Running Considerations

: today's episode, Running Considerations with your PHT Rehab. 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 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. Hey, we are back with another episode. Apologies for not having a new release in the last couple of weeks. I have been on holiday, been on a road trip, and I am excited to dive back in and release another episode. I do have, or I think maybe 10 to 15 ideas of episodes coming up, so they will come out quite frequently, maybe one or two a week, but more. Consistent, I guess you can say from this moment on now that I'm back from holidays. Today, I wanted to talk about running considerations. And while this podcast isn't specifically designed for runners and is designed for anyone trying to overcome PhD, a lot of them are runners. And so if you're not a runner, maybe skip over this one. If you are, or thinking about starting some running to help with your rehab. then we can dive into some considerations around technique or around speed, terrain, what might be influencing hamstring tendon load. And perhaps there might be some part of you running the spiking demands in the hamstring tendon that you haven't really thought about. And a lot of, well, I guess some of the stuff I'll be diving into today is based on the paper that I had a couple of episodes ago, the proximal hamstring assessment and management that research paper that I did, I think it was about three episodes ago and the title of that paper is proximal hamstring tendinopathy clinical aspects of assessment and management and one of the key authors is Tom Goom and Peter Malliaris and they're both very well renowned. And in that episode, in that paper, they cover like characteristics of PHT, what the intrinsic and extrinsic factors are, what are some diagnostic tests, and then most importantly for you guys, what is the management and what are the rehab steps that you need to take, what are the stages? And so that's what the whole episode consisted of, three episodes ago, and it did mention in there, which is relevant to today. They mentioned around say pain and pain levels, and they said that some pain is acceptable during and after exercise. And they usually said around zero to three out of 10, with 10 being the most pain imaginable. And the symptoms, so it should be. It's okay for it to be a zero to three out of 10, but symptoms should settle within 24 hours and should not progressively get worse over the course of the program. And so we should be slowly tending towards improvement in those loadings, but during the exercise and after the exercise, those low levels of pain is okay. And when we're talking about running considerations today, that's obviously... quite relevant. Before we delve into the running considerations, again in that paper, just a bit of a recap, they had the four stages of rehab, which usually takes around three to six months, sometimes longer, sometimes up to 12 months. We had stage one, which was the isometric hamstring loading, which is loading up the tendon and then holding that position without moving in and out of that position. So that's what we call an isometric hold. Then we had stage two, which is starting to incorporate movement through your strength exercises. So we call that isotonic. So stage two had minimal hip flexion, so avoiding compression of the tendon. Stage three, we're slowly working into more and more levels of hip flexion, so encouraging and allowing the tendon to adapt to more levels of compression, so more hip flexion. And then finally stage four being that... energy storage loading so you apply metrics and a bit more power based exercises. And then that sort of sums it up really well and is a nice reminder for when we get into these running considerations and so there may be styles like running technique or variations that may increase the load of the tendon especially when it comes to the hamstring and this like incorporating throughout your management can start at any stage. It just depends when the hamstring is ready. It's not, okay, once I'm finished stage one rehab, then I'll start stage two and I'll begin levels of running. It's not as concrete. It's almost, you can do some tests to see, increase the likelihood of you succeeding with your running, but really it's a trial and error. You wanna start at really small amounts with some of the clients that I work with. I give them a return to running program where the very first attempt at running is a five minute walk followed by three rounds of running for one minute, walking for one minute and then finishing with five minutes of walking. So all in all around about a 15, 16 minute exercise session, but it only has three minutes of running in there. And you can start that at any stage. And if afterwards, say the next day, it's a little bit sensitive, it's a little bit irritable. We know that you probably haven't. managed or tolerated that dosage quite well and maybe starting to run isn't, maybe not ready to start running. But nonetheless, let's talk about running technique and there may be some things to do with your running technique that overloads the tendon. The first one, probably the main one that I want to talk about is overstriding. So we call overstriding, if you can imagine when you're running. when you very first make contact with the ground, when your foot very first reaches and touches the ground, if you were to hold that, if you were to freeze that moment in time, we wanna see how far in front of the body that contact is, because everyone's slightly different, it would depend on their cadence, it would depend on their, yeah, how far in front of the body the foot currently is. And why this is important is because if you are, over striding and you are quite far in front of the body, that is applying more stretch and more compression to the hamstring tendon at initial contact in that phase of the running cycle. And it's not necessarily desirable for the hamstring tendon, perhaps unnecessary when it comes to managing the or running with those hamstring loads. And in fact, there's often there is some research to show that if you are over striding, then it can link to injuries because it puts a lot more breaking force through your body, this unwanted, unnecessary breaking force when we want to, when you do contact the ground, make sure it's a bit more underneath your body so that you're propelling forward rather than having this breaking force. And if you do contact closer to underneath your body, then it's less strain, less compression, stretch on the hamstring tendon. And so you can easily just have a look, film yourself running in front of, or while running on a treadmill and have someone record you, maybe in slow-mo with the slow-mo function on phones these days, and just freeze frame when you first make contact with the ground to see how far in front of the body it currently is. Now, it's impossible to not have you a little bit in front of the body. It's just the way we keep balance. Otherwise, if you contact behind your body, you're just going to continuously trip and fall forward until you face its ground. So there will be a little bit of this overstride, but we don't wanna overdo it. And that's where you can compare to other runners or maybe get someone to assess and interpret, maybe a health professional or running coach to interpret how excessive it is. And if it is excessive, then we can start making corrections, which we'll talk about in a second. So number one is overstriding. Number two is what we call excessive forward trunk lean. So if you look at your posture when you're running, essentially from the hips up, we're looking at what your general posture is. Do you have your chest upright or are you leaning a little bit more forward? And why excessive forward trunk lean? isn't desirable is because it can put strain and stretch on the hamstring. It's almost mimicking like that hamstring stretch. If you're in standing, you straighten out your leg, you kind of bend forward and it puts that stretch on the tendon, and compresses that tendon. It's almost a mild form. That's what it's the forward trunk lean is almost a mild form of that. And if we can run a bit more upright, it's putting less stretch on that tendon. So, potentially the combination of the two, that overstriding with an excessive trunk lean, if you exhibit both of those two things in your running and the hamstring tendon isn't really responding to levels of running, maybe it can be something that we can change. Number three is a little bit more technical, a little bit more or harder to visualize or wrap your mind around. But it's what we call anterior pelvic tilt. And if someone has an increased anterior pelvic tilt, then it may put more compression, more stretch on the hamstring. This is less important. I think we're looking at really fine angles currently. But when we talk about increased anterior pelvic tilt, if you look at your pelvis, say if you were sitting in a chair and you try and sit up as tall as you can and try and sit up all the way onto your sitting bones. anteriorly tilting your pelvis. Whereas if you go the other way and you kind of slouch and you're almost sitting on your tailbone, that is a posterior pelvic tilt. And so if someone rotates their pelvis all the way forward so that they're sitting on their sitting bones and then they adopt that same motion to their standing, that it's an anterior pelvic tilt. small in the small arch in the lower back, their pelvis is tilted a little bit more forward. I don't think there's much relevance to this one to be fair. I would definitely pay more attention to the overstriding and the forward trunk lean compared to the pelvic tilt which I'll talk about in a second but it's worth knowing, it's worth noting within this episode. So that's all I have on the technique. side of things and the posture side of things. But I do want to mention some other variables. So when you are running, we should make note to number one, your speed, because there's been tons of research to show that the faster you run, the more your hamstrings need to work. The faster they need to work, the faster they need to decelerate during that terminal swing phase. They just need to work harder. And if we start... If you try a successful return to run program and the hamstring's still flaring up, check your speed. Are you really taking it easy? Are you doing a slow jog? Or are you getting too ahead of yourself? And then when it comes to full rehab, let's just say you're back to running successfully, back to your slow jogs. and you want to start increasing speed, just keep in mind that the faster you run, the more the hamstrings are going to kick in. So yes, it is good to slowly, eventually start working on speed. Like we work on everything. We want to try and make sure we reintroduce everything, but it needs to be gradual and it needs to be systematic. And we, especially when it comes to speed, you can do, say a 5k run. If you can tolerate 5k's of jogging. How about a couple of minutes here and there within that 5k jog, just increasing the speed a little bit and then seeing how the tendon feels and then see how it feels 24 hours afterwards and then adjust accordingly. So speed is another factor that we need to vary in. The other variable is hills, particularly running uphill because when you do run uphill, you make contact a little bit more in front of your body. and your trunk has a little bit more of that forward lean and it puts a little bit more stretch and a little bit more compression on the tendon, which can be good in certain circumstances. Doesn't need to be completely avoided, but we need to make sure that the hamstring tendon is strong enough to tolerate heel work when we start introducing those sort of things, because it's almost going back to that overstriding, that forward trunk lean. We know that the tendon itself There might be something to change if you are constantly running with that over stride and constantly running with that forward trunk lean. But then when it comes to uphill, that's unavoidable. You're going to have to do that to get up an incline. And so it's not that we're going to avoid hills completely. It's we're going to factor this in and know that it is slightly more strain, slightly more load required for the hamstring. We're going to adjust accordingly. So if someone is trying to return to running and they're like, oh, I've tried so many times and the hamstring just flares up, ask them or ask yourself, are you doing a lot of hills? Are you doing an uphill really early in your run? Can you find a more of a flat terrain so that the tendon can adapt to running before you start to slowly implement uphill work? So they're the two variables. So just a bit of a recap. The technique side of things. Overstriding is the one thing you want to focus on. Number two is the excessive trunk lean leaning forward and three is just that anterior pelvic tilt and then your variables want to make sure we're factoring in speed and uphill and making sure that we're not introducing those if the hamstring isn't ready for those. This podcast episode is sponsored by the Run Smarter Physiotherapy Clinic. which is my own physio clinic, where I help treat a wide range of PHT sufferers, both locally in person and all over the world with online physiotherapy packages. In the years I've been self-employed as a physio, close to 70% of my entire caseload has been helping people with proximal hamstring tendinopathy, which is why I decided to launch this podcast. So if you're building upon your own rehab knowledge through the podcast, but still require tailored assistance, I'd love to be on your rehab team. Whether you are a runner or not, head to runsmarter.online to see your available options for working together. If you're still unsure if physiotherapy is right for you, or if you need a rehab second opinion, you can always schedule a free 20 minute injury chat with me. Find the free injury chat button on my website or in the podcast show notes to be taken to my online calendar to book in a time. So I wanted to kind of finish or the second half of this episode with gait retraining and having some ways that we can change how you're running if you are eliciting say an overstride or a forward trunk lean. And the first one I want to talk about is cadence. Now I have episodes on the Run Smarter podcast talking about cadence which you can go to. It's within the first 10 episodes of the podcast. But cadence is how many steps you take per minute. And we know that if you have a really low cadence. which is say, depending on the runner, but let's just say you have a cadence of 150, which is quite low, you may be eliciting more of an over stride and you may be just at a non-optimal frequency. So if you increase your cadence, say in between 160 and 180, because you increase your cadence, because you take more steps per minute, you have to tick the legs over faster, which means that you have to take shorter steps, which means you don't have the time to over stride, you simply just don't have that time available. So you start taking these smaller faster steps and it naturally will reduce over stride and will help out the compression of the tendon that way. So keep that in mind. We can't go really high up, like if your optimal cadence is say 172. and you try a cadence at 190 and really try and tick over, that's in the other direction. We want to try and find this sweet spot because if you're trying to tick your legs over so, so quick, the activity of the hamstring might start ramping back up again. So just keep that in mind. We do know that increasing cadence and in turn reducing like your stride length, it does help increase glute muscle activity. which is what we want when it comes to running. And this intervention has been shown to reduce the provocating factors when it comes to the hamstring tendon. And so there is a role for gate retraining when it comes to these sort of things. Some cues, when it comes to increasing your cadence, just listen to a metronome. Most of the runners I see, they fall in a nice sweet spot. They're already at an optimal cadence. But if your cadence is quite low, then work on increasing it by 10% is usually where the research lies to make a significant difference. So you can listen to a metronome, just apply a metronome to beep at say 165 or 170 beats per minute and then you just try and step to the beat. Other cues to reduce over stride would just be just to imagine you're just not... contacting really far in front of your body. Maybe you wanna contact a little bit more underneath your body. Sometimes that cue can be enough for people to make that change. And it's probably worth noting that we don't necessarily care about heel strike compared to mid-foot strike, compared to forefoot strike. It doesn't necessarily matter. What does matter is how far in front of the body it is. Cues to help say a trunk lean. When I'm working with runners, it's just as simple as like keep the chest upright. As soon as you try and run proud or run just with your chest as like a beam of light moving forward, most people make that correction straight away. It's usually pretty simple. When it comes to pelvic position, if they do have this anterior pelvic tilt, so this A lot of people have been told and health professionals usually tell people that they have too much of an anterior pelvic tilt and they should focus on tilting their pelvis back or leveling out their pelvis while they run and so they activate their glutes and they tighten their abdominal muscles to try and create that tilt in the right direction and then try and run like that. In my opinion, I don't think that's very productive. I think... Um, you want to kind of run naturally and I don't think activating your abs or squeezing your glutes while you're running is eliciting that a really efficient run. Um, and I think that if you were to tilt that pelvis and maintain that while you run, I don't think it has a great effect anyway, so you're probably doing so much effort for very, very little gains. And Nor do I think, I haven't really come to a conclusion of, if you were to do certain strengthening exercises where it will permanently change your pelvic tilt. That's just in my opinion, there may be research that comes out that proves me otherwise, but smashing out the glutes, really strengthening the glutes and really tightening the abs. And then running, like let's just say, we have a look at a runner who has this anterior pelvic tilt. We get them to do six to eight weeks of really intense strength work. where they do work on their abs and they work on their glutes to try and level out their pelvis and then we get them to run again to see if that pelvic position has changed. I don't think it would change. It's based on what I've read in the past and based on what I know about anatomy. We know that strengthening up a runner and then getting to run again, they don't really change their running technique. They don't really change their posture or their running position. So you're probably trying to make extremely hard. You're probably working extremely hard. in your strength and conditioning sessions for very little gain. So just keep that in mind. The other thing that we can implement when it comes to return to running is implementing some walk run programs. Like I said earlier in the episode, I like to give walk run programs to people who are just either if they've spent a long time out of running or if they're returning to running or if they just want to start running. Always start with implementing some walks in between. just to give the, a bit of a break for the tendon and just to give your body a bit of repair time in between those. And then once you're quite confident, once you're doing a lot of mileage just with those breaks, then we can start doing more continuous stuff. So that's the episode. So I know I recapped already, but over striding excessive trunk lean, that increased anterior pelvic tilt are some variables when it comes to your technique. some variables when it comes to the running itself, speed work and uphill, running, gate retraining, to help with that, you wanna increase your cadence, especially if your cadence is quite low, and you might need some professional guidance around that because everyone's cadence, ideal cadence, is a little bit different. Cues to help overstriding, well, increase your cadence and you'll help that overstride, or just imagine that you're contacting less. more underneath your body. When it comes to trunk lean, make sure your chest is up, make sure you're nice and upright and yeah, just the implementing walk run programs. On a final note, you may take all of what we've learned into consideration, might have had a look at your running technique, and then you try small amounts of running and you're still unable to tolerate low levels of running. It just means that we haven't bridged the gap of where your current capacity lies and what the demands are for running, that the current bridge of those two, where you're at and where you need to be is just too much. So keep that in mind. Also, further into your rehab, if you are starting some running, it doesn't necessarily need to be a stage of your rehab where you're like, fantastic, I'm back to running. Let me start reducing my strength work because I don't need that anymore because I'm back to running. Think of it as introducing running or starting to run is now a part of your rehab. Make running a part of your rehab. So maybe just doing those really small amounts of running, break them up with walk, run programs and do that for a couple of weeks, that itself will start allowing the tendon, bringing the tendon within this adaptation zone of running. And so, like all your other exercises, like the deadlifts that you're doing, like the lunges and adapting along the way, running can be a part of that and your tendon will get stronger, your tendon will adapt more to speed and the strength required for running if you start at low amounts and you build your way up. So it's not a milestone that we need to get to, it's just another part of your rehab and like I said if you start small amounts of running and you're not the tendon isn't really or is reacting to it or having a flare up because of it just means that we're not ready and that we still need to spend some time bridging the gap between where you are and where you need to be. That's all for me today guys. I hope you had a really insightful lesson. Hopefully it's sparked a few ideas for you to try 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.