The 3 stages of Proximal Hamstring Tendinopathy Rehabilitation

: On today's episode, the three stages of rehab for 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. Today we are talking about the three stages of rehab following off last episode and talking about some main stages of rehab and some. injury prevention tips. If you haven't had a listen to that episode, I don't know why you'd straight away go to this one, but please go back to the previous episode. Go back to episode one if you haven't had a listen. But it will discuss like universal principles for any hamstring management, hamstring tendinopathy rehab. So please go back. Otherwise it might not make a whole lot of sense. Once we dive into this episode and It might be a little bit confusing because last time we talked about the three stages, we talked about modifying daily activities, we talked about tendon loading, we talked about return to sport and then working the entire kinetic chain. I still have stages in this episode, but they're different types of stages. So bear with me while I, I should probably call them ABCD, but They're all stages, but they're just different from last episode. So keep that in mind. Um, treatment for this particular tendinopathy will depend on the stage you're at the moment. You might have an acute flare up where it's quite irritable and sensitive, or it might be stabilized and you're still experiencing pain, but we could progress quite quickly. Um, so it would just depend. Uh, the. While we talk about the exercises and the rehab exercises, it is nice to talk about the pain levels during exercise. And there has been some really nice evidence of late emerging showing that if you do have a tendinopathy, particularly if it's out of the acute phase, so beyond that, you know, one to two weeks of a big flare up, pain during exercise and during your loading rehab exercises can be fine. I'm not saying all pain is fine, I'm saying pain can be fine, particularly if it's below a 5 out of 10, particularly if it settles within 24 hours after doing that exercise. So for example, if your physio has given you deadlifts to do as an exercise and during the first set you are experiencing maybe a 3 out of 10 pain, that's usually okay and we'll need to know how it responds after the exercise. to know if it's successful or not. We can't base it on the pain during the exercise, we need to continue waiting. If you do your second set and that three turns into a four out of 10, and then you do the third set and it turns into a five or six out of 10, that's a pattern that we think you've probably doing too much. Maybe you're doing it too fast, too heavy, going through too much of a range of movement, but. we want the pain to be stable, if not decreasing. Sometimes when I do my loading exercises, the pain in my tendon tends to decrease. And so, yeah, it's a good thing to keep in mind. Let's talk about stage one within this episode, which is if you do have a flare-up or what we call an acute on chronic, if you have a tendinopathy for six months, and then all of a sudden it's become considerably worse because you might've overdone something. We call that an acute on chronic. It's like a flare up reactive tendon. It can be quite sensitive. The pain levels can be quite high. And in this stage one, we focus on settling down this pain. So I have five tips here to help settle down this pain in stage one. So number one, first of all, we need to identify the changes in load or what might've caused this flare up so we can learn from it and make sure we don't repeat the same mistake next time. Two. we can temporarily back off whatever exercises or activity levels you were doing. And when I say temporarily, I mean like two days, sometimes three days, and before you're going back into your rehab exercises and maybe resuming at 50% of what you were previously doing. But yeah, we can back off for one to two days to let those symptoms settle. The third one I have for you is to implement some necessary daily modifications. So if we're talking about hamstring tendons, it might be to modify your sitting, more so than when you did previously, or modify, say, stairs, or walking uphill, or fast walking, these things that can irritate a sensitive tendon, which might not have irritated it previously when I was a little bit more stable. The fourth one, you can take some ibuprofen or some... anti-inflammation medication if you found that it's worked for you. However, it's only during this flare-up and you should only be taking it for two days, three days max and not going beyond that. So that's okay. And number five is this trial, some loading, maybe some isometrics to see if during this flare-up period, if it helps stabilize symptoms. So for me in the past, if I've had a hamstring tendon flare-up, I like to do some long lever bridging. So just lying on my back, doing a double leg bridge, but my heels are quite far away from my body. A single leg bridge would be once it's quite stable, but during the flare-up, I believe that doing a double leg bridge with the long lever tends to help me stabilize my symptoms during a particular flare-up. So let's go through those again. If you are experiencing a flare-up, these are five tips to help settle down your symptoms. Number one, we need to identify the changes in load to start with, so we learn from the process. Two, we temporarily back off exercise for two days. Three, we implement our daily modifications that might be sitting, driving, working, depending on you as an individual. Number four, you can take some ibuprofen for two to three days. And number five, we can trial some low-level exercises to see if it helps stabilize pain. That's a trial and error phase, and everyone's quite different. So we also, when you resume some low levels of exercise. If it's during this flare-up period, you can do it outside of compression. So lying on your stomach and doing a hamstring curl is another good option. And yeah, we want to avoid things like long levels of long times of compression or stretching. We do want to avoid those during that flare-up period. So that's phase one, stage one in this episode when it's reactive. We'll move on to stage two when the symptoms have started to settle. It's still painful, but it's a little bit more stable and a little bit more predictable. So stage two covers a whole bunch of strengthening exercises within your rehab, which starts with doing exercises outside of compression. And then as we progress through your journey, through your rehab journey, we're slowly introducing more and more compression to the tendon. So what do I mean by that? outside of compression would be like I said before, doing some theraband resistance band hamstring curls. And so you can appreciate if you are lying on your stomach and your legs are out straight and you've got a band around your ankles and you're just curling one leg towards your bum and applying tension on that band. You can imagine when it comes to the angle of the hips, the tendon is out of compression. compared to if you were say doing a deadlift where you're standing up tall, you're holding onto that weight and then you're dropping that weight down as you go down into that deadlift position. The hips increase inflection under the weight and tension of that, however heavy you're holding. The further you go down, the more compression that tendon is subject to. So that would be working into more levels of compression. we might start with doing a quarter deadlift, then go to half a deadlift, and then do a full deadlift action as we progress and as we see how that tendon behaves and we work into more and more compression. This is a crucial part, and it's something that athletes might be a bit apprehensive to, because in the past, maybe some compression exercises might've fled them up, but you can't have a successful rehab and try and return back to sport or try and tolerate sitting or get back to your daily exercises if the tendon can't tolerate compression. So in these early stages, maybe compression is a bit too early, but it needs to be factored within your rehab. Eventually, you need to start looking at low levels of compression, seeing or allowing the tendon to adapt to compression, and then slowly progressing into more and more compression so that the tendon can tolerate that. That's the only way you're gonna start tolerating more levels of sitting. It's the only way you're gonna get back to fast running or cycling or squats, lunges, all those things that require the tendon to be under load and to be under compression. So that's stage two. Stage two is starting with exercises outside of compression. So some bridges, some bridges on a step or on a ball, Swiss ball rollouts. and then going into compression. So maybe bridges through range, rather than doing that hold at the top, that can get you to a little bit of compression. Like I said, deadlifts, lunges, squats, what I call these Nordic hip variations, if you do a Nordic drop, but instead you're just dipping at the hips. A lot of my athletes that I work with will be very familiar with that one because I give it to a lot of them. So that's what we do. Moving into stage three, once we can tolerate good levels of compression, we want to tick this third bucket, which is speed, power, plyometrics, kinetic chain based stuff. And so what that would be, that would be kettlebell swings, where it's kind of like a deadlift action but we're doing a lot more force production. Rocket jumps, you can YouTube those if you're not familiar what they are. Single leg deadlifts have a bit more control, a bit more balance, a bit more kinetic chain component to it. All of these exercises are very hard to explain through a podcast format. That's why I have my online course. And speaking of, let's jump into the ad and then we'll be back in a second. 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. Okay, and we are back. To finish up, maybe just a little bit of a recap. So We have what to do if you're settling down pain, like if you have a significant flare up and it's quite irritable and unpredictable, and we go through those five steps to help settle down the pain. Then we move into stage two, which is starting with some exercises outside of compression, and we're slowly working our way into compression over the weeks and weeks and weeks, seeing how the tendon tolerates it. Someone who comes to me and they're quite strong and quite stable, I might just go straight to the... tougher exercises and straight to the full compression, into compression exercises. But just so you know, that's kind of the process, that's the ladder. And then we're, once you can tolerate all of those, we're integrating some sort of speed, power, kinetic change, especially if you want to return to high level functioning. If you want to be a runner, a cyclist, if you want to be performing at the gym, that's when the speed power aspect really needs to come in. As we finish up, I really want to illustrate the importance of the psychosocial factors. There's some studies, I saw Ardern, 2012, released a paper showing that some patients have particular beliefs when it comes to tendon management that can detrimentally affect and have serious consequences on their management, on their recovery. and certain beliefs do get circulated into an athlete when they are doing their rehab. Pain during an exercise is one of them. I know I said at the start of the episode that pain during exercise is totally fine. if it's in low levels and if you've negotiated it 24 hours afterwards, if there's no significant flare up afterwards, then we know that you have successfully negotiated that level, that dosage, that exercise that we've given you. But some people might think that pain during loading equals damage or equals further damage or threatens the tendon to rupture based on what they've heard or what they've been told in the past. And these thoughts can have real consequences during your rehab moving forward. Another belief that I hear a lot is that pain equals weakness. They think that people have they've done months and months of rehab and built up and seen really good results and then had a flare up where they're back to square one and even just the most basic exercises flare them up and they think they interpret that as weakness and they've lost all the strength that they've gained and It's important to know, and it's reassuring to know, that you haven't lost strength. It's just painful. Pain does not equal weakness. And you can still, once we... Settle down those symptoms in the next week or two. You can still return back to those high level exercises and your strength is still maintained So keep an eye out have some self-reflection if you find that you are very apprehensive to load the tendon if you're apprehensive to feel any sort of tension soreness tightness within that area and you're just retreating and backing off to safety and Not doing any loading painful exercises then it's just going to contribute to further weakness and then further kind of anxieties and fears about doing those exercises moving forward. So keep that in mind. yeah, requires a bit of self-reflection. I will cover when it comes to treatment and rehab, I will cover aspects of shockwave and surgery and injections. I know PRPs and corticosteroid injections, all those things are quite popular amongst the community in terms of when they're looking for answers. I will cover those in another time on another episode. But for now, Just to close up, we had our flare up plan, we've got our strengthening exercises going from outside of compression into compression, we've done our speed work and we're making sure that your beliefs, anything that you have if you're quite apprehensive to load the tendon under pain or if you think it's going to contribute to further damage or rupture risk of rupturing a tendon just be reassured to know that tendons love load under the right environment pain during that exercise is okay just to help settle your mind calm your mind and attempt some more things in the gym. I often say to runners and the athletes that I work with is if they have a proximal hamstring tendinopathy and they do their exercises pain-free you're probably under loading the tendon. I actually prefer it if we can find some exercises that do trigger a little bit of pain during that exercise. That remains settled after the exercise and the next day. That way we know we're fostering a really nice sweet spot and we're not under loading and we're not overloading that tendon. So keep that in mind. Next time, I'm gonna introduce you to my ebook and a few relevant chapters I've picked out of my ebook, which will be more snippets from the Run Smarter podcast. And as always, tune in after that snippet to find the relevance to proximal hamstring tendinopathy. So I look forward to bringing you that episode next time, and I hope you enjoyed today's episode. Thanks once again for listening and taking control of your rehab. If you are a runner and love learning through the podcast format, then go ahead and check out the Run Smarter podcast, hosted by me. I'll include the link along with all the other links mentioned today in the show notes. So open up your device, click on the show description, and all the links will be there waiting for you. Congratulations on paving your way forward towards an empowering, pain-free future, and remember... Knowledge is power.