot of money, sounds like a lot of energy. That might be a good option for you as well. So we have now got through all of the PhD questions for this particular bunch. Maybe I'll do this again in a couple of months, but I do have some potential interviews and research papers that I do wanna discuss in the next couple of episodes. So we'll hold off on that for the meantime, but hey, as this episode comes out, it will be the 1st of January. So happy new year to everyone. Um, let's look ahead and work on your rehab goals, work on, you know, being a better you, I think everyone has that sort of focus for the next, uh, as the new year ticks over, so hopefully you found a lot of wisdom in the past 12 months, especially since you're now listening to this podcast, I'm very grateful for the audience and for the questions and for the interest and, um, responses and feedback I get for everyone who listens to this podcast. I'm very grateful for you. Hopefully you found this episode helpful and I'll catch you in the next one. and together we can start ticking off all of your rehab goals and finally overcome your PHT.