Sitting Successfully with PHT

: today's episode sitting successfully with proximal hamstring tendinopathy. 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 lot of questions come in, let me bring them up. I put onto a few Facebook groups and onto social media, asking a few questions that you want answered on this podcast when it comes to sitting with proximal hamstring tendinopathy. And I'll read a couple out now and we'll delve into all of the answers in a second. So Dana asks, I have read that sitting doesn't cause harm, but it hurts so much. How can it not be causing harm? Tori asks, how can we handle sitting for long car trips? Cynthia, how can we handle desk, like my desk job, if I'm able to stand every 10 minutes? Andrea, how much is too much pain? Is there a pain versus adaptation that we should follow? Holly, the best strategies for pain relief when sitting? Angela, best angle to sit? The height of the chair and back support? And Shelly, is it okay to sit on ice a lot? So I've written down some answers, let me pull these up. Let's go back to basics. Why does sitting cause irritation? Why is it so irritating? It is a huge debilitating issue when having this particular condition because sitting is a functional part of life. We need to sit for work, we need to sit to drive somewhere, we need to sit to enjoy a meal with our family or go out, sit at the movies. So it can be extremely debilitating, extremely impactful on our emotional state and our participation into society. So yes, it can be extremely frustrating, but it is irritating the tendon or starting to spark symptoms because we are putting the tendon through direct compression. If you've listened to the earlier episodes, we know that when it comes to the anatomy, the tendon itself wraps around the sitting bone. And so if you have direct compression on that tendon and the tendon itself can't tolerate that level of compression, then there will be some pain signals that starts a deep ache. However, we can train our tendons to start tolerating higher levels of compression, which I'll talk about later on this episode. And that's why if someone doesn't have proximal hamstring tendinopathy, they can sit totally fine. They can sit through a two hour movie. and not experience anything because the tendon can actually tolerate high levels of load, high levels of compression. And so that's why if someone does have a proximal hamstring tendinopathy, things like harder surfaces can be irritating, sitting on things like low chairs because you are putting your hips into more flexion where your knees are higher than your hips and it's almost under more stretch when it is under compression. And that's why sitting for longer periods will cause more pain signals because it's just subject to more and more pain. I say hard surfaces, but I do believe that some people, depending on the tendon that is actually affected, sometimes hard surfaces might actually help people because directly sitting on a certain angle or a certain part of the tendon that isn't irritated might lead to, like if you're sitting on a hard surface, it's more targeted to maybe a healthy area compared to that irritated area. So it might be something you can play around with, but depends on the individual and where the pathology actually is located in the hamstring. So I want to just start off with some basic sitting variations that I tell all of my proximal hamstring tendropathy patients in how they can modify their sitting. It's going to be very hard to just describe through a podcast, but let me try my best. What can we do? So number one, you want to change how you are sitting to reduce levels of irritation and to reduce levels of compression if you are unable to tolerate current levels of compression. So some variations that we can do is, first of all, we can move to a higher seat. If you are currently sitting in a chair at work or in the car, where your knees are higher than your hips. What we can do is elevate your sitting so that your hips are a bit higher and therefore we reduce the level of stretch. We can sit on something different. I know some people use like a donut, some people use cushions or pillows to soften and spread the load. Sometimes that can be really, really nice. So combining the two, so. having a pillow and also having a height difference, elevating the height. But most of the time, what I get people to do is just appreciate where the pressure is on their sitting bones when they are sitting. And if we can redirect that pressure away from the sitting bones and level it out to somewhere else around the hamstring, then we're reducing the level of compression. And if you're sitting in a chair right now, what I'd recommend you do is find, take away a cushion and reduce the height and just see where that pressure is on your sitting bones. Most of the time it's directly underneath that sitting bone. However, if we then change the height, you put a pillow underneath to see where it goes. I would guess that in most cases, the pressure is probably half on the sitting bones and half on the hamstring belly like closer to the knee which again is going to reduce the level of compression but I Tell some people they can sometimes go one step further and instead of having their feet on the floor actually tuck their feet in so that the feet are kind of crossing but underneath your chair and the weight of your feet isn't like on the floor itself, it's you're almost shifting your body weight forward and yeah, tucking in your feet, if that makes sense. That's why it's gonna be hard on a podcast. But I do recognise as soon as people do that, their body weight will shift forward so that the vast majority of their compression is in the hamstring belly, like closer to the knee and it's actually directed away from your sitting bones. And that can be very nice for people. However, I do find that once people make that correction, they'll find that their back goes away from the back support in the chair, to which I counter that with just some back support, maybe a pillow behind your back, maybe just getting a lumbar roll, lumbar support, so that you still have your lower back supported with some sort of device, but you have that weight directed away from your sitting bones. So there's some strategies you can do. and it might be enough so that you've gone from tolerating 10 minutes of sitting and making these corrections you can now tolerate 25 minutes of sitting and that's enough to then every 25 minutes stand up move around and can be a lot more I guess practical. So you won't be able to tolerate a whole day if you make these corrections it might just be able to elevate your level of sitting. to a point where it's a little bit more manageable. Some other options, yes, at work, there is a sit stand desk option. If you do have that luxury, I know me working from home, I've set up my own sit stand desk, really cheap version. I just get a, so from my desk where I work, I get my, just a really cheap chair. I put the chair on top of my desk, and then I'll put my laptop on top of the chair, and then I can just stand and work away. So it could be as simple as that just finding something to some boxes or some Books that you can put your computer onto and then something a little bit more elevated You can put your keyboard and mouse onto and there you have it. You've got a sit-stand desk but I don't recommend standing the whole entire day because You'll have other issues. It's a tremendous load on the back if you stand still for long periods of time It's a lot of load through the feet the plantar fascia and we don't want you getting another injury. So I do recommend if you can tolerate say 30 to 45 minutes or an hour of sitting with these new corrections then every hour you can stand up for about 15 minutes maybe 20 minutes before you sit back down and that could be a really nice option. So do these variations maybe come up with your own sit stand desk but the other thing that we can do is just remind yourself to take regular breaks. If you do have that luxury in your line of work, sometimes taking a break every half an hour and just walking for two minutes can make a big difference, whether it's going to fill up your water bottle, go to the toilet, talk to your colleagues, something along those lines, just those regular breaks really makes a big difference. So keep that in mind, maybe implement something along those lines. Which takes me to my next point, which is, Your sitting modifications, yes we can do that. However, you always need to have some strengthening program in place in order to tolerate higher levels of compression. And we know this from earlier episodes, but I'm starting to link this in with your sitting. You cannot just continue modifying your sitting and continue sitting less and less as you tolerate and expect to get better. What we need to do is currently your tendon can't tolerate high levels of compression. So we need to build up those levels of compression through strength training. And if you don't do that, it will just lead to further weakening and further reducing your capacity to tolerate sitting. And therefore it gets to the point where people are unable to sit and all they do is lie down or stand up and totally avoid sitting altogether. And it's directly contributing to that downward spiral, like I've mentioned in previous episodes. So keep that in mind, we need some strength training and we need that strength training to involve levels of compression that you can tolerate and then slowly progress your levels of compression because that way we can start tolerating higher and higher levels of sitting. Bear that in mind, it needs to be done. There is a lot of questions around does sitting do damage to the tendon? Does it not do damage to the tendon? It's so sore when I sit, how can it not contribute to further damage? No sitting won't cause damage to the tendon. It does, when we talk about pain, it does not equal worsening pathology. However, what sitting is doing if you are exceeding its current capacity is your increasing tissue sensitivity. And this is completely different because all we're doing is getting that tendon and all the other components around it. and just creating some sort of sensitivity if you manage to overdo things. So for example, if we have a runner who has proximal hamstring tendinopathy, let's use a severe case. Let's say they can only tolerate 10 minutes of running right now, otherwise they'd be flared up. If they stick to under 10 minutes and they run, they're totally fine. So that's their level of tolerance. So we've established that. If you go from sitting, let's just say you've had to sit for longer, you've gone for a big trip, you've gone away in the country and you've had to sit for a couple of hours on the ride, on the drive there, when it irritates things, when that tendon does become quite sore, it might be sore for a couple of days. In those couple of days where that tissue sensitivity is heightened, you won't be able to tolerate those 10 minutes of running. You'll probably go back to a level of load that you thought was quite manageable, but now it's not manageable. And people can interpret that as, oh, my tendon's getting weaker, or my tendon is undergoing more damage. However, all you're doing is just creating some sensitivity. And in that sensitized phase, it can't tolerate those levels. However, it just needs a couple of days to settle, and then you're back to tolerating the loads you once did. Now that's an extreme example, but... you can probably identify certain things throughout the day or certain things throughout the week, certain things throughout the month where there might be certain levels of sensitivity where it can no longer tolerate things, but then it settles back down, you can go back to tolerating certain things. So it's just finding or interpreting those symptoms a little bit more accurately. So sensitivity does not equal weakness. It's just a short term loss of capacity, we could say. So keep that in mind. Yes, the tendons are sore when you do sit, but keep in mind that tendons, the actual tendon structure is very, very strong and sitting just won't contribute to further pathology. It just won't do it. So some reassurance for you and hopefully that made a lot of sense. 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 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. Which takes me to my next point. We should not be avoiding sitting because like anything, like a return to run program or like a progressive strengthening program, we want to start, we want to start low and we want to slowly build up. If you're returning to running, we want to start with say running for two minutes and then running for five minutes and then running for 10 minutes. We want to slowly improve that. The same can be said with sitting. We need to find your zone of tolerance. We need to know what level you can currently tolerate. I'm not saying it needs to be pain free. I'm saying certain level of tolerance which doesn't produce a significant flare up, so it's completely different to just being pain-free. But we want to make sure that we don't exceed that currently, but then we gradually introduce more and more sitting over time and allow further adaptation, allow that tendon to tolerate more levels of compression and slowly sit more and more, so it needs to be a bit more methodical and we want to be systematically going through that. So your adaptation zone may fluctuate week by week, sometimes day by day, if it gets particularly sensitive during something. So all of a sudden, let's say you can tolerate 60 minutes of sitting, and then all of a sudden you do a gym class, which involved a lot of plyometrics, jumping, lunging, squats, and the next day you're quite sore, you won't be able to tolerate 60 minutes, but recognising, okay, maybe I just sit for 20 minutes now before I move around, and in a couple of days I'll go back to that 60 minutes. But all in all, we're not avoiding sitting. We're not retreating back to that familiar pattern that is as soon as it's sore, I'm gonna avoid doing it because that pain, rest, weakness, downward spiral is gonna start creating and manifesting within the tendon. That's exactly what we want to avoid. So bear that in mind. Let's find your adaptation zone. Let's find your current level of sitting tolerance. Keep up with that and then slowly but surely increase your level. And like in my before point, if you're still doing some strength training that's hitting your adaptation zone into compression, that's just going to enhance your ability to start tolerating more and more levels of sitting. There was a question about long car rides, which look, it's not the best scenario if you can't tolerate high levels of sitting and then you have to go on a long car ride. Sometimes we might just have to put up with it just being sensitive for a few days after that. However, there are a few... modifications that we can do so it's a little bit more bearable or just perhaps we can modify some things so it can be a successful car ride rather than just being a flare up. If you're driving, if it's an automatic car, you can straighten out your leg and sort of transfer a lot of that weight bearing position into the mid hamstring. I do know, like similar to what we were talking about with our modifications, raising the height of the chair, making sure we're bringing most of the, or distributing a lot of that weight load to the mid-belly of the hamstring rather than on your sitting bones. So you can do that in a car, whether you are driving or whether you are a passenger, some things that you might wanna play around with. The hips, like cars, most cars, especially like a small sedan, they do sit very low. so your hips are below your knees, which isn't that great. So you might wanna put something underneath and almost essentially do those same modifications we talked about at the start of the episode. As a last resort, and this is only a last resort, you might wanna shift your body weight slightly over to the unaffected side, so that your tendons and your hamstring and your sitting bones on the unaffected side, cop a lot more of the brunt, cop a lot more of the compression. That can be like I said a last resort and a short-term resort only. So if you're going for a long car ride, just making that gradual shift maybe like 20% over to the other side and that can be enough to take pressure off your symptomatic side. But why I say this is short-term and why this is last resort? Because we don't want to really start... applying loads to different areas of the body because then we can compensate then we can start getting injured in other areas. A lot of people when they start bringing weight onto the unaffected side they twist their trunk a little bit and it just throws everyone out. So keep that in mind if it's a long car ride that's you don't do that often maybe you can raise the chair up, maybe you can put a cushion under there, maybe you can distribute the weight to the mid belly of the hamstring and then you can just gradually transfer your, like 20% of your body weight onto the unaffected side. And then all of those combinations, you're probably taking away 80% of the compression that's on the affected hamstring anyway. So maybe we do that. And the, I guess the second last point, the question around ice. I'm not too sure with ice. I don't think it's a good idea. Tendons when it comes to injury and when it, well, when it comes to any injury, You recover with blood flow. Blood flow is the life force that triggers healing and has all those healing mediators. And we want blood flow. Blood flow is very good in areas of the body. If you get damaged or injured to an area of the body that doesn't have a lot of blood supply, that healing time is a lot slower than something with a complete rich supply in blood. So what ice is doing is just restricting that blood flow, restricts all of the blood vessels to that area. However, it does make things feel better because you are numbing the sensation. You're almost blunting a lot of those pain signals with ice and it might make things feel better, but it's only in the short term. And I will release the episode. Todd Czarniecki is a guy who's had proximal hamstring tendinopathy or managed to overcome proximal hamstring tendinopathy over a decade. And he spent years and years constantly just icing and icing and icing his hamstring. And because it made him feel better, it made him feel better in the short term. But when I asked him, is it really doing much week by week, month by month? It's a no, it's not really doing much, but in the moment it makes things feel better. And what actually turned things around for him was when he got rid of the ice, totally got rid of the ice and actually introduced some warmth and introduced some, a good strength program. where things started turning around. So I don't recommend ice. I do recognize that it is alleviating symptoms in the short term, but hopefully if you stick to all these points that I've made above, then you're not in as much pain. You don't feel the need to ice it. So, yep, keep that in mind. Hopefully this is all making sense. I have one last point, which is a quick word on pain science. And I know I haven't done the pain science episodes yet. I will release them soon. But a quick word on the actual what pain is and what we know about pain science. The severity of pain that you experience is influenced by multiple factors. And it has a very real, very profound effect on, depending on your thoughts, depending on your emotions, depending on your past experiences. And also yes, the neural sensations and sore tendons and everything that what the layman's person might attribute to pain signals, like triggering something through the nerve that travels to the brain, which produces pain. You need to recognise that all pain and all pain signals are produced and interpreted in the brain. So how is this relevant to sitting with proximal hamstring tendinopathy? If you are anxious to sit, If you have beliefs that sitting will cause further damage and cause more pain and create more pain, the actual thoughts and the beliefs and the emotions that you attribute to sitting will mean that you will experience more pain in sitting. And you could have, we could do a really nice rehab, we could increase your level of compression with strengthening exercises, we can start to increase your sitting tolerance. However, if you're still attaching those emotions and those thoughts and those beliefs that sitting is causing all this damage and pain is a bad thing with sitting and it's just a fearful anxiety driven experience, you will still experience high levels of pain. Even if you can, the tendon starts operating and tolerating a lot of level, a lot of load. Keep that in mind. So hopefully the information that we've taken on board helps settle a lot of that anxiety, a lot of those emotions, because I do know and I do appreciate that a lot of people are very, very anxious to sit. However, we need to train the brain to recognize that it is okay to start sitting. You're not causing further damage. We can do these modifications to help settle things down. And hopefully that starts calming you and calming your brain down so that you can start experiencing lower levels of pain when you sit. This will all make more sense when I release those pain science episodes, but I thought I would release this episode quite early in the podcast because I know a lot of people have a lot of questions and it is something that highly affects people and their day to day experiences. So I want to get this out as early as I can. Take on the information we've learned throughout this podcast episode and hopefully it can start having you move forward to a less stressful. and more empowering path to recovery. We're all done. Thank you so much for listening. If you are finding extreme benefit from what you're learning on this podcast, please share it out to someone who does have proximal hamstring tendinopathy. And yeah, it will do me a massive favor and do them a favor as well. That's all today guys. For now, take care. 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.