Richard's PHT success story

: On today's episode, Richard's PHT success story. 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 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. guys are asking for them and I'm trying to search for them. Um, today we have another success story. We have Richard and he has, uh, we did it a little bit differently today, rather than just going through the journey of developing, um, and the moments that like progress the condition and then finding the right answer and managing it to overcome this and then the success afterwards, rather than doing that, we kind of structured a little bit differently. So, um, had developed PhD in 2009 and it was a five year stint that he eventually overcome and we talk about that in a second but then he also had another resurgence as he went into lockdown, was unable to go to the gym which was like last year and he'd been battling like a kind of a second wave of PhD and so we talk about that, we talk about how it first set it out in a bit of a different format because he emailed me a fair few dot points of what He found tremendously successful for the rehab of his PhD. And we go through those today. So we go through like loading and pain levels. We go through recovery days and sleep. We go through training intensities, weight training, timeframes and a few other modalities, a few other treatment things that he has tried like dry needling and PRP. And we talk about his experience and the successes successful with a few of those approaches. And so yeah, hopefully you can dissect this success story and apply it to your own management, to your own recovery and keep you in an optimistic state, because we know learning from these success stories, even though they've had them for several years, still managing to... overcome them once they implement the right strategies. And Richard did confess that the five years of PhD was mainly contributing to mismanaging it. And once the management like kicked into gear and like good long-term management kicked into gear, everything fell into place with a bit of patience. And so let's hear Richard's story. Richard, thank you for joining me today. Yeah. Thanks for asking me along. You've got a great podcast. I love listening to it. Yeah, brilliant. So how about we get started with you just introducing yourself, where you're from and how your PhD injury came about. Yeah. So in normal life, um, I'm a specialist doctor and I'm very interested in, um, exercise, particularly in older people like myself, being 60 plus years old. I'm also very supportive of the community being involved in exercise. So I'm one of the organizers for Park Run in North Sydney. So I think Park Run is a wonderful, all-inclusive thing, which, you know, people don't have to be athletes. They can just turn up and walk as much as they want. And it's really supportive and people progress from there. So Runs became a great community event and lots of social supports. And the other group I'm with is Kirribilli Runners, which are a great group. Nice one. And when it comes to the injury itself, like how long ago did that arise and how that come about? Well, I've always been quite sporty. Um, I've done. many city to surfs since 1976, and I played soccer for about 15 years. And when the world masters came to Sydney in 2009, I thought, well, here's an opportunity to do something. What can I do? And unfortunately, just before then playing soccer, which is sort of explosive, spinning type sport, I hurt my right hamstring. So it was a high hamstring injury. And I just... Foolishly, I decided, well, I'll just ignore that and push on through. And I thought, yeah, what event can I train for the masters? So I thought, yes, I'll do the a hundred meters, which was in retrospect a silly idea. So it's a pretty high risk for tendon injuries, you know, in retrospect, I should have gone for a longer, slower distance, but, um, you know, I've got a coach who was very good and I sought out a good physio who said, Oh, well, we'll just try and get you through and then we'll do some rehab afterwards. So. I tried a whole. gamut of different treatments. But I think, you know, in retrospect, it was the failure was my own self-management where I just kept going and going. So, you know, I was 50 years old and I thought, oh yes, I still feel like I'm 18, it'll get better. But one thing is you get older, you know, older, certainly over about 30. If you get a tendon injury, it's very slow to heal. And this is my first tendon injury and I just didn't understand what was going on, even as a doctor. And it's safe to say that like the longer you have it for the harder it is to get rid of like, I think one of the most profound things about running injuries is if you can. catch it as early as you can and be proactive within like a couple of days, you can make significant gains really quickly. But if you like I say, if you ignore it, and it starts to develop, like the symptoms start to get worse, but also the longer you've had it for as well. Once that starts to manifest itself, then it's very hard to start progressing in the direction of recovery. Yes, absolutely. So that's what I did. I was silly, I kept pushing on and I had that injury first time for five years. And it really only got better when I stopped playing soccer with that explosive acceleration type movement. And just let it settle down. And then I started getting to the gym and doing some weights, progressively doing it heavy and heavier, like doing deadlifts and squats. And I think doing that at a time where I'd stopped exercise, the sprinting helped a lot and that made it like a hundred percent better. But in the meantime, I did try lots of other different treatments as well. I'm not sure if you want to go into those. We might go into those at the end. Um, but I'm curious, you said you've had this for five years and I'd be curious to know like at its worst, like did it. Okay. And did it ever stop you from running? Did it ever like inhibit a lot of those activities? You just kept, kept staying active. It just was sore. Oh, it came to the time even just walking. And sitting, you know, sitting is classic. And that's another thing I didn't realize that sitting causes compression of the tendon and I just didn't understand what was going on there, but you know, with, you know, with further research, I discovered, you know, sitting causes compression. So, um, you know, initially trying to limit the sitting, but then progressively getting back into it, you know, and not, not avoiding it. So I guess sort of taking a sensible balance, non avoidance strategy towards it. with coming up with like the content of today's episode, you sort of emailed me a whole list of dot points that you found was very profound and very beneficial to your recovery. And the first one was being like when it comes to loading in general, and running, keeping the pain levels below a three out of 10. And I'm curious into your, I guess, definition or like internal perception of what how you classed it less than three or over three, were there any sort of characteristics that categorized it into those pain levels? Well, I guess like, you know, the usual thing is the way we talk to patients, 10 out of 10 is the worst pain you could ever imagine, like if I sawed your leg off and zero is nothing. So with running, my aim was to keep it very mild. And I think what's really important for people to know is that a bit of mild pain is not bad. So as you've mentioned, your tendons need a bit of loading to heal and remodel and complete rest is not going to do that. So just being in tune to your body and being careful when you're running. thinking about it's not the run you're doing today it's about how you're going to be tomorrow the next day and the week and the months after and just being very patient. How I would like to usually when new runners beginners they really struggle to internalize what a five out of 10 might be compared to a three out of 10, particularly if you have that entire scale of 10 being the most pain imaginable. It's, it's sometimes very hard to gauge what the twos and threes are and what. the best way I could come up with it is like a pain level which is severe enough where you notice it there like during the run it's definitely there but it's not severe enough that you it hinders your mechanics in any way like you feel like you're able to plant yourself on the ground confidently you're able to kind of take off produce force from the ground comfortably compared to the other side it feels quite even in terms of confidence is that kind of what the sort of in internalizing, trying to see if it's an okay level of pain or not. Yeah, that's a great way of putting it. So being able to run the pain is mild, but doesn't inhibit with your ability to run and doesn't, you know, you obviously don't end up limping or anything like that. And I think if you go out for a run to try and test it, if it doesn't work out, you just go realize, well, today is not the day. You just got to stop and walk back home and don't keep pushing on because you're regretted later on. You just got to find that right balance. And I think with experience, you just get in tune with your body and get to feel what's going on. Definitely that experience, definitely learning from. The past experiences, like you might've said, okay, maybe this was a, a three out of 10 pain, or maybe this is an acceptable level of pain. And then it's not only until afterwards where the, it might've been aggravated the next day, it's probably a bit worse. And then you kind of reflect back on that experience, say, maybe those, that level of pain was a little bit too elevated from B it's a bit beyond that acceptable level of pain. And so you kind of try and remember those past experiences and just like learn along the way what your level of acceptable pain might be. Yes, that's right. So it's not the pain so much during your arm, but it's what it's like in the next few days. So you think, yeah, in a couple of days, if I'm sore, you think back, what was I doing? The other point that you had was the importance of recovery days and the importance of sleep as well, and recognizing that, you know, when it comes to tendon adaptations, it's not during the running that. enhances all the benefits, it's actually the recover after that exercise bout where the tendon starts to get stronger, starts to adapt and starts to heal. When it comes to that, I guess, insight was the, did you have to enhance your sleep? Did you have to enhance the recovery days or was it just a process that you naturally followed? to me the importance of sleep. But one of the best books I've written, I've also read in recent years is called, Why We Sleep, by Matthew Walker, he's a professor of physiology from Berkeley. So it's the real deal. So he basically says, sleep fixes everything. So sleep is when you're making a growth hormone, which is very important for recovery and also testosterone as well. So you don't get fitter during your run, you get fitter during the recovery phase afterwards. So it's not just the days off, but also getting good sleep as well. And there's also been some interesting stuff about what professional athletes call sleep stacking. So you get some really good sleep before an event and that helps improve things. So good sleep improves things like how high you can jump, muscular force and VO2 max. And I guess we've all had experiences where we've had a big night and you go out running and it just doesn't feel anything like you're normally used to. really emphasise the importance of sleep. And in relation to your recovery, did you kind of reverse engineer that and recognise the importance and implement stuff to enhance your sleep? Or did you think that the, um, the level of the quality of sleep that you're already getting was adequate enough and just made sure that was maintained? No, I sort of realized, you know, like everyone does, sleep is good. But what this emphasizes is good quality sleep. And one of the big tips that Matthew Walker gives is having a sleep schedule. So you not only have an alarm when you wake up, you set a time when you go to bed. So, and you wind down before you go to bed as well. So you're not on your devices or, you know, watching TV or doing anything else stimulating, you know, you turn down the lights a bit and, you know, get into bed by 10 o'clock. It's a good quality sleep. And the other thing is looking at what interferes with sleep. So certainly caffeine, uh, in the evening's bad and alcohol is bad. It interferes with the type of sleep you're having. So the beneficial type of sleep is, uh, REM sleep and, um, and deep slow wave sleep, that's where all the good stuff happens during the sleep, not night sleep. Hmm. The other points that you made, um, one of the the stuff in the email preparing for this content was the tune your body to stay in tune of your body to like kind of gauge its limits. And often when I talk about running injuries or preventing injuries, it's trying to establish the current capacity that you have established the adaptation zone that you're currently within and not exceed that adaptation zone. Otherwise, the body starts breaking down rather than building up and the next question that a runner has is, well, how do you actually know where your limits are? How do you know, um, the threshold that will take you into that injury zone and just below that, which is that nice sweet adaptation zone. And had you had any experience with that? Had you tried to, um, come up with any strategies in order to gauge where your limits were? I think it comes a lot with experience. So obviously that's very difficult for a new runner, but with years of running, you get in tune with your body and you can sort of feel with how things are going during the run and you have a memory for what that feels like in the days after as well. And I think one strategy is like every time you go out for a run, it's not gonna be a smash out run that you're gonna post on Strava and think, yeah, that's fantastic. But I think a good strategy, a lot of people have talked 80-20 rule where 80% of your runs are just an easy run and only 20% of the time are like speed work or intervals. So it's very important to balance the over the week the type of running you're doing and don't feel you have to go out and you know smash it out every time you go. That's very important. For sure I think that 80-20 rule not only has good applications for recovery from injury but also for want to build a big base of low intensity so that the legs are fresh enough for upping those higher intensities. And so that's a really nice lesson. And I think when it also comes to recovery, when people like, well, where is my adaptation zone right now? Where can I, how can I test it out without it flaring up? Well, sometimes my advice would be you can, if we're unsure of where that gauge is, we're unsure of where your limits are, let's just start embarrassingly slow, embarrassingly low and build up from there because eventually we're going to reach your adaptation zone even if for the first couple of weeks we're under loading you, at least we're a bit more cautious rather than just... guessing and you going out and overdoing things and flaring things up and making things considerably worse. So, um, around this topic of like this gauging those limits, sometimes it's nice just to underdo yourself because runners kind of have that. It's a very common characteristic to easily overdo things based on, you know, they just want to get out there or maybe it's frustration. They haven't ran for a long period of time and they just want to get over this injury and they just overdo things. Did you find that, that 80-20 distribution, um, did you find that was beneficial for your performance as well as your injury? Yes, I think so. I think people have got to realize that like doing a long slow run is not just. something to fill in the time, but it's actually something that's really quite beneficial for building your overall performance, particularly in longer runs as well. So, yeah, certainly, you know, don't feel embarrassed about it. Like what I heard is like Kip Choge does his long runs at six minutes per kilometer. So if the world record holder can do long runs at an incredibly slow pace, there's got to be something good in there. When it comes to the... Strength training itself as well. I know you mentioned a bit earlier that strength training had a real, um, benefit in your recovery. How far into having this PhD, did you start doing some of the, um, some of those weight training exercises? Well, I, when I got fed up when it was really bad, I was having trouble walking. I just like, stopped running and then got into the gym and then had her personal training in the gym and learned how to do his lifting and that was something that's quite new to me and I think the evidence now is that quite different from what was told to runners in the past that, you know, lifting heavy is very beneficial for tendons. And, uh, what we don't realize is when we run, it puts, you know, several times your body weight through tendons, you know, particularly say the Achilles. And, uh, humans are really good runners because your tendons are sort of so strong and store energy, that's very important. You have good, healthy tendons to improve your running efficiency. So I guess if you hadn't done that, if you hadn't had much experience around starting point for you and how did it progress? How long did it take to progress? It probably took several months. I mean, what surprised me is that if you regularly lift weights, you can quite quickly improve your strength, which quite surprised me. And it's not certainly not bulking up. You're not any up looking like hard Schwarzenegger, but it's just improving the strength without the bulk. So probably about three to six months, you get a significant benefit. And what surprised me is I could go out and run hard, do a hard 5K. wasn't sore anymore. It was quite surprising the benefit. I guess my, my next question would be like, how would you progress? Like exactly what exercises were you doing? And, um, from your starting point to, you know, several months down the track, were you following a particular method of how to increase the weight or how to increase the sets and reps? Yes. Um, I think the The weight to choose is what you can reasonably do, 10 reps off, and then only increase about 10% per week. And just another thing which comes to mind is that when COVID happened, I stopped going to the gym and I wasn't doing that, you know, heavy weight strength training. And that's when my proximal hamstring tendinopathy came back. So I think it probably means that if you've had tendon problems, it's probably good to have a maintenance program of weight training to keep your tendons healthy and stop an injury coming back. What were your favorite exercises? Do you have like two or three that you regularly would go back to that you found beneficial? Oh yes, I think carefully doing a deadlift. I want to emphasize carefully because if you don't do it carefully, if you do it too heavy or too much, that's obviously going to stir it up. You're going to go way beyond your adaptation zone or the Goldilocks zone where it's just right. The other one would be squats and the other one is lunges with dumbbells. And I think also weights are better than machines. Machines for people new to the gym, machines seem to be something new and interesting and easy, but I think the important thing about weights, it means you have to incorporate balance and coordination and your core as well. Whereas the machine is very efficient as exercising, you know, one particular muscle, but it misses out on coordination and engaging your core during the exercise. Great. When it comes to the, the patients, you said like, tendons take time to heal and I guess you may have experienced like this slow improvement. Can you just talk about on like a time scale when you when you mentioned that tendons are so are slow to heal and to have patience, like what that time frame was like for you? Yes, I mean, you just have to understand tendons have very poor blood flow. It's not like a muscle which has great blood flow and can heal quickly. So, and particularly as you get older so that your composition of your tendons tends to change as well. So it's really important to realize one, your tendinopathy will get better. Don't be exasperated. You've just got to give patience, sometimes extreme patience. So I'd say at least three months, probably six months, just to this very graded rehab. uh, with weights and sensible return to running and being in tune with your body. So people tend not to just have to be very patient, but it will get better. Everything gets better. Yeah. And did you notice that same time scale? Did you notice around about that three, four months was the, um, that timeframe of noticing improvement? Yes, absolutely. Yeah. So if you just stick with it, uh, maybe go to the gym, you know, two, three times a week or buy some weights at home. And that's what I did during COVID. that's just sort of the right dose. But again, for each person, just being in tune to your body and just seeing how it responds to that loading and making, because one thing you can do being going to the gym is a bit like running. You can get a bit overexcited and just do too much and then end up too sore, particularly at the beginning. Yeah, good lesson. And I often see like people ask me questions, I often see like Facebook posts of people with a certain tendinopathy for several months and they just ask, will it ever get better? circumstances where it just doesn't it seems like never ending and constant battling like flare ups or you know, just plateaus and improvement and what I like to have that same timeframe in mind to say it's like around four to six months is what most the research shows but that's four to six months from when you do really well structured rehab. If you just continue to mismanage it, it can drag on a lot longer. It's four to six months from a good strength program and like all the stuff we've discussed today. That's the type of time scale we're expecting. those expectations are quite met. But obviously the maintenance side of it is quite important as well. You might be a few months in, notice some improvements and then like your experience back off the strength training like not have access to gyms and back off that heavy kind of strength work and then there might be a bit of a resurgence in symptoms and so throughout those four to six month timeframes, it needs to be quite diligent, it needs to be quite progressive and it's to be expected that some pain would arise if there was a bit of a lack in progress or if you were to back off a lot of that strength work or a lot of all that, those beneficial components in your rehab. I think that's really important to consider. those expectations of those timeframes is really important. So I am curious about your other experiences with treatments and treatment modalities. I know you said that you've mentioned PRP was one of those and you may have had it twice, I believe. What was your experience with that and what was the outcome? What did you experience? Well, PRP is interesting. It seems to be quite- popular amongst professional athletes like football players, I think like Tiger Woods has had it and another people. The evidence is probably supportive. There's been some systematic reviews of it for different types of tendinopathy. So I think for an individual, if you've tried everything else, it's something worth trying, but I certainly wouldn't promote it as a magic bullet. So seek out a sports physician that has experience in it, particularly a sports physician that treats say, you know, a professional team that's used to elite athletes, not just someone who does So try and search around and find an expert that works at a high level sports group and try it out. So the rationale about it is they take some blood out of your arm and they spin it down the centrifuge and the top where the red cells are, they take off a little tiny bit which contains the platelets, which is said to contain growth hormone. and try and promote healing. So that's the rationale about it. It's also been used for osteoarthritis of the knee sometimes and maybe gives a little bit of benefit, but it's also like used for people have it stuck in their faces to look better. And so, you know, there's a few sort of extreme uses of it, but I think, you know, the systematic review of its use in sporting injuries, particularly tendon injuries is probably supportive. So if people haven't tried it and they're looking for something new to add in, ago. And I think just the general principle that there's not just one thing you need to do for tendinopathy. You need to look at the whole gamut of things like, you know, I mentioned sleep, but there's also nutrition as well. So it's the whole package. And I guess one of the interesting things related to that. probably heard of David Balesford, who was the head of performance for Cycling UK. And when he came on board in 2003, the UK cycling teams was hopeless. They'd only ever won one gold medal in the Olympics. And he came on all this philosophy called the marginal aggregation of gain of the aggregation of marginal gains. So he thought, you know, if he can tweak, you know, 50 different things by a fraction of percent, the overall benefit will be quite huge. So I think that's an important philosophy. towards your rehab management and training as well. 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 hamstring 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. When I look at the research around PRP and look at people's experiences as well, it does seem to be, I kind of put it in the same. basket as shockwave therapy, where it can work really well for some people if they're in a particular category, like it tends for some tendons works really well. But for other people, it just like indifferent. What doesn't necessarily make it worse. But they just don't see much of a benefit. And it seems like there is a certain characteristic or a certain type of person who will favor one or the other. However, very similar to shockwave. I think if it is beneficial, then it's only a short term benefit. you need to do all the other long-term. things really well alongside it, accompanying it maybe like once the PRP settled down after a period of like one or two weeks, but you can't expect it to be the silver bullet. Like you said, especially for the longterm, it seems like it's designed to, if anything, like reduce pain and like, just like trigger, stimulate some sort of healing, but then needs to be backed up by that longterm. You know, stuff like strength training, like the load management, like being progressive with your rehab. Would you agree with that? Oh, absolutely. And I think that sort of reflects a lot of people, whether it's in sport or their health, they just want to get a pill or a one-off fix that'll sort things out. And there's not just one thing that'll fix it and PRP may be useful, as you said, for some people. It's certainly not harmful, it's safe. So if you look for something to add on, it's worth giving it a go. Hmm. And how about your personal experience? Did you notice a benefit? Did you notice any reduction in pain symptoms or any increase in function after having the PRP? Yes. I mean, initially when I got it, it seemed to be quite helpful for several weeks, but then it just sort of faded off. So, and I think again, my own sort of load management at that time was wrong. So I thought, Oh, yes, I've had the magic injection, I'll get, you know, back out running on the soccer field or, you know, doing five K's. And initially was good. And I thought, Oh, yeah, this is pretty good. But then, as he mentioned, it's had a limited benefit. So it really needs to be backed up as a component of a proper rehabs scheme. And the second PRP that you had, was there a similar benefit initially? Um, I, yeah, it was, it wasn't as good as the first one. maybe, I mean, with all these interventions, it's very hard to separate the true effect from a placebo effect. And I think, you know, you go to the famous sports doc who, you know, is responsible for a professional team, you think, yeah, this is going to be great. So there's high expectations and, you know, it's a bit hard to separate what's going on in your mind, what's going on in your tendon. So I think the second time it wasn't as, I didn't find it as beneficial. So, you know, for listeners, you know, if a person wants to try it, there's nothing to stop them trying it. But being mindful, it's a component of the whole rehab process. Yeah, definitely. And I always think like before doing shockwave, before doing PRPs or any other injection based therapies, just get good rehab basics down pat like do all the good stuff first do all the sleep, the strength, the load modifications, do all that properly first for a good three to four months to see if there's any benefit with that before getting that kind of quick fix that's a little bit hit and miss sometimes as well. patients, some people might be encouraged by other like specialist or doctors to just quickly have the injection. But I do think the foundation needs to be set in place first. And I think like based on the clients I've seen in the past and the experiences I've encountered in the past, I think you just The quick fix is not always just going to be there. You do need to do the right things and you do need to have patience. I'm curious about your other treatment remedies, any other methods, any other like hands-on therapies that you may have found beneficial or ones that you just found weren't really that effective. I think that might be helpful to go through. Yeah, I mean another thing I had at the physio, which I never had before was dry needling, which is sort of when you see it, it looks a bit like acupuncture, you know. So with your hamstring, you just lie face down, I stick a series of needles into your hamstring. And, you know, my own personal experience, maybe it was a little bit better. So I don't think it's something which is going to make your tendons get better. It's sort of a symptomatic relief. And similarly, hands on massage, it certainly feel a lot better afterwards, but I don't think it helps in the healing process. I think it's a really good symptomatic relief if you're quite sore. So you go out of the physio's room to think, oh yeah, that feels a lot better. But then a week later, you're still pretty much at the same level. Another thing I did similar to that, I've got an impact massage gun, which if I use that, that provides quite quick relief just in terms of pain, but it doesn't really help healing or progression over the long term. But it's a good relief and it's handy to have at home. You just do it for a couple of minutes and the hamstring feels better. Okay, I do think they can be classed within the same like basket, I think dry needling massage, massage guns, like those hands on sort of things. Um, while they do relieve pain a lot for some, um, maybe that's just enough to say if they have a treatment. And their pain subsides quite substantially for a couple of days. Okay. Well, now you can get back into doing maybe, um, your deadlift exercises, or maybe you can get back into the gym and do a little bit more while these pain levels are quite suppressed so that you can be proactive in this sort of moment. Because as we know, massage, dry needling, massage guns, they are quite short term, but you can use it to your advantage and being more proactive within that window of benefits, um, so that you kind of combining. the short-term benefits with the long-term benefits and I guess being as efficient as you possibly can be. Yes, and also similarly other types of symptom relief like taking non-steroidals. I'd be pretty careful about that. I mean, anti non-steroidal, they can be quite helpful for pain relief, but there may be a bit of a concern that it may interfere with healing. Because I think when you first get an injury, the initial inflammation is probably quite important to promote healing. And if you dampen down that inflammation by taking anti-inflammatories, it's probably not beneficial to help your healing. So I tend to steer away from anti-inflammatories. Hmm. I think there's also research to show that, uh, long-term use of. Um, these sort of medications can actually be detrimental to tendon health as well, especially if it's a tendinopathy, I think the ability to heal, to produce force through those tendons, I think they're inhibited and, um, detrimental for those. And sometimes I think that with the, there's a new, um, injury acronym around, um, injury management, it's like peace and love. And it's a huge, like long acronym. piece, they've got the A and the A stands for avoid anti inflammation medication. Because of the, the research is showing that it can be detrimental in the long term and if you are experiencing quite a lot of pain and you are quite irritable. Sometimes I do prescribe it, but it's only for a day or two, just calm down symptoms and then get off it. I think some people tend to overdo it a little bit and go for, you know, one to two weeks of taking these sorts of medications, which isn't really recommended. Yeah, that's right. Just very short term for a couple of days, just as needed during the acute period. And also similarly, injections of cortisone type medicines for tendons that they definitely settle down pain, but they may end up causing long term weakness of the tendon. So it could actually, you could end up being a lot worse in the longer term. So I'd be quite cautious about cortisone injections for tendons. Hmm. Yeah. Good. Well, um, very important to, to highlight that as well. What, as we wrap up, like, what have you returned back to like over the past, you know, a couple of months, what have your symptoms been like, and what is your current capacity? Um, it's really good now. Like, um, yesterday I went out and did a, the virtual CID to surface. It did 14 K's hard. Um, and today I'm completely fine. So no pain this morning. Um. sitting down now there's no pain. So that was you know a good hard run, you know maximum capacity and over a long duration it was completely fine. So just to give listeners some hope that with patience and the right program, you will get better. But you just got to be patient and realize these tendons have poor blood supply, they're very slow to heal. And if you're older, it's even more difficult. But just be positive, get the right help and avoid doing the things which are wrong. Yeah, well, and like the, the stuff that we've talked about today to actually help your, your rehab has been, um, one of the foundations for a lot of injuries as well, you know, you're talking about low levels of pain during exercise is acceptable, you've talked about the importance of recovery and sleep and then making sure that you have the right intensity distributions and like not pushing yourself too much, obviously the importance of weight training and term kind of modalities to go alongside it. Is there any other takeaways, any other things that we haven't discussed yet that you think people like struggling to recover from running related injury or PhD might benefit from? I think the two important things, one is patience, which we've mentioned, and two, there's no one quick fix. You need to implement a whole broad-based program for your rehabilitation. And just set your expectations and listen carefully to your body. So if you go out for a run and then a few days later you think, oh, that's sore. And then you think back to your run. What was I doing? You know, how hard was I going? How long was I running for? often am I running? So that's the whole total load on your tendon over the week. So you just got to manage that. So it's no good thinking I feel okay today I'll go and run a hard 10k and then that sets you back and you know a few days later you think I was silly. So when you go out for a run you think about your thinking is now not just what it's like today but what it's like the next few days and weeks and months and particularly if you're training for an event, if you've got an event coming up in three months time that's what your focus is on. on how am I going to be my best on that day? Not how am I going to be, but you know, how am I going to go over the next day or week or so? So it's, it's a long-term focus. Yeah, really well said. Richard, thanks for joining us today. Thanks for telling your story. It was really insightful and will help a lot of people. So thank you. Okay. Great to chat. 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.