Q&A: When will sitting ease/foam rolling/massage guns/PHT warm-ups & cooldowns

: On today's episode, we're diving into another Q&A. 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. answering three more questions on today's Q&A. Sort of, I've tried to clump them together to have a certain theme. Today we're talking about recovery expectations. We're talking about shockwave, PRP and surgery. I thought that would be nice to group together. And let's dive in. Today we have the first question from Leslie Sinclair, who said, I'm managing to get back to running and close to my previous pace. Do you ever recover from this injury and do you have any, any more good news stories? Uh, thanks Leslie. I am planning a few more success stories that are in the works at the moment. Um, as I think I should start asking more clients about their stories and coming forth on the podcast. Um, But yes, I know success stories are high in demand. It's not always on the forefront of my mind, but whenever I do get a really, really nice story, especially one that's slightly different to the success stories we've had in the past, definitely reach out and see if they want to agree to share their story. But let's dive into the, does this ever recover or do you ever recover from this injury because it's something that hit time. And time again, a lot of times on Facebook groups, a lot of times people messaging me, like, do you ever recover from PhD? And will it ever completely go away? Just trying to answer that in itself is very, very hard to say. Will it ever go away for good? Um, it's almost impossible to answer or to answer with real confidence because it just depends on what you're going to put yourself in front of for the next. like the next goal that you have, or, you know, we're constantly trying to challenge ourselves and challenge what we're capable of. And so we're always flirting with that line about that would potentially resurface symptoms. Um, and let's just say if I have what injury, I haven't had it up and been injured for a while, but, um, say I was dealing with a shoulder injury a couple of weeks ago and. to say, okay, will I ever get back to my gym work symptom free for the shoulder? Well, yes, but if I underload my shoulder constantly, then the pain just goes away. But if I were to next week, overdo myself with way too much like shoulder press or bicep curls or chin ups or chest press, then the symptoms will come back. So it depends on what you want to do with moving forward. Do you want to continuously float with that line between rehab strength progression, building upon your strength, the next running race that you have, how much are you willing to push and how much you're willing to float with that boundary line and floating with that boundary line is totally fine. But if symptoms do arise, just accept it. That's a part of process and accept that that's a part of the journey and the risk that you take on when you decide to do these things. So saying will it ever come back? I believe when someone asks me that, will my tendinopathy, no matter what the tendinopathy is or what their injury is, will it ever come back? I believe it's unrealistic to think that it's never going to come back. But unrealistic, especially if you've had the tendon symptoms for more than several months, say four to six months, if you've had a tendinopathy beyond six months, it's still going to come back here and there. I believe it's going to come back here and there just as you flow with that boundary line. But however, with proper rehab, it should be less and less of an issue. you'll build up the capacity, you'll build up your strength, you'll start to return to more and more meaningful exercises and it just becomes less of an issue. Might pop up here and there, maybe just very mild symptoms, maybe for a few hours to 24 hours and then just fade away. And as you continue to build, continue to build on your mileage, the baseline symptoms start to settle. all of a sudden it just fades away to pain free symptoms, but then any gentle fluctuations in your training load, if you start to challenge yourself for races and things coming up, yes, it might resurface here and there. If requiring like a hard session, like a lot of people, when I'm talking with PHT, they are training for a marathon or something and they build up their mileage and they're successfully building up their mileage. and they're back to running speeds and running hills and like I've totally overcome this issue. And then all of a sudden they prepare for this marathon and it's a getting to the marathon is a bit of a long drive if it's about two hours and so they drive for two hours then they run a marathon then they have a two-hour drive on the way home and that starts to produce an ache and that starts to produce symptoms they haven't had symptoms for a long time they're thinking oh damn it's come back. But that's okay. It's almost expected. You've run a marathon and you've sat for four hours in a car and symptoms have slightly come on and slide starting to produce an ache. I would be happy with those symptoms if it returns back to baseline within a couple of days, because it's such a challenge. You've put your, your tendon, um, through such a workout and combined with all the sitting. that you can probably live with that. Most people will live with those particular symptoms, but it's the meaning that you attribute to that. Because most of the time, I would say, okay, I've expected this, I've drove for this period of time, I've ran the marathon, which was successful, but all my PhD didn't hinder me during my marathon. So I'll definitely live with that. And if I'm a bit achy for the next couple of days, that's fine, because I know my tendon is really strong through all the rehab that I've been doing. I know it's going to revert back. relatively soon, then I'll just continue moving without losing fitness and still maintaining my strength. And so it's very manageable. And which is why when someone says, will it ever get better? I say it's unrealistic to think it's, it's going to go away for good, because it can resurface here and there, but it becomes less threatening becomes a lot more manageable. And you're kind of okay, and you can live with the symptoms if you decide to push yourself. So if you ran an ultra marathon and your PhD is a bit sore the next day, you can live with that. Um, but try to attribute, don't try and attribute fear and, um, worry when symptoms do arise, there's something that you've kind of expected. Yes, I've challenged myself. Yes, it's a bit sore. It's going to revert back. Um, this is, it's a totally fine. So for me, as an example, Uh, because I've had PhD several times in the past and I think the last six months I've had it really under control because I have installed a gym in my house, I'm constantly doing my deadlifts and my squats and my lunges and I'm progressing that strength and I'm also, um, writing down my running mileage, my running intensity and keeping real close attention on, uh, my overall workload. And so because I'm doing everything really well, I haven't had PHT symptoms for six months or so. And if I decide to drive, I guess sometimes if I have a really hard running session and then I do a gym session and then I'm driving with my girlfriend to Ocean Grove, my tendons might be my proximal hamstring tendons on both sides might be a bit achy after that drive. And I'm okay with that because I know, okay, I put myself through a bit too much. I know tomorrow is going to be totally fine. So this isn't an example of my PhD doesn't completely go away, but I'm okay with that. So just keep that in mind. That's my best, I guess, realistic expectations for the recovery. So I hope that helped Leslie and hoped helped you other listeners as well. Next we have Lazeel Pujita. Hopefully I pronounce that okay. Asks how effective is shockwave therapy and PRP to treat PHT? This is a bit of a loaded question for me because I get this all the time and often jumping onto injury chats with a lot of PHT clients. I see this quite often and see the results of it and we'll start with shockwave because shockwave there's a lot more science to point to and a lot more advice that I would have for people when it comes to treating PHT and I'll start by saying shockwave can be effective for some but you need to fit within the certain criteria. And if you don't fit within that criteria, then shockwave is probably less likely, it's less beneficial for you or the outcomes or the odds of you having a successful outcome is a little bit less. So I do have a podcast episode with Benoit Matthew. He's a shockwave specialist and he goes through this criteria, but let me talk you through this. It is for people who have very stubborn PHT that just hum at a very low background pain and doesn't respond to effective evidence-based treatment. And so a good candidate would be someone who has had PHT for more than six months. Their pain is around about a one or two all the time. They've tried doing their dead lifts. They've tried doing their... progressive strength rehab, their load management, everything that we talk about in this podcast and it just still doesn't respond. It's, it just lays dormant, it lays in its stubborn little state and is the shockwave is designed to wake up, kind of spark that tendon back into action. And so then hopefully after doing those sessions, it should start. you should start responding to that effective management after that. And so usually you should notice an improvement after about three sessions of shockwave. And if you are responding in those three sessions, usually about five to seven days apart, if you are responding well to those sessions, then you might require three to five sessions, never really beyond five sessions. Uh, so keep that in mind. A lot of health professionals that have shockwave might think that you need more, but sometimes it's a bit more of a money grabbing kind of scheme. Others try and deliver that it's going to heal your tendons. That's another big misconception. It doesn't do anything to recover the state of the tendon doesn't do it doesn't have any healing properties is there to actually irritate things to actually make things worse in the short term to wake it up because that stubborn it's the stubborn low lying tendons or the low grade tendons that don't respond to treatment that need that aggravation that need that irritation to kind of wake it up and you know kind of smack it around say okay let's start responding to strength and conditioning. So there's a few things on the back of that so yes you do need to be the right candidate and I've seen a lot of people that just aren't some people have like five or six out of ten the shockwave is going to heal the tendon. It's not going to heal the tendon if you are operating at like a five or a six out of 10 pain, and then you have shockwave, it's just going to irritate things. It's gonna spark things up to an eight out of 10, and then it just irritates things. So you need to be very careful and choose the right, make sure you're a good candidate for undergoing those sessions. But accompanying that needs to be rehab. needs to be strength and conditioning. Because if you just if you are a good candidate and it is this stubborn, low level pain type of tendinopathy, and then you do some shockwave and then you stir it up and it makes things a little bit worse, it's in that moment, a couple of days after that shockwave, that it should start responding to effective strength and conditioning. So if you just do the shockwave and then don't do anything else, then it's not going to make things better. needs to be accompanied with some progressive strength and conditioning exercises. So really keep that in mind. The next we have PRP which is kind of a touchy subject. I believe when I look at the research I see a treatment that is a lot less effective and no more beneficial than a placebo. So if you get groups of people you have someone inject PRP into a tendon and then you have group of people and they inject saline or just inject a solution that just does nothing and then you see how both groups go they both recover or fair or their response their outcomes are exactly the same so it seems to be no more beneficial than placebo there may be more evidence research that gets published in the future I'm yet to see it but I did interview Peter Maliaris who is one of the leading, the world leaders on tendon management and suggests the same thing. He just doesn't recommend injecting anything into tendons. So keep that in mind. In my opinion, it's rarely helpful. I rarely see PRP that has actually been beneficial for someone's rehab. Someone, a client of mine, actually asked me this because she had PRP and it just irritated things. It made things worse. And she asked me like, do you, is this common? Do you see this? And I made me think and ponder of like how often I would see PRP is effective. And I would say that out of all the PhD clients that I've seen have PRP, I'd say about 60% of them, PRP is just ineffective. Just didn't do anything, did make it worse, didn't make it better, just indifferent. 30% of the time, I would say has made it worse. Uh, which is really, really unfortunate because a lot of, um, those health professionals that are pushing this particular mode of treatment, um, you know, over-promising the, the effects that it would be beneficial. And for some reason it's just not. And so that's like 60% ineffective, about 30% worse. I'd say 10% of people that have come to me and said, yeah, I did PRP and I'm actually feeling a lot better, which is maybe a placebo effect or when I start to question further it's usually other rehab stuff that they're doing at the time of PRP which I believe has made things better. So they might have got the PRP but they also decided to stop running because they need to stop running for two weeks while they after the PRP but then after that two-week rest they started their strength exercises and then once they started their strength exercises, then progressed, and then they resumed running. Um, and then after a couple of weeks, they're feeling a lot better. And so they say, yeah, the PRP really worked, but maybe it was all that those other things that made it effective. Um, however, like yes, 60% ineffective, 30% is often worse. So it's not looking great based on my clinical experience and the people that are coming to me. However, I'm very conscious to know that I am receiving. a biased sample size. So I am seeing the people who haven't got better, they're more likely to reach out to me and say, I need help with an effective management plan because this hasn't worked in the past. However, some PRP people who were successful, and it was beneficial for them, they're less likely to reach out and seek my advice. So I'm getting a bit of a biased sample size there. So I'm wary of that. But if you're listening to this and you're like, oh damn, so if I can't do PRP, then what can I do? I'd say you don't need PRP because it's so ineffective, and people are delivering all these promises and I'm saying that it's probably less likely to be effective. Don't worry that it's just another treatment option that you can't do because you do have good effective treatment. It is tailored rehab. It is tailored. progressive strength and conditioning, all the stuff that we've been promoting throughout the entire podcast in every 60 odd episodes. So you can still be proactive. There are still options out there, so don't be too discouraged. 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 henshing 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. Lastly, we have our question from Donna and said, I've had PRP three times. I've had PT many times and months. I've had ten jet, which is just like removing damaged like tendon tissue. It's like a very minimally invasive kind of invasive procedure. Growth factors and wondering if there are any doctors that do surgery to remove the micro tears. I can find doctors that do surgery for complete tears but not these micro tears that I have. So my advice would be I believe micro tears don't need to be removed or don't need to be fixed. Because you have micro tears there doesn't mean you need to do something about them. In fact, I often see people who are asymptomatic that have micro tears in their tendons. So it's less important and you don't necessarily need to think about it. And that can be quite tough for someone to manage or handle if they look at their scans or their doctor has told them they have micro tears. It could be a very threatening language. It can attribute a lot of negative emotion like... drive a lot of fear and anxiety and worry and be like, oh my God, these micro tears are here on my tendon, on my really painful tendon. Can we do something about it? You've already had that ten jet kind of procedure. So any sort of things that are worth removing and cleaning up have already been removed, but these micro tears are still there. But I guess like if it is a micro tear, what the best they could probably do, like if they decide to remove, micro tears, they're just causing more damage. And I think you probably best I'm not a surgeon, but you probably best just to leave it there and just use your rehab to strengthen the healthy part of the tendon. Because the micro tears themselves won't be the main driver of your pain. It's very hard to kind of wrap your head around if something if a tendon has tears. that should be the driver of the pain, but in fact, it's probably not. In fact, that's usually the intact, but sensitive part of the tendon that's actually driving your pain. And so what we do for rehab, if the tendon itself isn't this 100% healthy, strong, pain-free tendon, then our goal is to strengthen as much of that healthy tendon as possible. And once it does get super, super strong, the rest of the tendon, those little micro tears, little damaged parts of the tendon, they no longer need to, they're no longer required to apply load or they've just got so much more support around them that the pain just kind of fades away. So this is why you're unable to find surgeons that- actually do this procedure because in my opinion, it's totally unnecessary. You don't need to do anything about those little micro tears and instead just have a really good management. And I'll say it again, it's progressive strengthening exercises, doing lunges, squats, deadlifts especially, finding a dosage that you can tolerate and it might be body weight. It might be just a little bit of weight, a little bit of reduced reps. might be reduced range of movement, just find a starting point and then progress from there. Once you progress from there and pay attention to symptoms along the way, your odds of success greatly improve. So just keep that in mind and I hope all of these answers to your questions, I hope you're satisfied with a lot of these. Hopefully it's giving you a lot more realisation about PHT. So just keep in mind as I kind of recap these particular questions, keep in mind that when it comes to recovery, yes, you can definitely recover. Being more realistic in terms of will it ever come back? Is there a time when this completely goes away? I'm a little bit more on the realistic side of things and saying yes it will come back but it'll be a lot less of an issue. It'll just be less and you can manage it super easily and you don't worry about it. It's like, okay, push myself. Here's a little bit of soreness. I know that it's gonna return back to baseline or return to pain-free relatively quickly. Shockwave, that you do need to fit the criteria. You do need to be a specific candidate for you to respond well to Shockwave. Should only take three to five sessions over three to five weeks. And that if you are a good candidate, candidate you can do that in accompanied with a strength and conditioning program. PRP less effective don't recommend it for a lot of people instead just do the tailored rehab. Similar to micro tears I don't believe you need to actively address this I do think it would just resolve itself just recover strengthen the healthy parts of the tendon and as long as you're diligent and the strength program or the management plan is effective enough, you shouldn't have any issues. Good luck with your rehab throughout this week. Next week we're going to be answering more questions that looking at am I improving if sitting remains painful, the role of foam rolling and massage guns and looking at the best warm ups and cool downs of PHT for your cardio exercises. So I'll delve into that next time. And until then, good luck with your rehab. 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.