Tendinopathy Rehabilitation & Prevention

: on today's episode, tendinopathy rehabilitation and prevention. 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. the stuff that you're probably all waiting for. How can we start rehabbing this properly? What does the evidence show? What's the most effective way of doing so? We will start delving into this today. I will be getting another snippet from my episode on the Run Smarter podcast. And we will be delving with, I guess, the universal principles when it comes to dealing with any tendinopathy, because they do follow a very similar pattern. into that recording in a second. It does reference running because it is from the running podcast but you can still follow the same advice but just replace running with your form of exercise if you're a swimmer, cyclist, gym goer. it can easily be substituted out. My last tip at the end of this recording talks about the pain rest weakness downward spiral and how you should be avoiding complete rest, which we will go into more detail later in the podcast. I have specifically organized these episodes to help your understanding and put these concepts in a nice order for you to follow. But when I'm repurposing a lot of content, this is some overlapping that doesn't quite fit the pattern. But it will be an episode I'll do later on, this pain, rest, weakness, downward spiral, because it is a key concept. But for now, this will be vital information for you. into the recording. And we're starting today when it comes to rehab and prevention, working through a few stages. And I was listening to a bit of Tom Goom's lectures with the online course that I have. And he likes to say, relating to that donut, and we're not just, we're not rehabbing the whole, we're rehabbing the donut, signifying like the. degeneration part of the tendon and the healthy tendon. He says, we want to treat the person and the donut, not the whole. So we're really bringing in concepts of what this person is doing throughout the day, outside of their running, why they run, what this pain means to them, what significance they're giving this pain, how they interpret their pain, what they think is going on. And so it's bringing in these factors. which kind of ties into this stage one. So I've got three stages when it comes to this rehab and preventative process. And so stage one is identifying compression for the tendon. Any excessive compression of that tendon needs to be addressed. So this can be stage one. If you have an Achilles problem, if you have a high hamstring problem, or if you have a gluteal tendinopathy, these are probably the three major areas compression really needs to be addressed. Because we can do all the rehab we want. If you are significantly compressing that tendon as becoming irritated outside of your running, then it's gonna be extremely difficult for that tendon to recover before you start that rehab process, before you start the strengthening and the returning to running and all that sort of stuff. This needs to be addressed. We could change their running, we could put them in higher wedges. for their shoes throughout the day, we can do all this sort of stuff. But if you go home, let's just say you have a gluteal tendinopathy, if you go home and sleep in compression and then wake up feeling terrible every morning, it's not setting up a really good foundation for recovery. In episode three, we're gonna go through detailed examples of what getting someone out of compression might look like. But just for this episode, just recognize that that's gonna be stage one. Stage two, is gonna be loading that tendon. Tendons really love load. If you give it the right amount, in the right conditions, under the right circumstances. And we wanna see the loading response. So we wanna make sure that when we load up a tendon, we start at a level that doesn't irritate the tendon. It doesn't matter if there's a little bit of pain during the exercise. There's some evidence to show that pain levels of around about four or five out of 10 during the exercise. is quite healthy, but we want to make sure there's no irritation afterwards. So after you do these strengthening exercises, you're not walking around for an hour being like, oh, it's a bit sore now, it's a bit irritated. That's a sign that it may have been overload. The exercise that you did may have been a bit too much. And also we want to see what it's like the following day after you do your exercise program. the following morning is that tendon flared up. That's another sign. And that goes back to one of our universal principles, observing pain over 24 hours. So what could be a starting point for you if you do have an irritated tendon? The first step could be to do what we call isometrics. And that's applying load to that tendon without the tendon actually moving. So it's holding a certain position for a certain period of time. and then resting. An example for an Achilles would be to bring your toes onto a step so that your heels are off that step and just keeping that foot flat and just holding that. You could probably hold onto some weights or hold onto a heavy backpack and load is being applied to that tendon, but it's not moving anywhere. You're not pushing up on your toes. You're not bringing the heel down towards that ground. It's just staying there. An example for your patellar tendon could be like a wall sit. Maybe you want to do a quarter squat and just sit with your back to the wall. You're not moving down and up into that squat position. You're just holding that position for a period of time. And as soon as you're finished with that you stand back up. So we're not moving in and out throughout the set. And there's some evidence from Ebony Rio that can show that I think she used a patellar tendon. But if you do say five sets of around about 45 seconds at 70% of a maximum contraction, so quite heavy load, you actually can sustain pain relief for up to 45 minutes while doing that exercise. So if you have that sort of response during your tendinopathy, it can actually be used as pain relief. I know I respond quite well to isometrics and I feel like if I have tendon pain do some isometrics. I feel like I have more power. I feel like I can jump, hop, land with a bit more confidence and I'm not as reluctant to load that tendon. So there can be some really powerful benefits if you do apply these isometrics carefully and work out how you respond to those isometrics because it can be really useful in your toolkit. I'm getting some clients these days to... load up their tendons, do some isometric work before they go on a run and seeing how they respond. And it will depend on the level of irritability, it will depend on the exercise we give them, whether it's too much or too easy. It can have a significant benefit throughout their run and how they recover afterwards and how they recover the next day. So keep that in mind. So step one would be those isometrics. Step two would be eccentrics. And there's some controversy around how effective eccentrics can be compared to concentrics or utilizing both of them. So an eccentric would be when a tendon is being loaded as it's lengthening and concentric being as it's loaded while it's shortening. So if we think of a calf raise, if you do a calf raise on a step, let's just say you're onto your toes, you start up onto your toes, you apply load and then you slowly drop that heel down. past the step towards the ground. As you're going through that phase, that tendon is lengthening, but it's under load when it's lengthening. So eccentrically loading that tendon. If you're responding really well to isometrics, our next step can be trying some eccentrics, and then again, seeing how you respond. See how you respond after doing the exercise, see how you respond the next day. And if you respond quite favourably, then that can be introduced into your rehab process. Step three would be introducing concentric and eccentric. So really doing some heavy, slow, resisted work. If we're continuing with this Achilles example, it would be again, applying load, bringing your toes off the, bring your heels off the edge of a step, slowly working your way down. But then when you get enough stretch on that Achilles, pushing up onto your toes and getting that concentric phase. And it... has also been shown with some evidence that eccentrics and concentrics can also reduce pain depending on the individual, depending on how much we load, but it tends to be the heavier the better as long as it's a slow controlled movement for these type of pain-free responses. So I've spent a couple of weeks working on some isometrics. We've seen that the tendons responded quite well and we want to progress to... some eccentrics or concentrics, whatever we want to play around with, and we've found out after a couple of weeks that we're responding really well to some slow heavy eccentrics and concentrics. The next step would be to slowly and gradually start applying some power, speed and plyometrics. And so that would be, I think we all know what power and speed are, but plyometrics would be things like jumping, alternate lunges as you lunge from one foot to the other, all these bounding type exercises. And we're looking at the rate of force production. The tendon will undergo a significant load really quickly if you put it through a really fast, powerful action. And so we need to, like I said, take this really gradually. Maybe start with a session of isometrics and eccentrics and then once the tendon feels like it's warmed up and it's good to go. start doing some plyometrics, trial and error the dosage, see how you feel afterwards, see how you feel the next day, and if you were a little bit worse off the next day, we probably have to back off, um, we probably have to modify that plyometric exercise a little bit, maybe lower the dosage, maybe lower the speed, the rate of contraction, or just the overall dosage, and then slowly build ourselves back up. But once we're into plyometrics and you're plyometrics really well, your body's going to start tolerating running and running at a faster speed a lot better. This podcast is sponsored by the Run Smarter series. If you want to take your knowledge building to the next level, I have built out a proximal hamstring tendinopathy video course which complements the podcast perfectly. Sometimes it's tough delivering concepts and exercises through an audio format, so the course brings a visual component full of rehab exercise 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. The last step I wanna talk about once we're really doing plyometrics and we're responding really well to that is starting to address the entire kinetic chain. So if we're looking at Achilles and we're responding really well to those plyometrics, making sure that our knees and our hips are functioning really well. And this does a really good next step at injury prevention. And this is a step that's often missed in your rehab because once someone feels better, they're like, okay, I'm responding well to running, let me just go back to running. They're back off their strengthening exercises or at best, they probably just keep up with the exercise that they're doing, but they don't go beyond that. If you're looking at your maximum threshold and that maximum capacity line for your tendons to tolerate load, we want to restore that back to your normal load of running. What I like to explain to clients is let's go beyond that. Let's get that maximal capacity line through the roof so that no matter what you do running wise, no matter what speed, hills, whatever you wanna throw at it with your running training, it cannot exceed that load capacity. That way the tendon's not gonna be reactive and sore if you do overload it, if you do have a hard session. So it's addressing the tendon specifically, isolating that tendon, but then it's looking a bit more broader and looking at the the joints above that tendon, the joints below that tendon, and the joints throughout that whole kinetic chain, and addressing any sort of power issues or any strength issues that might be throughout that whole chain. So let's recap. So we've got stage one, which would be avoiding compression for your tendon, and that could be daily activities, or it could be changing like a running shoe or the way you're running slightly out of compression, which I'll talk about next episode. applying load. Tendons love load and we work through our steps. So our load and holds, our isometrics, then intermovement, which would be concentric or eccentric, into then power, speed, plyometrics, and then that last step working that entire kinetic chain. And it doesn't need to start at step one. It is however a good starting point to see how the tendon reacts. But depending on the level of irritability and the overall reaction of that tendon, someone might start at stage three and we might start straight away with concentrics and eccentrics and see how the tendon responds. And if the tendon responds really well, we don't need to start with isometrics. We can go straight to step two or step three or even step four, just depending on the overall reaction of that tendon and how it's responding. So keep that in mind, it's not. a formula that you have to follow. It is a bit of trial and error depending on the individual. So that's stage 1 and stage 2. The third stage is kind of interlapping with stage 2, but it's throughout the stages of resistance, carefully balancing what running loads you can tolerate. So if you are moving from isometrics to eccentrics, we can judge how the tendon is responding and maybe give you permission to start running. Maybe you want to start with a walk run program while you're doing these exercises. And then as you're going into say the plyometric phase, it's reintroducing a little bit more running. Okay, maybe we can start slow, but maybe do longer and longer mileage. And once again, it's putting that scientific hat on, doing a certain dosage and then seeing how the tendon reacts. later on that day and the next morning. And this is where you need to work really carefully with either a running coach or a physiotherapist because they will formulate a plan for you. Most runners aren't that sensible, I always say it. They tend to overdo things, so having a structured plan to being told what to do is sometimes the best option for most people. So an example might be, let's just say we've started plyometrics. Okay, now you can start running five. kilometers at a 6 minute pace. Do that in the morning, then do your resistance training in the afternoon. We'll see the next morning how you've tolerated that. If there is a slight reaction, okay, let's go back, let's give it a day off. This time, instead of doing your running and your resistance training in the same day, let's break it up. So every day you're going to either do a resistance training, followed by the next day going for a run and repeat that cycle. See how the tendon responds. If it's not responding really well, okay, we have to have a rest day in between to allow that tendon to recover. Let's run every third day, resistance training the day after that and then having a day off. So this is where it comes into a bit of an art as well as a science. It's really just playing around with the dosages and seeing how you're going to or your running coach would know just exactly how to test and tweak those variables, because there's so many variables to consider. Initially, when you're introducing more running, we do play it safe and avoid running on consecutive days. There is a tendon synthesis process that goes through, so if you subject your tendon to load while running, the overall synthesis will be degraded over 24 hours and then in that 24 to 48 hours the synthesis actually becomes positive. So within 24 to 48 hours after exercise it's actually restoring. So if you do hard sessions on back to back days you're not really giving that tendon time to synthesize and actually get stronger. So especially in those initial days when you're it can be a really powerful tool to avoid consecutive days and always see how you respond 24 hours afterwards. So hopefully that's laid down a good principle for how you're going to rehab your tendon and then once it's rehabbed, having some principles for injury prevention. Let's avoid compression, let's start applying load under the right conditions and slowly increasing that load and then having that delicate balance of integrating running. while you're building up that load tolerance with your resistance training. I thought I'd finish this episode with five prevention tips that I've come up with. And so the first one being understanding your loading factors and consider them when planning your training and making sure we're not doing any drastic change. There's so many variables when it comes to running. It might be a distance, it might be speed, it might be hills, transitioning shoes, like if you want to go from a bulkier shoe to minimalist shoes. If you're running on the beach, changing your terrain, changing your overall volume, you really need to understand the loading factors and consider these in your training plan to make sure you're not avoiding, to make sure you're avoiding big spikes in your training. Very, very key point when it comes to injury prevention. Tip number two, make sure you're recovering well. Make sure you're sleeping well. Make sure you have a really good nutrition and make sure you have a really smart training plan. Also avoid long-term anti-inflammation medication. That tip can sort of find its way into the nutrition and sleep side of things. Tip number three would be cautious with your pre-season and your extended times off running. If you have more than two or three weeks off, if you go on holidays, or if you have a couple of months off, if it's the off season, very cautiously work your way back in. This is where injuries are. at the most prominent because people think they can jump straight back into the loads that they used to do. It does take a couple of weeks. If you are really strong, it still only takes a couple of weeks for you to build back up that load, but it still needs to be done gradually in the initial stages. So be very cautious of that. Tip number four is be mindful of compression outside of running. So your Achilles, your and you might have to modify your daily activities out of compression in order for that tendon to recover. My fifth and final tip for prevention is to avoid complete rest. We wanna stay away from that pain rest weakness downward spiral and that spiral all starts if you undergo a tendon reaction and your solution for that is a couple of weeks of complete rest followed by resuming back to the load that you used to. because that's gonna produce another reaction, you're gonna take some more extended time off, it's gonna get weaker, and we're already starting to head down that spiral. So those rehab tips. Number one, understand those loading factors. Number two, make sure you're recovering well with sleep and nutrition. Number three, be cautious of pre-season or extended time off running. Number four, avoiding compression of that tendon outside of running. And number five, avoiding complete rest. Okay, we are back and talking about my follow-up, I guess proximal hamstring tendinopathy related. I guess the one, my first point I guess would be when we're talking about the kinetic chain, when we're going through the stages and it gets to that third or fourth stage when we wanna start integrating the entire kinetic chain, it just means we're talking about involving other joints, other muscles, and specifically when it comes to this condition, the glute strength or power strength control of the hips. There is some evidence to show that those with proximal hamstring tendinopathy do have weaker glutes than a healthy population. So we wanna make sure in our rehab, once it gets to the appropriate stage, we are strengthening the other muscles and other joints away from that. So keep that in mind. And also when we're talking about the tendon synthesis, please we need to make sure that we're allowing 24 hours to recover, especially if you feel that you're not really tolerating back to back days. Let's just say you do strength training on one day and then you're cycling the next day and then you're running the day after that. Yes, you are offering variety, which is good, but it doesn't give the tendon enough time to recover. And the older you are, the longer the recovery time does take. So we want to really respect recovery. want to respect rest and just know that you are being proactive because the body gets stronger. Not when you're doing your hard workouts, but when you're resting, keep that in mind. When we're talking about these stages of rehab, it is super, super important that we progress your rehab should be progressive and should start working in some more strength based work. So many times the number one mistake I see is, um, athletes would come to me with years of proximal hamstring tendinopathy and say, I've tried everything. I've even tried strength work and it's still not making it better. And then I delve into what exercises they're actually doing. And they're all just doing body weight bridges. Um, and some really, really light stuff, mainly just body weight lunges, squats, and doing like high reps of just these body weight exercises. And they're just not progressing the way they should. You should start once you're able to tolerate it, start piling on the weights. and slowly but progressively getting heavier and heavier and heavier. You're only creating a ceiling to yourself if you only just do body weight exercises and work within yourself or at least self-reflective. You've been doing the same exercises for six months and it's not getting better. Continuing to do those exercises is not going to make it better. Keep that in mind. Um, so that's my key takeaways. Next time we're going to be delving into rehab stages. when it comes to proximal hamstring tendinopathy. So we'll be working through these stages, the specific exercises. And so yes, really delving into the meat of rehab with this condition. So we'll catch you next time. 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.