Q&A: Yoga & Nordic Curls / Hip Extension Irritation / Return to Running

: On today's episode, we have another PHT Q&A. small hamstring tendinopathy. This podcast is designed to help you understand this condition, learn the most effective evidence-based treatments, and of course, bust the widespread misconceptions. My name is Brodie Sharp. I'm... 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. Welcome back, PHT Rehabbers. We have another Q&A, as I said at the start, and as I said last episode when I answered all of your questions from Instagram. This time I've picked the best from our Facebook responses. And so let's dive in. The first one I wanted to cover was a question from Craig who says, can yoga and or Nordic curls help produce hamstring issues? Okay, this is... It was a little bit tough for me to try and work out, decipher what help reduce hamstring issues is. Like, do you already have hamstring issues or are we talking about preventing hamstring issues? But nonetheless, I've tried my best to answer this one. Let's start off with what exactly, well, I'll start off with Nordic curls and let's start with Nordic curls, what they actually are. So if those of you who aren't familiar. Essentially, what we need to do is be kneeling. And we have some sort of device, you can slide your heels under a couch, or put your lock your ankles in place with something called a Nordic T bar. Or at the gym, they might have some sort of contraption where there's just some padding sort of fixed into place where you can just slide your ankles under and they just lock them into the ground. And so you're kneeling, ankles are locked in. and the Nordic curl is essentially starting in an upright position. So everything from your knees up to your shoulders is completely vertical. And then you are lowering yourself down as far as you can control. So the aim is to slowly control your descent as you're everywhere between your knees to your shoulders stays completely straight. As you lower yourself down towards the ground and they'll get to a point where you can't control that slow descent anymore, but you still try your best to lower yourself down as gently as possible until you can't control that anymore. Then your hands sort of catch your fall as you hit the ground. And then you passively just come back up. You can just like sit yourself back up and repeat that process. So we're only focusing on that eccentric portion or that descent, the down phase. And what that does is do a really good job of strengthening the hamstrings as they eccentrically contract. I've done episodes in the past talking about the importance of hamstring eccentric control, especially when it comes to things like running, where the demand for the hamstring to tolerate eccentric control is really, really high. And so Nordic exercises can be perfect for adapting your hamstring to tolerate more. eccentric control. So that's the Nordic curls. Okay. Is can Nordic curls help reduce hamstring issues? If we're talking about injury prevention, yes, it can. I actually did in my last year of uni, did a, wrote up a systematic review and my, the title or the topic of my paper was Nordic curls and whether they can help prevent hamstring muscle strains. And the main demographic was sports athletes, mainly soccer. It seems to be the research out there was mainly around soccer players, but there was some rugby, some football, Australian rules football, and so compiled those. And while the participants in a lot of those studies, so with a systematic review, it was my job to see all of the available papers that had already been released on a certain topic and I picked sports athletes. So I gathered papers where the athletes would do Nordic Curls and there would be soccer players, there would be basketball players, rugby players, and then I had to gather all those papers and gather all the data and sort of come up with a unified summary of all the data. Is it effective? And turns out it is. A lot of the athletes in those papers weren't that compliant to the Nordic curls and they had to do it like say three times a week, two or three times a week during their trainings. And it was like five sets of five. So not a lot, but the athletes didn't really do them. But those who did do them, even those who only did 50% of the agreed upon dosage, they still saw improvements. curls doing those does prevent hamstring injuries in sports athletes, which is why it's kind of tough to answer your question, Craig, because you said reduce hamstring issues. So if we're talking about the hamstring muscle belly, then yes, definitely does a good job of preventing hamstring issues. There's good research out there, because I've seen it personally myself. If you already have issues, if you already have hamstring soreness, does it do a good job of reducing hamstring issues? Just taking another interpretation of this question. It could, it could definitely help reduce hamstring issues if you currently have soreness, but we need to make sure it's within your adaptation zone. So that's hard to determine because someone with a really irritated hamstring could do their hamstring curls and they're just so much worse because of it. And it's essentially the hamstring curl has been, is above your current adaptation zone. It's above what you can currently tolerate. Whereas if you're really strong, you can handle a good eccentric load and your symptoms are mild and non-irritable, then definitely you could do these Nordic exercises couple times a week and that can help reduce the hamstring soreness because you're building up your capacity. It's within that, your adaptation zone and you can built upon it. And it will do a great job, like I said before, of working on your eccentric strength for the hamstring muscle belly. Like I said before, my paper was on hamstring muscle strains. So we're talking about a strain in the muscle belly, but won't really do a whole lot. Won't isolate the proximal hamstring tendon. Because like I said, when we do this our knees and our shoulders are like everything straight, completely straight from our knees to our shoulders. So we're not in hip flexion. We're not bending at the hips. And it's when we bend or hinge at the hips is when we start targeting the upper hamstring. And since we don't do that in that movement, it doesn't really do much for the proximal tendon, which is why if someone is used to doing Nordics and they do want to target the proximal hamstring proximal hamstring tendon, I like to do a variation called a Nordic hip dip. I don't know if that's a name that's universally used, but it's the one I use. I don't know if I made it up or not. Uh, so we have the same start point. We had the same ankles, like, um, fixated on some sort of contraption. You're kneeling. So knees are bent at 90 degrees. You're straight up from the knees to the shoulders. And this time we are bending at the hips. We are hinging at the hips and keeping everything fixated. So you're kind of doing this like little drinking bird. And if done to full range of movement, what you would see at the end of range is ankles locked in place, knees are bent at 90 degrees and hips are also bent at 90 degrees. And your chest is working your way towards the floor. And it's extremely tough. will, you know, most people can start off with like one quarter range of movement, potentially doing three sets of four. And this time you are dipping down and unlike the Nordic dips where you hit the ground and then you sort of passively just crawl your way back up, this time you're dipping down and then you are contracting your hamstrings to bring you back up. So you're actually doing the dipping down and the rising up. portion. Very very tough to do and it's tough to kind of get your head around when you're doing the maneuver. It's kind of foreign, kind of hard. A lot of people sink their hips back into their heels which is kind of cheating. You really need to feel like you're falling forward but your hamstrings are strong enough and your ankles are fixated enough to keep everything stable. And so that's a variation you can do if you do want to target the proximal hamstring. Um, I like to do this in replacement of someone's dead lifts. Let's say I always want to do a dead lift. That's always number one, but if someone's traveling, someone doesn't have access to weights, um, they don't have a gym membership, all those sorts of barriers can be in place. This is like a secondary. If we can. So then we would progress to doing full range of movement, which is that 90 degrees, we can even progress by having someone hold onto some weight like close to their chest. So they get like a weight plate or a heavy backpack or something that weighs heavy and just hold it close to their chest as they do that dip. But like I said, this all needs to be within your adaptation zone. We need to try and work out what that is. We can do that documenting symptoms during after the next day to see if it's acceptable and then we can build upon that. that would be very, very good for the proximal hamstring. All right, Craig, you also mentioned, can yoga help reduce hamstring issues? It maybe can reduce hamstring soreness in the immediate term for some. I think some people like to poke into pain a little bit. And it's like, oh, it feels so nice. It's like scratching an itch or like feeling like you're paying attention to a sore area, which is why people started. stretching or over stretching their hamstrings back in the 90s and early thousands when early 2000s when this wasn't really well known this condition and people like oh yeah I can really find it hits that sore spot so they just kept doing it kept doing it kept doing it to the point where they stretch so much that it exceeds their capacity and doesn't and continues to mildly irritate things and doesn't make things a whole lot better. but made people feel better in the immediate term, so they just persisted. So it can help reduce soreness in my interpretation of your question, Craig, but only for the immediate term. I don't think hamstring or yoga would do much to heal a proximal hamstring tendon or hamstring soreness in the long term. Doesn't seem that likely because yoga doesn't really do too much to raise the capacity of the muscles, tendons, which is what we need to do in our rehab to actually make long-term improvements. Will it do anything if you aren't injured? Would it do anything to prevent hamstring issues? Probably not. We know that most of, it might play some role. If we know anything from the origin of PHT, it is exceeding your capacity. So if you go for a run, that capacity needs to be quite high. If you exceed that capacity in your run, say with speed work, you increase your risk of developing PhD. Does yoga do anything to increase the tolerance for you to run further? Probably not. But I have seen people develop PhD purely from sitting for too long. and they sit for too long and there's that active compression on the sit bone. And does yoga play a role of increasing your capacity to tolerate compression? I would say slightly. If you're used, if you've, if you're used to stretching and you've done a lot of stretching and to the point where your tendons and ligaments can tolerate a lot of compression through hamstring stretches, then my guess is that individual can probably sit for longer. without developing PhD in that very small demographic of people who develop PhD purely from sitting and not through athletic backgrounds. So yes, I would say slightly, but in most cases, probably not. Hope that helps answer that question, Craig. It was kind of a little bit hard for me to take one direction on that one, but hopefully I got there in the end. Okay, we have Tasha. Hello, Tasha. Asks. Single leg hip extensions with a band tend to irritate my pht However hip thrusts in brackets with heel on a chair or a step do not Any advice ideas on why that might be? Thank you, Brody. Thank you, Tasha First of all, let's bring everyone up to speed on what these exercises are You mentioned hip thrusts as the exercise but then you put in brackets with the heel on a chair or on a step. I'll, this is where my definition slightly changes. I would determine a hip thrust as someone who has their feet on the ground and their shoulders or their back on a bench. And so they're sort of elevated up where their head is at the highest, not the other way around. I would call that a hip thrust. So weights are on your hip crease and like I say, feet are fixated on the ground, back of the shoulders on the bench and then your hip thrust, your hips thrust towards the ceiling. If you go the other way around where your head is on the floor and your chest is on the floor, but your feet are high up on a bench and then you thrust your hips towards the ceiling, my terminology of that would be a bridge. the same action as a bridge like a glute bridge that everyone knows except it's just a glute bridge with your feet up, with your feet up on a chair or up on a bench. So I'm assuming you're going to mean by my definition, a bridge with your feet up, with your feet elevated. Then we have the hip extension that you mentioned. So you say that these, the hip extension is what provokes or irritates your PhD. So for those who aren't familiar, a hip extension would be in standing where the band is fixated to something in front of you on the floor, say around like a table leg, and the band goes around the table leg then goes around the back of your heel as you're facing that table. And then against resistance you're keeping your legs straight and with one leg, the leg that the band is wrapped around, you're extending back behind you. So, Tasha's question, why does that irritate my PHT? But if I do these, well, what I would deem, a bridge with my feet elevated, does that not cause any issues? I would say probably because it's a different stimulus. It's a different activation for the hamstring and a different stimulus for the tendon for a number of reasons. I've listed these differences. One, is the degree of hip extension or degree the different angles of the hip. Like I said the differences between the Nordic drops before and the Nordic hip dips, what helps preference those is different hip angles. So we're using our hip angles to sort of change the demands of the tendon. When we're talking about these two exercises, we're looking at the hip that goes into extension beyond zero degrees. So like, um, completely standing up straight. If you go backwards, your hip is going into extension. If you are, if you're doing a bridge, your hip is already inflection. When you start that exercise. And then when you hip thrust up towards the ceiling, you're going, you're technically extending the hip, but you're going to zero. You're essentially. extending the hip back to neutral because you've already started inflection. So there's a difference there. But then there's another difference which is what we call open versus closed chain. A closed chain exercise is when your working leg is just fixated, planted onto something. It's planted to the floor or it's planted to a piece of equipment. A Nordic dip would be an example of a closed chain exercise because everything's fixated to a structure. Whereas hip extension with the band, like I say, it's, this is what we call an open chain, because your leg is kind of like moving in space when you do it. And that can be a bit more challenging for the hamstring tendon and the muscles because it needs to sort of control it. There's no stability there in that exercise. The other differences would be like, I'm not sure. We haven't mentioned if it's double leg or single leg, but if you're doing a hip extension and it's a single leg compared to a bridge, well that is double leg, then there's obviously big differences there. I think Tasha, your hip thrusts that you mentioned are probably single leg, but just thought I'd mention that anyway. But also we have another difference, which is the knee angle. Because The hamstring is unique in a sense that it crosses two joints. The muscle itself crosses two joints. It crosses the hip and it crosses the knee. So if we manipulate both of those angles, I've already talked about the hip. If we, um, change the angle of the knee, then it changes the demand. And so because the knees are bent during the bridge exercise, it is. What we call short lever. Whereas with the hip extension. the legs stay completely straight. And that is tougher to move through space when there's a longer lever and resistance at the end of that lever. And so that's another reason why it can be a little bit more challenging. But combining like, or like mixing and matching all of those variations, those four variations I mentioned, just makes it harder or weaker for people. And the same reason why sometimes a glute bridge can be perfectly fine for PHT, but people really struggle with that shoe off test. Not all the time, you can have PHT and have a fine shoe off test, which is essentially like you're in standing and you dig your heel, essentially trying to slide your shoe off your foot by digging your heel into your other, into the toes of your other foot. That could be... uncomfortable for people just because it's longer lever, it's straight knee, it's extending the hip, all of those compared to like a glute bridge. Yeah, a lot of differences. But this is a really good insight Tasha to learn that hip extensions are irritating. This can be considered like a weak link that we need to strengthen to really build a lot of resiliency and fortify the hamstring for your future goals that you have. Because I love when a client comes to me and says, yep, deadlifts are fine, step ups are fine, but I really struggle with hamstring curls. Or vice versa, like hamstring curls, I could do fine, single leg, eccentric hamstring curls, done, but as soon as I do a deadlift, I really struggle. It's these sort of identifying these weak links to say fantastic. Let's not shy away from that particular exercise. Let's not focus on, you know, keeping it really, really easy. Let's try and find whatever variation we can so that we make that weak link your strongest link. We can't simply ignore it because as soon as you try to ramp things up, say in your running or cycling or sitting, it heightens the risk of symptoms returning only because we haven't addressed that weak link. We've simply just shied away from it. But if we make it your strong link, fortifies everything. So good insight, Tasha. I hope it all goes well and hope that helped answer your question. We have a last one from Caroline who says, I've been wondering during my PhD rehab, if it's okay to start running again, how will I or others know when it's okay to start jogging? Feels like there feels like it's getting there, but figured it must be a common question. It is a common question and one I love answering. So I'll do exactly that. Everyone's different. The green light to return to running is based on a number of factors, which I'll list, which I don't always use. Sometimes it's just, you know, you just get a sense and sometimes it's just, let's make a start to start really small. But for those who are listening, some helpful factors that can... Play a role, okay, how severe is the injury? How long have you had the injury for? And how irritable is that injury? Severity is like how painful it is, at its worst, at its best, what levels are we talking here? Duration is okay, how long have you had it for? Has it been two weeks, two months, two years? And irritability is okay, once we've overdone things slightly, how long does it stay irritated for? Does it stay irritated for two hours? two days or two weeks. That's what we're talking about in terms of irritability. So we sort of gather a, you know, an image or just a snapshot as to how things are behaving to be like, oh, do we risk going for a run or not? We look at strength history. Okay, how strong do we think this person is? Are they in the gym? Are they doing fitness classes? Are they doing deadlifts? If so, how heavy? Fitness history. Okay. Have you been a runner before? If so, how long ago were you running? If so, what distances were you covering successfully? That is very different. Like a runner who has spent four weeks not running, but has ran for 10 years of their life before that at a high mileage is very different from someone who hasn't really ran before, but wants to start running, um, you know, overall. But then we look at fitness history as well. Like, okay. Um. What's their cross training history? If they haven't been a runner in the past, but they've done a ton of cycling, ton of gym classes, spin classes, HIIT classes, aerobic classes, all that sort of stuff, then we know they have some sort of capacity to do that. Then we look at their, this is all like looking at their history, but then we look at their current rehab. Okay, what is their deadlifts? What is their step-ups? What is their hamstring curls? What is their eccentric strength? Like currently, what can they tolerate in their rehab? that symptoms are falling in within acceptable limits of their rehab. That's the strength side of things, but then we can look at the function side of things. Can they jump? Can they hop? Can they run, jog on the spot? Can they do jump rope? Can they do cross training? Can they do elliptical bike? All those sorts of things. All of these is just painting a picture to say, if we do decide to run, how risky is it? Because there's gonna be no right or wrong. there's going to be more and less risk involved. That's a big, you know, some people like to put benchmarks in place and therefore have a little bit more confidence to say, okay, I need you to do these check marks before then deciding, before then starting a walk run. But someone can be really poor in a lot of these. But we still make a start anyway. We can say, you know, just jog for 10 minutes and jog for 10 seconds, do that a couple of times and see how you feel. No right or wrong, only just greater and smaller risks that we take on board. But for this to be a little bit more helpful, a little bit more practical, some benchmarks that you can try is jogging on the spot. So you can do three rounds of 60 seconds jogging on the spot. You can do hopping three rounds of 10 seconds on each side. If you can tolerate that, if things fall within acceptable limits, I would say, you know, let's give it a start. Some other benchmarks might be walking for say 30 minutes, fast walking or hill walking for say 10 minutes. If you can tolerate that, I'm more than confident that we can start a walk jog program. But this all goes back to, okay, Caroline's question, when is it okay to start running again? What does running look like? Because I could easily say, you know, you're good to go now, but let's do a walk jog program where you are jogging for 20 seconds and then walking for three minutes and we're doing three rounds of that. See how you go. That is a very small conservative start and there's nothing wrong with starting. really, really conservatively because if you say, all right, my symptoms were fine during fine afterwards and fine the next day, then we can repeat that same thing again, if not a little bit more the next day or every second day. And then we just build up from there. And so my role as a physio and something that you might want to take on board as well is just saying, okay, what risk do I want to take on? And how conservative of a start do I make? progression, acceleration do I make after I know that dosage was acceptable. My role of physio is just having piecing all of that together to say, okay, this is our best guess. Assumption is what we think you can tolerate. See how you go. If it is too much, hopefully we've done a good job of not really ramping up and overshooting things so that you're flared up for several days. Hopefully if there is a slight Um, if we've overshot the mark slightly, hopefully it saw only for 12 hours back to baseline after that we've learned from it, we'll adjust because of it. And then we move from there, but in most cases, if our assumptions are correct, it's well tolerated, we can do a little bit more next time and then continue from there. So Caroline hope that answers your question. I hope this has been helpful for everyone who's listening. Um, I'll plan to do Q and A's maybe every couple of months. Um, we'll see what the. Um, enthusiasm engagement is like, and your feedback. So if you do have any feedback, feel free to reach out to me. Um, I hope all goes well with your rehab this week and for the next two weeks. And we'll catch you in the next episode. 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.