Should you try shockwave therapy for PHT recovery?

: today's episode, should you try shockwave therapy for pht recovery. 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. a shockwave episode from my pre my other podcast the run smarter podcast I split that into two episodes where I talk with Benoit Matthew who I'll introduce in a second and it kind of got split up into the generic information that everyone should know to do a shockwave and then in episode two of that podcast I break it down into certain conditions like plantar fasciitis Achilles and. Proximal Hamstring Tendonopathy. So what I've decided to do is kind of edit out all the unrelevant information and then just kind of squeeze it into one episode. So there will be a little bit of editing involved. Hopefully it's a bit seamless for your experience when you're listening. But yeah, we're gonna delve into Shockwave today, exactly what it is, exactly who will favor or be the most beneficial for and... what's type of stage and then yeah, we'll talk about the proximal hamstring tendinopathy specifically later in this episode when I splice in episode two. If you are enjoying this, if you are an Apple podcast listener or if you are listening on an Android app that's where you can subscribe, make sure you do so because then you get reminded, you get notifications and prompts whenever an episode does come out. Just because I'm doing releasing these episodes a little bit infrequently, different times, different days, different frequencies of the week. It's always good to have it just pop up on your phone saying, Hey, there's a new episode and you can find a time to listen to it. And also another prompt, just make sure that if you are getting a lot of benefit and you do have other, or you know other people that have proximal hamstring tendinopathy, feel free to share this out, share out the podcast or if there's someone on social media or one of your friends asking about it. specific topic like what exercises should I do, what should I do, shockwave, is it beneficial? Just share them the episode link and then start spreading the right information because that's what this is all about, right? Cool so I will splice these two episodes together, hopefully it's quite seamless and I will chime back in as usual at the very end to summarize and kind of talk about my key takeaways when it comes to. So here we go. Benoit Matthew is an advanced practice physio, a sonographer and teacher shockwave. He's done so for the last four or five years and he has a special interest in hip groin and running injuries. And he doesn't like being called a shockwave therapist, but he is definitely the go to when talking about shockwave, looking at the latest research in shockwave and I couldn't think of a better guest. It was awesome having him on. And I hope you get a lot out of this. I always get a lot of questions around shockwave on social media. So I hope, so hopefully this answers a lot of questions that you might have. Let's bring on Benoit Matthew. Uh, Benoit, welcome back to the Run Smarter podcast. How are you today? Thanks for the invitation. It's great to be back and really enjoyed last time. Yeah, fantastic. I have so many people on social media come to me with running injuries that are super chronic and they're like, Will shockwave benefit me? Um, I've had shockwave. It hasn't worked in the past. So I try again, there's so many questions around shockwave and I can't think of a better person to have on the podcast to talk about this. And I just want to start off with a lot of runners. They don't have this medical background. They don't have the physio knowledge. So if you could start off with just explaining what exactly is shockwave, uh, as a treatment, yeah, I think. You know, before we go straight into. running injuries, it's quite useful to look at the bigger picture of shockwave. So for example, if you Google shockwave, you know, in a Google search, you're going to see it's been used in variety of different fields. So if you're a physio or somebody using shockwave or you need to know that it's sort of something been around for a long time. So it's been around for 40 years, first used in breaking kidney stones. So it's called as lithotripsy. So I think it was 1970 where it was first used. So it's still used as one of the non-invasive option for breaking kidney stones and renal stones. It's used in cosmetic industries. It's used in wrinkles cellulite. It's used in men's health and women's health for chronic pelvic pain, erectile dysfunction. It's used in neurology for spasticity and is used in a non-union. So I think it's sort of, it's well established. So I think what we know is you've got a technology which has been around for about 40, 45 years, very safe. approved by the US FDA and a nice guideline. So it's very safe. So what we know is it's a very safe treatment. And obviously there are some side effects which I can go through and it's not for everyone. There's a specific indication. So I think for me as a journey was, as you might know, my special interest is lower limb. So I love treating active people, hip, hip and groin, runners, achilles. So I was sort of reaching a point where a lot of patients were getting better obviously with rehab and exercises. I would say there's a small, quite a significant group, I would say at least one in four, or at least 20 to 30% of patients where despite good rehabilitation, they were still struggling with pain. Obviously they had improvement. So this is sort of nine, 10 years ago. So I'm talking about patients with, runners with Achilles tendon and lateral hip pain and peltrile tendon. And many of them didn't want injections or PRP and things like that. So that's where I stumbled across Shockwave and I look at the literature. And obviously, there was some good literature, some not bad, and that's what got in my journey. So I think from a very simplistic point of view, when you talk about shockwave, when I explain this to patients, I don't really use the word shockwave. I say it's a high energy sound waves. So it's basically sound. It doesn't have any magnetism or medications or anything else. It's just a high energy sound waves. So if you look at, just to compare it for ultrasound. The peak pressure of shock waves at least thousand times more powerful than ultrasound. So you could you could do use ultrasound on somebody for 15 hours But what you can do that in 15 hours you can deliver that in like one minute much quicker So it's a very powerful high energy and it's naturally found in nature. Like when you have thunder In physics, it's called sonic booms it's powerful enough to break glasses, so it's sort of a modality which is sort of used to kickstart the healing process by It's a pro-inflammatory response. So what it does is it causes a bit of microtrauma because the idea is in chronic tendon, your body is not healing. It sort of reached a point where it's not kickstarting. So what are we trying to do is create a bit of control microtrauma. I guess it's quite similar with like deep friction massage or dry needling, but what it does is this and it's caused much damage on the skin. So it goes straight to the tissue, causes a bit of inflammation, microtrauma. And then we know inflammation is not a bad thing as long as it's not chronic. So your body just kick starts the healing. So what do we do when my Mac is not working? What I do is just switch off and start it again. So the same thing is you just like a reset button. So that's what I say to my patient. It's like a bit of a reset button to kickstart the healing process. And the evidence is also quite good in lower limb. And if you're somebody like me who's been using, I've been using it for eight, nine years and we're teaching for the last four years. you would quickly realize that he's very good in lower limb, but I'm not very impressed with the results in upper limb. So I would say in tennis celebo and shoulder, uh, I would say it's not something you're going to miss, but definitely in lower limb, my favorite, my top three would be is a plantar fasciitis, achilles and lateral hip pain. So those three, I think you're going to have a good result. It doesn't work like anything. It doesn't work equally for everything. So, uh, every tendon is different. You know, tennis celebo is different from achilles. Upper limb is different from lower limb. So for lower limb tendon, which what I see with runners, it's a good, right from the beginning, when I teach courses, I make it very clear. It's a second line of treatment. So it's not something you give when you have pain or symptoms. So I've never given anyone shockwave if the symptoms are less than three months. That's one of the criteria which all guidelines says. It's always done after three months of the symptoms. and after completion of rehabilitation. So it's not a quick phase. So you've done your physio, you've done your rehab, and we expect changes in 10 to 12 weeks. And it's very reasonable. If you've got a runner who's been coming to you doing everything you've said, but not making any progress after 10, 12 weeks, it's very normal as a human to get frustrated. You're going to look for something else, isn't it? And that's where I think shockwave is a good option rather than jumping into more expensive and more painful option like steroid injections, PRP and things like that. So I think... It's a step in the treatment ladder is I think as a therapist, the more you get experience, you're very comfortable to say if like a patient comes in, I am more than happy to say, if things don't work, I have a plan B, I have a plan C because I'm not expecting every patient to respond to physiotherapy and exercises. Although I love exercises and that's the gold standard, we have to admit that there is under the literature supports me. And if you look at there's at least 30 to 40% of patients who don't respond to rehabilitation after 12 weeks of exercise. That could be many factors. Maybe they're not loading it enough or maybe it's because of pain. Maybe they're not interested, but patients are going to look somewhere else. And as therapists, we need to have a plan B when things are not moving forward and we can't put all the eggs in one basket with just exercises and load management. Okay. So if I could just reiterate a little bit. So a runner will go into the clinic. Uh, if they do have a shockwave session and it's kind of like a, a gun kind of thing, it places on the skin. It releases a shockwave multiple times a second, sometimes two or three times a second, and it's releasing this high focused, uh, direct sound wave to try and stir up the tissue. Because like you said, sometimes a tendon might get, say dormant where it's painful and it's sore. But everything that we throw at it, treatment wise, it's just not responding in the same way and it's just, uh, needs to get stirred up in order. So like you say, kickstart that rehab. But one of the criteria for shockwave would be you need to have a really good go at rehabbing it properly to start with. You can't just mismanage it for four or five, six months and then think shockwaves the answer. Let's give it a good hard crack at doing some really well designed rehab. And then if it's still remaining dormant and we're not seeing the results we're after, that's when we go out that treatment ladder, try another option and say, okay, let's kickstart it with shockwave and then go back to that evidence-based like real strength based rehab programs. Is that right? Of course, of course. We, we know that, you know, progressive loading, uh, shockwave. I keep it simple with my patients say shock waves for pain relief and kickstart the healing. Whereas the function. and the long-term recovery and also getting back into that full sport can only come from exercise and progressive loading. Shockwave is not going to make you turn stronger and it's not going to get you into the performance area as well. The two points I would like to pick up here is, is the timing. So one of the reasons where you might have a bad reaction with shockwaves, the symptoms should be stable. So many times I will decline shockwave in my clinic because they come to me with very high levels of pain. So they're coming in. like eight out of 10, they're limping, they're having night pain, that is a bad patient to really give shockwave because it's a painful stimulus. You don't want to be really be giving shockwave who's already very sore and tender. So sometimes I might give a bit of prehab before shockwave just to make their symptoms quiet. So for me, an ideal patient for shockwave is somebody whose symptoms are stable, sort of not more than five out of 10, they don't have any night pain at a decent level. So I like this sort of pain where it's more like achy. pain than a sharp stabbing pain or throbbing pain. So they should be fairly stable. The last thing you want to do is if a patient comes to me with pain nine out of 10, they're really struggling. So I say to them, you're paying me to give you more pain. You know, if you're nine out of 10 after shockwave it will be 12 out of 10. Why do you want that? So let's bring you down to, and sometimes just the rehab might be enough. So a lot of patients, I might start them on rehabilitation just to get them back and they don't need shockwave to go forward. So... The first point I would like to emphasize is the right selection of the right stage. So ideally you want patients who is not in a flare up, not in a reactive stage, more in a stable chronic. So let me give an example. So you could be a runner like a 42 year old, half marathon runner or a triathlete who is saying like he can run for 45 minutes, but after 30, 35 minutes it starts aching and it's a bit more sore the next day, or it's more painful when he starts doing speed work. So that would be a perfect candidate for shockwave where it's not too sore, you can push hard. And the second thing is if you start giving shockwave and it's too sore, you get a bad flat up and then people say shockwave doesn't work. It's not because of shockwave because you didn't choose the right period to give shockwave. So one of the biggest limitation, I would say right from the beginning, I can say what are the key limitations of shockwave. The number one is it doesn't work in acute stage. So it's not a good option. So if somebody comes to the very high levels of pain, you're not going to think of shockwave. And the second major limitation of shockwave is it doesn't work if the pain is diffuse. Maybe that's one of the reasons in tennis elbow because the pain is not just localized. They say the whole arm hurts. So the more focused the pain is, the more likely you'll have shockwave. So it's again picking the right tool based on a clinical findings. And a lot of times I'm seeing shockwave used as a massage tool everywhere. It's a very powerful tool, but again, you need to pick your patients. So as long as they're stable, they're chronic. and they're willing for the rehabilitation, then you might have a good success if you're going to throw in anyone. So I get a lot of patients who are disappointed once they buy the machine because they think it's going to fix everything because the human body is more complex than that. So from my experience, and I think the literature also supports me, my sort of key areas where I would start, somebody who's like a clinic or starting on the shockwave journey, it would be the, even for a runner, what are the areas where you might get a good result? will be heel pain, definitely plantar fasciitis, achilles, both mid-portion and insertional, patellar tendon, lateral hip, proximal hamstring, tendinopathy, that's pretty much. And I do treat, might not be relevant for owners, I do treat a lot of groin patient on adductor tendon as well. So that might not be relevant for us. So those are the areas where it's very reasonable to try shockwave, especially if they're failed with good quality rehab. Okay, so we're looking at those areas that you listed and we're looking for a kind of... low level, achy, high functioning, uh, candidate who might be, um, more suitable. So those who will respond less favorably or have a less likelihood of recovery would be those who come in with high levels of pain, just walking around. I meant at an eight or a nine, because like you said, that shockwave therapy is designed to irritate things and we can't irritate something that's already a nine out of 10, that's not going to respond too well or someone who's very acute, someone who's really flared it up over the past week or so, and it hasn't necessarily settled down just yet and haven't probably sorted out other options that might be more effective. Yeah, perfect. That's exactly. So it's not a quick fix. So I never give shockwave to a patient. On the other side, it's really bad practice to give shockwave before, in my opinion, before a race, because I'll give an example. So I had this 42-year female runner who... had a nagging achilles tendon, not a surprise there. And she had a big event and she went had shockwave because I never give shockwave before an event for at least eight to 10 weeks because the problem with shockwave is it can numb the pain and you overdo it. So she had shockwave, obviously she had a good result. And then she did the marathon or half marathon well. And after three weeks, because she didn't have a pain, she overdid it and she had a massive grade three rupture of the medial gastro, luckily it was not the achilles. So, and she couldn't run for 10 months. So that is a good example where trying to use it as a quick fix. Sometimes pain is not a bad thing because it protects you from overdoing it because your body doesn't want you to exceed that speed limit. So using it as a quick fix before an event is not a clever idea. I see this all the time. People try to want to do an event two weeks or one week before and they want to have a shockwave. Obviously it might reduce your pain. but the tissue capacity is not improved. You can't improve a tendon in one week or two weeks. And you're just masking the symptoms and you're just asking for trouble. So I generally, I've never given anyone like before, even at least you need eight to 10 weeks before you can make a difference. This podcast is sponsored by the Run Smarter series. If you wanna take your knowledge building to the next level, I have built out a proximal handshaking tendinopathy video course, which compliments 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. Okay, and I think that's a really nice segue into talking about the dosage of Shockwave. And before we started recording, you did mention that you see a lot of cases where Shockwave is underutilized and then sometimes it's overutilized and... we need to try and find that therapeutic sweet spot. So can you enlighten us on this topic? Yeah, so I think it's, you know, this, if you look at most trials, what we know is there's a sweet spot, like we can't put humans exactly one number, we know that it's a range, most things are a range. And what we know is the minimum dosage is three sessions. So I've seen some clinics offer just one session, two sessions, and that doesn't really do anyone any good because the effect of shockwave is cumulative. you need minimum of three to make any difference. So the way I give an example to my patient is it's like a cause of antibiotics. If your GP has given you seven days of antibiotics, you're not going to stop after day three just because you feel great. You need to complete the whole thing. And what we know with shockwave is you don't make or break with one session. The thing changes, it takes at least three sessions. So if you're going to have shockwave for any part of the body, the minimum dosage is three. And what we also know is we hit a ceiling effect after five or six. So I've not seen any good study where it's beyond six. So for me, I think I sort of keep it between that range between three to six, three to five is pretty much your normal range. So ideally you don't want to be giving less than that. So I was, you know, we are discussing, I had this patient with chronic echelon tendon who had 30 sessions. So this just, in my opinion, just abuse of the system and the body is. it's the 30 sessions on Achilles, two sessions back to back. So I see this quite common. People have 15 sessions, 18 sessions, 20 sessions. So it's being used more like a massage tool rather than trying to kickstart the healing. So the way I explain to the patient is, if you've been to the gym and had a very good workout, the full benefits of the exercise, you get while you're sleeping, not necessarily when you're doing it. The same thing with shockwave is, the full benefits of shockwave happens 12 weeks after your last session. So this is a very crucial point. where people are a bit disappointed is, when you finish, let's imagine you've got an Achilles patient and you're given three sessions, the full benefit of the treatment will take 12 weeks after the last treatment. So therefore it's not a quick fix. So a lot of patients call me after three sessions and tell me like they're not happy. And I say to them, your body, the tendons and for the, you know, your collagen remodeling and everything, it takes good 12 weeks. So we need to educate patients. Most patients when I finish shockwave, they're only 20% better. So, and then you need to start loading them. So the way, when I give shockwave with my patients, the way I say to them is three plus 12. What I mean by that is three weeks, you normally give once a week. So three weeks of shockwave plus 12 weeks of rehab. And if you're not happy with that, then I would suggest not to do it. So it's never three plus zero, it's always three plus 12. So three weeks or five weeks of shockwave plus 12 weeks of greater loading program. And that could be one of the main reasons where I get great results for me. I think it's a facilitator, a tool to reduce the pain and start loading them so they're going to get the full benefit. So regarding the dosage, anywhere from three to five. So how do I decide whether to go five or six? I keep a very simple rule. If your symptoms are very chronic, suppose, let's have an example. Like you have a runner who had plantar fasciitis for four months and you get another runner who had plantar fasciitis for two years. The one who had it for more than a year is more likely to need more. So I keep it quite simple. It's not really based by science. This is based purely by my experience. I tend to give more for patients where the symptoms are more than one year because I feel they need a bit more. But I've never given anyone more than six maximums. So that sort of is my limit. And I don't feel, if a patient has not responded in that five or six, in my opinion, you're wasting your time with shockwave. Either the diagnosis is not right. So the two, if a patient is not responding, that might be a good point to raise here. If a patient is not responding to shock, it's usually because of three reasons. One is the diagnosis is not right. So a typical example would be, I've seen a lot of runners with plantar fasciitis have shockwave not improving because they have calcaneal bone stress reaction. It's a bone marrow edema, it's not plantar fasciitis. So they're having a lot of swelling because you see that in ultramarathons. So if things are not improving, it might be useful to get a diagnosis. That's number one. The number two reason things don't improve is because they are not given at the right stage. They have been given too sore. They are already very sore. So you make them worse by giving them shockwave. And the third and the most important thing is they have not the rehab. They didn't have the rehab for 12 weeks after. So for me, the shockwave is a part of the package, you know, trying to get that tissue healing and then getting it stronger by your normal thing. So it doesn't replace anything what you've done. It just, because if you're given shockwave, you know, it's very quick. It just takes three minutes. So for me, it's a very simple tool. You just give it for three minutes and then you do everything else you're doing. So it doesn't change your management massively, but it's a quick add-on just to kickstart the healing and then to get things going. Yeah, I like that you're repeating this message and I think it's worth repeating, one, that shockwave therapy is used as a tool. It's not the complete treatment. And two, the message that people should realize is that shockwave doesn't heal the tendon. It doesn't make the tendon stronger. It doesn't make the tendon tolerate more capacity. What we're doing is kickstarting it so that it can tolerate and can respond and adapt to a progressive loading rehab. And so it's not, it's like a, it's like a reset button, really. You know, you just, you hit a wall and you're frustrated. What you can't do is as you know, we've got a saying in English, you can't flag a dead horse again and again, if a patient comes to me, So 99% of patients who come to me have had physio. They have seen two physios, they have done rehab, they have done exercise for five months, six months. I can't say to them, come on, let's do another three months. They just, they're fed up. And sometimes getting a bit of pain relief with shockwave is just a bit of a psychological, you know, it just gives them a window of hope and then they're more likely to do things. So sometimes we have to have that option for a plan B so that we can get going, because sometimes you can hit a wall. I'm sure you have the patient like proximal hamstring. they've had done right here for eight months, nine months, one year, two years. We can't just keep on saying, do it, do this, because humans, we have a finite amount of patients and hope, you know, they will, if you don't, as a therapist, if you don't offer a plan B, they're more likely to end up with unnecessary, unsafe procedures like surgery. And we know that we should not be sticking in a steroid or PRP into the tendons because, you know, one, we know that the evidence is very poor. And number two, we don't want to put the risk of ruptures. I don't mind putting injection for a sedentary population for somebody who's like 60, 70 plus, but somebody who's like a runner, very active person, there is no justification for putting a device, like a substance inside the tendon, unless you've exhausted all options and they know the consequences, like ruptures and things like that. So for me, if you're done physio, good rehab, three, six months, if you finish shockwave. then if you're still struggling, maybe there might be a role for surgery and injection, but that should come last because you can never undo surgery. Whereas if shockwave works, it works. It doesn't work. It doesn't work. That's it. You know, you're not going to lose anything by that. And like you said, you're going through that, that treatment ladder and shockwave is somewhere on that ladder. And it's somewhat low down on the ladder. Because like you said, there's no risks that while there's not a lot of risks, because you're not damaging any tissue, as in, if we were to get injections, or if we were to have surgery, there's a whole lot of risks associated with it. That's why it'd be higher up on the ladder. One of the questions I you can't, sorry, you can undo surgery, and you can't undo injection, you know, what is done is done. Whereas, you know, the worst thing which can happen is shock waves, it doesn't work, or you might have a flat out for two weeks, you know, patients are okay with that. So as long as you know, it's a very low risk. Modality and as I said, it's used in medicine for kidneys, it's used in the heart, it's used even in very sensitive structure for erectile dysfunction, a different type of thing called a focus shockwave for a, you know, men's health. So it's been used in very sensitive parts of the body. So you're not going to damage anything with the long-term, you know, I guess if you keep on giving people 30 sessions, then you can end up damaging or causing more problem. But if you're just sticking to the guidelines of between three to five, you're very safe in giving shockwave. Yeah. And if we're talking about safety, I'm just fine to your input on this. I hear that a lot of injections for tendinopathy actually make the tendon weaker and actually puts them at risk of further damage. Do you know much about that topic? Yeah. So I think what we know is steroid, you know, one, it sort of causes the weakening of your tinnocytes and increases the risk of rupture. So when a patient, for example, let's look at a tennis elbow patient, if they come to me who had a steroid injection, I will not give shockwave for at least 12 weeks because One, you know, the high risk of ruptures after steroid injection. And number two, I don't want to stir up things. So generally, it's good to give shockwave before, you know, injection. So a top tip for somebody who is using shockwave is one of the worst patients who will not respond to shockwave is somebody who had multiple injections. Suppose you had a patient, a lateral hip, who had three or four steroid injections. They don't seem to respond. And I've got very good research to back me up. There is. Multiple steroid injection is a poor prognostic factor. So if you get a patient who had four injections in the hip, three into the tinnitus, you might not get the same response. So you need to be very honest with the patient and say, it's 50-50. It might not respond because I think the tendon changes the whole response. The injection changes the response. So I'm not a big fan of giving multiple injections and then having shockwave. So it's best to exhaust shockwave first before you go in the injection route. But sometimes you don't have a choice. injections elsewhere. So, and generally more and more people are not giving steroid injection because you know steroid injection increases the risk of rupture, especially achilles and things like that. So a runner should really think very carefully before they put in any steroid. But the problem with the steroid is people, let me give you an example. There's a procedure called high volume injection or tendon stripping, HV, you know, it's high volume injection, HVI or called tendon stripping. It sounds nice, fancy and very scientific, but if you look at it, what they do is they put a lot of, you know, local anesthetic, but they sneakily put a little bit of a steroid as well within that injection. So what actually works is actually the steroid, which they put into that tendon, especially at this. So I've seen quite a few patients where they had the high volume injection. They feel fantastic for the first two weeks and they come back after eight weeks with the symptoms back to where they were. And then I've even seen partial tears and ruptures following the procedure. So I think, you know, as a runner, you need to really be wary of putting any steroid near your weight-bearing tendon, especially your Achilles and patella, because, you know, we know that it just causes, you know, it's not worth it really. You're just asking for trouble. And you know, runners won't keep quiet if the pain is less, they're going to run and start sprinting. And we know that the ruptures are much higher, especially if you're 40 plus, especially a male. So for an active person, steroids should be the last thing on your mind. you shouldn't really be doing that unless you have very strong reason for that. Okay. I have a question written down here, but I think you've already answered it. I wrote down, are there any precautions or any running injuries that are not appropriate for shockwave therapy? But I think you did mention like the ones that are really appropriate are the proximal hamstrings, the Achilles, the plantar fasciitis, the patellar tendon. And that's where a lot of the research Are there any other precautions? Yeah, yeah, that's a good point is like with any device it comes with the manufacturer's safety precautions. So the general ones, if you look at the list, it's pregnancy, obvious. With pacemakers, it's only on the shoulder. So if you have a pacemaker, you can still treat your other parts. So. If you want to go more on the guidelines, there's a website, the International Society of Masochistic-Lithal Shockwave, ISMST. So if you Google ISMST, you'll come with a list of quantification. But anyway, I'll go through the key ones. Active cancer, big one is patients who are taking warfarin and heparin. Shockwave just doesn't go well if you're on blood thinning tablets. I've seen, you know, where you get massive bruising. It's not worth it. So if you're on strong... Woffrin, Heparin, blood thinning tablets, then generally not a good idea. And also acute swelling. So I've seen where people have given shockwave to the calf where they had a hematoma and then just ended with a DVT. So the last thing you want to do with a swollen, so basically if you see anything which is hot and swollen, best not to shockwave, it's already inflamed. Why do you want to add more to it? So it should be stable. So anything which looks not right, inflamed skin, swollen joints, swollen calf, acute injury. I don't think there's much scope for a shockwave. In fact, I would say it's not really good practice to do that. You could look into other modalities rather than giving shockwave. Yeah. And you did mention the chronic patient who's like two years down the track might respond quite well. Stable, stable. Yeah. Is there a stage where a particular client is very chronic? Are we talking like five years plus that are demonstrating certain characteristics that you think might not be appropriate for shockwave? Yeah. If you look at the signs, the best patients are symptoms more than three months and less than one year. So the more chronic it becomes, for example, like if you had a lateral hip pain for four years, if you know that when you have chronic pain, then you're going to get a lot of changes, central sensitization, psychological issues, anxiety, depression, and also other associated factors with kinetic chain weakness. So generally, the more chronic they are. If a runner comes to me and they had like lateral hip pain for four years, of course it's very safe to try shockwave, but I'm going to dampen their expectations and say, see, you had it for four years. And once you have it for four years, it's very unlikely that whatever we do, we're going to make it zero, back to zero again. We can make it better, but please don't expect that. I'm going to totally fix it. So it's really important to be honest, especially if they had it for such a long time. that because you know, once pain becomes chronic, it becomes part of the whole fiber, isn't it? There are a lot of adaptations. So we need to be quite mindful of that. And one of the worst prognoses is if they have a neuropathic pain, if a patient has pins and needles, numbness, a bit of altered sensation, I generally don't give shockwave because neuropathic pain and shockwave don't go well together. So it should be more like a mechanical type of pain, more like an ache. If it's very sharp, very sensitive. too sensitive to touch, then I think shockwave is just going to irritate them. So ideally you want a patient whose symptoms is more than three months. You could sort of up to two years is okay, but once it becomes three years, four years, five years, I guess it's reasonable to try, but don't expect anything great to, massive things to happen, or you might reduce the pain by 20% or 30%. So I think you're totally right. There's that sweet spot, where you don't want to be too, too chronic. But I guess once you have symptoms for four, five years, I think... you know, most things don't work, isn't it? There's no magic fix, you know, whether it's an injection or a story, you know, we just have to educate them on the pain signs about trying to, the coping mechanisms and things like that, and maybe try to make them pain a little bit better, but you know, we can't be talking about cure or fixing once you have symptoms for such a long time, isn't it? Like you said, you're dampening their expectations. And I think that makes perfect sense, as we know with chronic issues. it becomes less about the tissue and it becomes more about the body and the brain and how people think about that issue, how people start to associate like depression, anxiety, like all these emotive states with, um, levels of pain. And like you said, like if there's, if someone is quite chronic, and it does become more of a whole body thing, it's less likely to be that localized pain. It's more likely to be widespread, which you said at the start of the interview, which they don't really respond well if it's not that high focused in, um, pain area. And yeah, like you said, it might need to, if you're, if you're five years down the track, but you're still getting that achy localized pain and you are, I guess, responding to mechanical load. Like the example used before, if someone does go for a run, a 5k run, and then they're flared up the next day, that's kind of responding to a mechanical load. Whereas on some on the other side, if they. Uh, say frustrated and depressed and like highly anxious and they're noticing their flare-ups are something completely different. Their flare-ups are on days where they are feeling particularly stressed or days where they're not getting a lot of sleep. That's not responding to a mechanical load. And then I guess those expectations or the benefits of shockwave might start to skew in the less likely to respond. Yeah. And the problem is also is if the pain is very high and they're very sensitive, you can't give them the effective dosage because it's too sensitive and they just flat up. So I find a lot of patients when they're very chronic, they just flat up when I give them and they just take some three, four weeks. So normally this might be quite useful for the listeners is when you have a shockwave treatment, it's very common to be a bit sore for anywhere from three to five days, but within a week it should be back to normal. That's why we generally have like once in a week gap. So the gap between session can be anywhere from seven to 10 days. It doesn't have to be, I'll give an example, I treat a lot of petal tendons. So those usually are jumpers like young men in the 20s, early 20s. And for them, they're fine within two days. So I usually treat them once in every five days. For them, once in 10 days is not necessary. So the younger you are, the fitter you are, you handle it, you manage it very well. So obviously, your general fitness also has an effect on that. So if you generally decondition, having medical issues, poorly controlled diabetes, you will tend to flare up. So I think... your tendons is a good marker of your health. So if your general health is not great, then I don't expect that to happen massively as well. So it's looking into those factors. And if it's very diffused pain, poor sleep, other factors, then the last thing you want to do is give a shockwave treatment, just make flat up things. So the more and more I get experience, I'm more confident to say no to patients. I would say at least 30 to 40% of patients who come to me for shockwave, I decline them. because they come to me too late or it's not appropriate, or they're quite weak. So for example, like, you know, I give you in the case of where I treat on the NHS, where I get a bit of deconditioned patients. So if they come to my clinic, they're struggling, they can't even do like 10 or 12 calf races. I won't give shockwave. They're not strong enough to have shockwave. So a lot of time you need a bit of pre-habilitation just to make them strong enough to handle the shockwave before you can give them, because it's a painful stimulus. Your body should be good enough to handle that. So the last thing you want to do somebody who is in a lot of pain, who is quite deconditioned is to give them shockwave because your body can't handle that stimulus. Yeah. It makes a lot of sense. And it would be understandable if you have a really weak tendon and then you shockwave them and then they're flat up for 10 days. Uh, yeah, it makes a whole lot of sense. This podcast episode is sponsored by the Ransmata Physiotherapy Clinic, which is my own physio clinic where I help treat a wide range of PhD 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. The last question I have, or the last topic I want to delve into, I see a lot of people with proximal hamstring tendinopathy and they are ones that get very chronic, very debilitating. a lot of the runners are very desperate and they want clarity, they want control. What can we do? You've said that proximal hamstring tendinopathy can be effective, well, shockwave can be effective. Is there any considerations we can do in that three week phase, or are there any proximal hamstring tendinopathy specific instructions that you can have for people to increase the effectiveness? Yeah, so I think proximal hamstring is quite a funny. area because it's quite deep, you know, quite hard to get in. So some practical point of view is it's quite an awkward, awkward treatment to give when you give on that. So I always have a chaperon when, if, if I'm treating a patient, because you have to get straight into the sitting bone and I normally bring them to the edge of the table so that open up the space because it's pretty much medial to the sitting bone. Now the few considerations. So a small group, I would say quite a significant group of patients with proximal hamstring also get a bit of irritation of the nerve as well. So if you've got somebody who have a bit of sciatic nerve type of irritation, from my experience they don't seem to respond with shockwave. Anything with nerve don't seem to do well. So if you've got somebody who is complaining of a bit of pins and needles, a bit of burning pain, sharp pain, maybe shockwave is not the best option there because they're having a combination of tendon pain and nerve pain because it's so close to the sciatic nerve as well. So... And when you're giving the shockwave, if you look at the anatomy, it's sort of the sciatic nerve is around three to four centimeters lateral to the tuberosity. So when you're giving shockwave, always, aim medially, so don't go laterally. And obviously if a patient says, when you're giving treatment, I've seen two patients actually, where they had raging sciatica after they have completed a course of shockwave, where the patient complained having pins and needles while they're having treatment. So. If a patient says they're getting pins and needles, you just stop. Maybe you're not on the right spot. Maybe you're on the nerve. You should not get pins and needles or numbness. So again, best not to choose patient who have a neurogenic involvement with the sciatic nerve. That's the key thing. Second thing is exposing it so that you can really hit the bone and you have to dig in. There's no, it's one of the most, I would say it's one of the most technically challenging shockwaves, the proximal hamstring, because it's intimate. It's awkward and you have to really get bang on the bone as well. Well, another thing to remember here is Is once I give that let's imagine that I'm giving three or four weeks of shockwave You I find it makes a big difference to reduce the sitting time. So Direct pressure on that. So I usually ask them to use like this sort of, you know, wedge shaped You know like what you use for coccyx that sort of cushion, you know where you have the cut in to reduce that, especially when they're involved in a lot of driving and things like that, to use the cushioning on that so they're not sitting and every 20 to 30 minutes to stand up, you know, not to have the direct pressure. So that's really important. So the first thing is, you know, desensitize the region, not to put direct pressure. A lot of times they go on the internet and start stretching the hamstring and that just irritates things. So when you're having shock, there's no point in doing your hamstring stretches or putting a foam rolling right onto the bone. We don't want that. We just want to desensitize the region. So a lot of time is education on reducing the, we don't want to say like sitting is harmful, but the way I say to them, you're just sensitizing the tissue around it. So use a cushion surface, try not to sit on hard surfaces, try to take breaks every 20 to 30 minutes, and also try not to overstretch it. So I think the main thing is desensitizing that sort of area by not direct pressure. Because a lot of people feel like putting a needle in or dry needling and you might feel a short-term benefit, but that irritates that more and more. So reducing the direct pressure, reducing the sitting and as I said before, stopping totally all hills and speed. I usually stop that for a good six to eight weeks. No hills, no speed. But they can continue with the flat. That's fine. The hills and speed usually retains that. So I think you have to be very strict. Let me give an example on lower limb. The one where I'm very aggressive in my treatment is petal tendon. Petal tendons can handle it very well. So petal tendon doesn't seem to, so I'm very aggressive. I'm not too worried about flat ups. In the two other areas where I'm very, very sensitive, where I give them very, you know, very slow approach is proximal hamstring tendon and insertion alkylis. Those two areas are very, they take much longer than you think. So clear advice, taking the time. insertion of the Achilles, they also get flat up quite badly. So those two areas, it's definitely not easy, but as long as you, number one, don't irritate the nerve, make sure that you know your anus and knee, try to go always medial rather than lateral, reduce the sitting time, best not to stretch it. We know that stretching doesn't, you might feel good for a minute or two, but it doesn't do any much harm and definitely stop the hills and speed. And definitely it's not an easy one. So normally most tendons, if it, when I, When somebody comes to my with runners, so most lower limb tendon, I say three to six months. That's what, you know, even with all my experience, I've not found a hack to make it quicker. It just takes time. You know, it takes six to nine months for you to really get a good results. There's nothing. There's no shortcuts there. As long as they know, it's a long, long drawn process and we need to decentize. So I think the way to progress would be really. make them tolerant to sitting, you know, avoid local irritation, and then build up the strength, and then build up the volume, and then keep the speed on the hills to the last. So it's a very slow progression. So very hard to buy in people for that six to nine months, but you know, it takes time. So a lot of people, what they do is they go to a therapist, try for one month, it's not working, they jump to the next therapist. So I see the sort of people go under this conveyor belt, you know, I see this sort of they've seen three therapists, they come to me. And then they disappointed because they thought I'll fix them in one month. And then they go around. So I'm sure, I'm sure you must've seen people where they, the runners, they go on in this sort of, they see six therapists because they don't want to hear that it's going to sit here, take such a long time. But in my experience, you know, it takes that good six tournaments. Would you agree or have you found a hack? I haven't found the hack. Unfortunately. The, I think that's a very good advice though, in those three weeks, we're kind of desensitizing the proximal hamstring with. sitting modifications, avoiding stretching, just taking it easy. But when you get into that 12 week phase, we're slowly reintroducing some levels of loading. We're probably still avoiding a lot of stretching, but we're seeing if you can slowly start to implement more and more sitting, more and more strength work, a little bit more running. But like you said, that the real powerful stuff, the plyometrics, the speed work, the heels that comes at the very end of rehab, once you're able to tolerate. once you have a really big base of load tolerance and strength. And the key thing would be not to change more than one variable at a time. So if you want to increase the distance, do that. Don't try to do the distance and the speed and the hills at the same time. The common mistake I see the best way to get injured as a runner is trying to change two variables at the same time. So, you know, for me, I want to build up at least 30 to 40 minutes of flat running with good strength, you know, a good hamstring control and things like that, general lower limb strength. And then. for me, I think the way I always have done it is build up the volume first, then go to speed, control speed work, and then the hills the last. With hip patients, I always keep the hills the last. And that seems to work for me, because trying to do everything at the same time is just flaps up things. So as long as you've got a sensible progression, you're not going to flat up. And again, even with the best late plans, I said to my patients, I'm going to see you for eight months. I expect at least three flat ups. That's normal. So always pre-warn them that even with the best rehab, it's just getting a cold or a flu. You're going to get a little bit of occasional like a sore throat or something like that. So you're bound to have a flat up on the journey. For me, I expect at least three flat ups in that six to nine months. And then the important thing is always, always give every patient expression of ten-minute apathy a flat up plan. They know exactly one, two, three, four, five things to do. So for them, it's not a shock anymore. So they know that if I get a flat up, So a simple flat-out plan could be reducing your strength, taking painkillers for three to four days, getting into the pool, reducing the sitting time, using a cushion, going to some cross trainer, taking a bit of easy on the running for a week and then going back. So a very simple flat-out plan can make a huge difference. So they know that it's like an asthmatic has gotten, or somebody with an allergy has got an epipen. So they know that they have a backup. So every runner should have the flat-out plan because they know that it's going to happen. And then we try to... make them accept that it's part of normal recovery because a lot of people freak out when they get a flat up and so oh god it's all back to zero i was so i was doing so well and then i just screwed up by these things i said that happens you know you're going to have one or two flat ups so not to worry just you know calm it down and just back you go on the bandwagon and you can start rehab so i try to downplay the flat ups and say uh i say to them on session one you know i could do it very slowly but i can't prevent you from getting a flat up it's going to happen So let's get prepared for it so that you have a flat plan. Is this something you give to your patients? Like a flat plan for most conditions? Definitely expectations. I definitely agree with you with changing the variables, change one variable at a time, because we want to learn how a tendon responds and you don't learn anything if you try three things at once and it flares up. It's like, well, what flared it up? You have no idea. So documenting, writing things down and just being very patient with implementing one thing after another. Uh, with flare ups, I'd say that I do make sure they are aware that flare ups are a part of rehab and make sure that they do have a flare up plan in place, but just let them know that when we are rehabbing a tendon, we're trying to find this adaptation sweet spot. And that's like, if we under, if we hit it too low, then it's not going to trigger any adaptation. But if we treat it too aggressively, that's when the flare up happens. But. we know where the sweet spot is when a flare up does happen. Cause we know, okay, we're slightly below that right now. Let's we learn from flare ups. And we, as long as we learn from those flare ups and adapt it or modify your treatment as a response to that, then you're just learning along the way. And it's, it's kind of like a good thing. Okay. Now we know where your ceiling is. Yeah. And not to, as a therapist, especially as a junior therapist, I felt really bad because I felt things were going well. And when you get a flat up, you feel sad for the patient and you feel like You're responsible. And I think it's just acceptable. It's inevitable. It's inevitable part of rehabilitation is to get the flat up. So you get that with O&Es, you get with back pain, you get with tendon rehab. So for me, it's a part of the journey. It just makes you, you appreciate your success better when you've been through that sort of rough patches. So as therapists, you know, it's good to be caring, but you know, not to get too bogged down when your patients get flat ups, because you know, that's as long as you pre-warn them on session one, because most people can take it as long as they know it's normal. that you're not damaging it. So if you tell them it's normal, so the key messages just like we use it with any pain condition, it's normal, it's expected, and it's not causing any structural damage. Just a bit of sensitivity around the tissue because it just overloaded and the body just telling you maybe I did too much. And the key thing which I think this might be highly relevant here is a lot of runners don't tell you the total training load. So I've seen a lot of runners come to bang and say, I had a blast. I've not made any change. What they won't be telling you is they've been walking the dogs for four hours, two times a week in the weekend. They won't tell you the whole story. So a lot of patients don't tell you the whole load of they do. So sometimes what happens is they're doing the exercise well, they're doing the right rehab, but their other activities in their other areas of their life are spiked up. Or maybe they've started a new job where they are now walking 18,000 steps, where they were doing only 5,000 before. So it could be, that's why you need to be like a detective, try to find out. all areas of their life, how much are they walking? So all my patients send me a log of the steps and their whole activity for the whole week. I keep a track of their whole life because as therapists we can just stick to running and gym, but humans, we have to look at the whole package. What are they doing at home? How much are they working at home? How much are they working in the weekend? Are they doing like six Zoom classes, like HIIT training on the top of your exercise? So... All these things adds up. It's the total load we need to look at. And obviously the psychological load as well, the sleep and other things, because sometimes the patient will say, I didn't do anything, but I've got to flat up. It's not as simple as that. Maybe they've done a lot in the other aspects of their life, which they might not have imagined, they're not taught to let you know. So again, is having that full connection with the patient where they can open up on all aspects of their life, both in the gym, but in the home and as well as with work aspects, because... Sometimes it could be nothing to do with the exercise you've given. It's what they're doing in the weekends. You know, so one perfect example, which we wind up would be, I had this plant a fish at his patient. This is not a runner, but she was like in the late fifties. So, uh, she was doing everything I was saying, but she was not getting better at all. So I just scratching my head and finding what, what should we doing? I think, I think she was from Nigeria or Ghana and where, because she had a large family show on every Saturday, she used to do like, is a group cooking for the whole family and just freeze them. And she used to cook for about. Nine hours standing barefoot. So that was the trigger. And there's no way, you know, so I was digging my head and finding what was, why was she not getting better? But she never told me. And finally I found what was she doing in the weekend. So sometimes there are some facts which they don't tell you which could be one of the reasons things are not improving. So maybe they're doing something crazy in the weekend or they're just going six hours walk or some speed work with the dogs or some back to back, you know, Zoom classes. So we need to know the whole story. so that we can give that appropriate advice because patients sometimes compartmentalize treatment. They just say some things to physio. They don't think they need to, we need to know the whole story. But as therapists, we need to the whole life, isn't it? We can't compartmentalize this work and physio and running and things like that. I think a lot of the clients might not know that certain parts of their life are important when it comes to the rehab. Like you said, the cooking, and I do find they could be logging their mileage. They could be logging their speed. logging their steps per day, but it's not until you find out that they're sitting longer or going for longer drives or stuck in traffic where the proximal hamstring might start getting irritated. Or like you said, even just standing still can be a lot of load through planar fascia and they're just not aware. So they don't share that information until people go digging and actually trying to work out what they're doing outside of their, their exercise. Yeah. Brilliant. And as you said, he's For me, it's the whole package, isn't it? Like your life, we can't compartmentalize. The load is the load, whether it's a physical load, psychological load, as well as workload, the body acts as one unit. So it's really important to get that confidence. And sometimes it may take a few sessions before they open up, they feel like it's 11. So I guess you learn with experience that as a therapist, you're only doing exercise for that half an hour, is that what happens to that 23.5 hours later, that's equally important, if not more important. than actually what you're doing with the rehab, isn't it? Yeah, very, very true. Okay. Hope you enjoyed that conversation with Benoit Matthew. Um, I've got some key takeaways, some dot points here that I have written down. Um, and just a bit of a reminder for you. So the first one that I wrote down was shockwave is kind of like a reset button. It has no healing properties is not going to, um, improve the quality of the tendon. Um, If you wanted to improve the quality of the tendon, long-term strategy is always strengthening. I know we go on and on about it. And first you meant to start rehab before doing shockwave, see how it goes, see how you respond. If it's quite dormant and not reacting to anything, any stimulus, any rehab that we're giving it, that's when we try shockwave. It's not designed for irritable patients. I know PHD, chronic PHD can get extremely irritable. It's probably not the most suitable and we need to wait for things to settle down, calm down before we can try some shockwave therapy. It needs to be stable. It needs to be quite localized. It can't be this widespread pain and it needs to be chronic. It can't just be a two-week injury that you think might shockwave might help with. So like Binoje said, it's about picking the right person, but it's also picking the right person at the right time of their rehab because they could be We need to find the right time, that sweet spot of when it's not too irritable, but irritable enough and just not getting better and yeah, which does require a bit of insight and experience. Minimal dosage. So three sessions as a minimal dosage before you can actually work out whether you're responding well or not and maximum five to six sessions. You shouldn't be going beyond that if you're not really responding and people aren't really giving you the loading exercises associated with it. It's not right for you and you're just not responding. I've had people have shockwave 15, 20 times plus and they keep buying into this belief that it can get better with more and more sessions. This is not going to work. The other point I wrote down was Benoy mentioned there's three reasons why you wouldn't respond to shockwave. One, either the diagnosis isn't correct, you're not in the right stage of that rehab or the right stage of that tendinopathy. And three, it's not associated with any loading that people just think that shockwave is going to heal the tendon. They do shockwave and they think it's gonna get better. It just doesn't because they haven't compiled in or mixed in some sort of loading program. So that was those three points. What else do I have written down? If it is more chronic, like if you've had it for four or five years, There is more sensitivity to those areas. A lot of the pain or a higher percentage of the pain might be psychologically driven, the brain changes, and we're just not dealing with the tissues at the same relevance. And this goes back to our pain science episodes. And once we start listening to all these episodes, you'll find that these patterns tend to start tying into one another. And this is the perfect example, because when we know, we do know with pain science and chronic pain now that we've listened to those episodes, that the brain has massive influence on what, how we perceive pain. And the longer you've had chronic pain for the more of those, the brain patterns, the neural connections tend to wire up for signaling pain becomes overly sensitized. And we're now dealing with the brain perceiving pain in a different way. Your relationship with pain and your behavior towards pain is completely different. And so shockwave might not be as effective because we have those brain changes. And an example that I can think of, I was just listening to an audio book on pain signs yesterday, and they were talking about how chronic low back pain patients sometimes undergo surgery because they have like say an X-ray or an MRI and show some like degenerative discs or nerve impingement or something. and they decide to go under the knife and get surgery and they've had pain for say 10 years and it doesn't do a lot like surgery won't do a lot because we can change the structures of the back but we're not changing the structure of the brain. And so that's why we see this discrepancy of why isn't it getting better? Like everything structurally is fine but I'm still experiencing pain and that's a perfect example of that. So you can... Like if you are, if you do have chronic PhD, then shockwave, we can give it a go. It's very low risk. It can make, it can make things better, but we need to dampen our expectations. Um, it's still reasonable to try. Uh, the last one I have written down, uh, have a therapist who is experienced with treating PhD, like experience with administering shockwave, um, for PhD. Cause like we said, there are. we know and we don't want to have someone who's a bit inexperienced and start irritating the sciatic nerve because that can be unpleasant and can be unavoidable if we choose the right therapist. So just ask them, have you had much experience because I know that the sciatic nerve is quite close to that tendon and we do know that it can irritate the sciatic nerve if it's not in the right place. So and then if you are during the session getting some pins and needles or numbness down the leg. We should cease the shockwave, change the location, or just try something else. So keep that in mind as well. So those were the points that I had written down. That's pretty much all you need to know on shockwave. I'm very happy with how comprehensive and insightful this interview has been with Binoy. I hope you enjoyed as well. Hope it answered all your questions. So I look forward to bringing you the next episode and we'll keep learning together. 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.