Why your hamstring tendinopathy isn't getting better with Maryke Louw

: On today's episode, why your PHT isn't getting better with Mareika Lowe. 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. such a small group of online physios out there. I feel like we just need to band together and really support each other. So I was delighted to have Mareika Lowe on today's episode. And I interviewed her last year. And this is the grab from that episode. We do a deep dive. Mareika was fantastic at listening to a few of the past episodes on the Run Smarter podcast and found some like gaps in knowledge or stuff we haven't necessarily covered yet. and decided to share her five tips of why your proximal hamstring tendinopathy is not getting better. She has had, um, a lot of experience with working with PhD sufferers, and it just allowed for a very insightful, very informative chat. So like I said, repurposing this episode again, but it needs to be on this podcast. And I'm excited to dive into the chat. So here is Marekha. Marekha, thanks for coming on and taking the time to your wisdom on proximal hamstring tendinopathy. Let's just start with your career, how your physio career has transformed into where it is now. Okay, thank you for having me on the show Brody. So yes, I started life as a physio in South Africa and then moved to the UK for a couple of years, thought oh can't stand the weather so went back to South Africa and then actually realized that no the UK was actually quite nice so went back to the UK in 2010 and did a masters in sports injury management. And then after that, I really kind of honed in on sports injuries and stuff. And I was lucky enough to start work in a clinic with a multidisciplinary practice where we had one of the top UK sports physicians, professor Nick Weborn working with, or in charge of the clinic. And yeah, for the last 10 years or nine years I've worked there and it was just so good for learning about different sports injuries and stuff. And then in 2014 I started my online physiotherapy practice which at that point all physios I spoke to thought I was absolutely nuts for doing physio online. And it was quite a slow burner because people were used to that physios have to touch you to get you better. And But the more the research came out, it showed no, actually our bodies can heal themselves. All you need is the right combination of rest and exercise. And finally, the message has gotten through to people and the business have become a lot more popular. And the service also with people not wanting to travel for physio really. And of course, at the moment with the current conditions, in a lot of countries you don't have online physio, you don't have physical physio available. So online physio is now the go-to for loads of physiotherapists. So yes, and here I am now I've, I've pretty much specialized in sports and online physiotherapy. Right. You're preaching to the choir here when you're talking about the benefits of online physio. But to do it from 2014, like I think I first heard about online physio maybe two years ago. And, um, well, I've just seen like this emergence in the last maybe 12 months of different clinics, transforming or changing how they're practicing. Did, had you seen much? online, like even just any health professional doing online stuff back in 2014? So when I Googled it, there were two other sites that I found and the one was, they were both Australian sites. So the one was a physiotherapist and she's still working. She specializes a lot in, I can't think of her name now, but she specializes a lot in office workers and things and adaptations like that. And her website was already up and running and she was providing a really good service at that point. Was it Karen Finnan? The other one, yes, that's her. And then the other one was more like a physiotherapy guide site. So it wasn't actual consultations, but you could subscribe to them for step by step how you treat different injuries. Yeah, so those were the only people going at that point. And I have to be honest, the reason I wanted to start it was I love traveling. really travel with my profession because every country you would need to register with their health profession councils. And that usually entailed writing a exam in their language in physiotherapy. And I think you also know that once you've been qualified for several years, you kind of forget what you did in the hospital phases, just doing sports physio and stuff. So yeah, I wasn't keen to study. Again. Yeah. Half the stuff I've learned isn't relevant anymore. Yes, exactly. And that's why it's so important to keep up with the research. Yeah. And so we decided to come together and talk about proximal hamstring tendinopathy. And before we dive into your five key points that you've written down, um, why is there a need to address proximal hamstring tendinopathy and why is it such a problem for runners? I know a couple of ants myself, but, uh, what would you say? So. The problem with this condition is that it's probably one of the more pesky types of tendinopathies to get better and it can really drag on for years if people don't get the right management. So the reason I've actually in my earlier years as a physio, I tried to avoid these patients because it can be so difficult to help them. But since I've started my online practice, I've somehow managed to, I made one video that was about proximal hamstring tendinopathy on YouTube. And it just seems that every single person have watched this video and somehow they've started contacting me. So I've had to become a bit of a specialist in treatment of this online. And it's just so heartbreaking when you hear the stories of these people that they've had this pain for so long and it's really, it's not just affecting their running, it's also affecting their social lives because they can't sit. So they can't go to meals. They kind of dread. having to go to parties because they know how frustrated they're going to be. They, they can't even drive their children to school properly because they can't really sit comfortably. It makes a whole lot of sense because like I said, sometimes you can drag on for years and if you go, if you put on a YouTube video explaining it and some treatments, like the people who are watching that, that have chronic proximal hair string tendinopathy, they, they get quite desperate. And so I guess reaching out to you is, um, the next step. Yeah. And it's quite shocking how much bad advice is out there as well. And you mentioned it in your podcast. I think it was the one about compression that you did, where you mentioned about the compression. Which one was that? The second podcast possibly, about how a lot of people get told to stretch. And it's amazing how many of these people who contact me, who's got ongoing pain, who's given hamstring stretches to do and stuff. Yeah. Yeah, there's a flip side to getting advice from, from YouTube is that you can get totally wrong advice as well. And I think it's like people's natural inclination to do, because sometimes when things feel sore, they can also be perceived as tight. Like if they straighten out their leg and it feels painful when you stretch it. That can kind of create that perception of tightness and okay, it's tight. It needs to be stretched, which ends up making things worse. It can feel satisfying to feel you nailing the bit that's hurting. True. Very true. Okay. Uh, let's dive into your five things that you have written down. Uh, so what's the first one? Okay. So I looked at the main reasons or the main things that I find in my patients when they contact me and say, I'm not getting better. And these are the five main things that I usually find they do some of, maybe a combination of them. So the first one is that they're not addressing the compression component of the injury. So in podcast number one of the tendon talk that you had, you spoke about how compression contributes to tendinopathies, and especially for the high hamstring tendinopathies, the compression of the tendon around the sit bone. Now, it's not just that they're constantly compressing it through the day, so it's sometimes also that they're not actually doing exercises that strengthens the compression capacity again, or builds the... compression capacity. So the four main things on a compression, I would say, is that they're continuing to sit for way too long, or they're continuing to sit in positions that really aggravates the tendon. So you have to address your sitting position. And if you can't sit comfortably, you should think about getting a sit-stand desk, that you go between sitting and standing, that you don't think of sitting capacity as the same as your running capacity. So you wouldn't expect to be able to run a marathon on a sprained ankle. And the same thing, that tendon only has the capacity to deal with so much compression from sitting in the day. So you need to slowly build that up, but not kind of overstep the mark by sitting for long periods when it's not ready for it. Then the second part of compression that they may have in their day or in their program that can be causing trouble is like I've just said about the stretching. If they're doing any hamstring stretches or performance stretches or glute stretches. All of those type of things I find can add compression to the tendon that it's often not happy with. Even if it feels better at the time, it may make it hurt a few hours later. Then the third place where they can get compression that can irritate the tendon is if they are trying to do different things and they're running, that's not quite good for it at the moment. So if they're giving big steps or they're running uphill, and I think you mentioned all of that in your podcast as well. you separate your legs when you run, the more you'll get compression of that tendon over the sit bone. And then lastly, it's not just about avoiding compression. You also actually have to build the capacity of that tendon to cope with compression loads again. So often some of these patients, because they've heard that they need to avoid compression, have gone and avoided all types of compression for months and months and months. So the problem with that is that you're never going to make your tendon used to being squashed again. And you have to do that because you want to sit on it. So it's important that your rehab program actually also includes some exercises that does cause graded compression in the tendon and that you build how much compression and load it takes in that compressed position over time. And that will feed into my next point as well in a minute. Okay. I'm glad you addressed that. that it needs to start tolerating compression because I was going to be on next point I was going to make people once they, even once they get better, they then have fear of sitting and they say, yeah, Oh, because the long standing hamstring tend not be so hard to overcome. And it can be so traumatic and debilitating for a lot of people. Once they're better, they obviously don't want that to happen again. And so they realize that compression was bad for before. And then. They're like, I'm fine now. I just never sit and you know, you still need to get on with everyday life. It's encouraging or like you try and really, um, make sure that they're, they're fully understanding that the tendon can undergo compression. It's healthy for the tendons to undergo compression, but like anything, we need to build up its tolerance in order to take that, um, because fear can be another, uh, psychological component that needs to be addressed as well. You did mention... You're jumping to my point number five. Oh, I'm sorry. I'm sorry. Don't worry. I said that. I'll go back to that sitting part that you're talking about because that is a big part. You did mention a sit-stand desk. If someone is in the car or if they're sitting at home and not in the office where they have a sit-stand desk, is there any other modifications we can do in order to avoid compression? Absolutely. So one of the best... things I found actually in the past for myself, because I always tend to get these injuries myself to an extent as well, is if you can find a soft, really soft like a feather cushion, or for me, my feather jacket worked really well. And the reason those things work well is because they're so pliable and you can really change where you take the pressure with that. And often if you don't actually sit directly with your sit bone on it, so it's not that you're sitting on a soft surface. But you create a little gap for it. So if you have a cushion, you don't push it all the way under your bum. You leave a little gap. Sometimes that can be quite comfortable, but otherwise just something really, really soft, like a feather cushion or jacket can be really good to sit on. Yeah. Cause you're dissipating the load, um, underneath your sit bones instead of having that dislike direct compression through that bone. Okay. Very good. Um, And back to the running, you mentioned like overstriding or maybe running uphill can put compression. Um, I haven't seen it too often, but what I've heard is also combining that, um, overstriding with a forward, like trunk lean, like people who do lean with a little bit of a, um, a forward lean in their torso, if they combine that with overstriding, that can also create a lot of compression. Um, it's not a common running pattern that I see too often, but, um, Yeah, can definitely put a lot of compression through that tendon. Absolutely. And it's, it's quite difficult to change your running style if you're used to it. So I just, I just find that telling my patients to just give really short strides at the beginning works quite well to get them to, to not have that overstride. Yeah. Great. And you're also maintaining, um, some strength in that tendon. If you're not just completely backing off and you're still maintaining some running and it might just take some slight adjustments. So that's a good thing for the health of the tendon as well. That's a very good first point, dealing with compression. I think it's a key one because a lot of people, especially in the early stages, they don't directly link sitting and compression with their pain. They usually associate it with the actual running itself. So identifying that factor straight off the bat is very good, I think. Is there any other points you want to touch on with compression before we talk about your second point? think it's just to kind of summarize that point in that, um, under compression, you can say, avoid excessive compression at the beginning, but make sure you build back your capacity over time with regards to that. Don't just for always or forever avoid compression. Good. It's the same thing as if you have, um, like a running injury and you just stop running, you haven't gone over the injury yet, you just haven't, um, addressed the aggravating factor. So it's not a very good rehab if you get injured running and you just completely back off. So very good point. Building up that load tolerance once again. Okay. Point number two, what do we have there? Okay. So it's exercise choice. So I'll get these runners in and they will say, I've done all the strength training. I've done these exercises, blah, blah. And then you listen to them and you go, oh my soul. Yes, there are exercises you can use for this, probably a few stages later than where you are at the moment. So what people often do is they read about, you've got to do high load training for tendinopathies and you've got to do squats and deadlifts and everything. But yes, you have, but at the right stage. So a lot of the tendons, if they're really, really sensitive and aggravated, if you're going to start with a heavy squat or deadlift, you will make that pain a lot worse. So it's... And you spoke about this as well, about how to start with your isometrics and things and positions where there's not a lot of compression on that tendon. Where you're actually just getting a bit of blood flow and just a bit of activation. So I would definitely say with your exercise choice, it's got to be at the right range of movement that you work it. And also the weight needs to be relative to what the tendon can take. So heavy may mean a different thing for your muscles. If you're somebody who's really strong. then a heavy weight may not be heavy for your muscles, but it may actually be quite heavy for the tendon because the tendon may not be strong enough to cope with it at that point, or it may just be too sensitive. So the exercise choice is really important. Okay. Do you have like in the, I guess the stage numbers, is there, if someone's not too sure about the stages, you mentioned one of them being out of compression and two being within compression, how do we know? what stage we should start with or how do we know when to move to the next stage? Yeah. So it's really simple. It's, I always just, you test. So how you test is you start with the easiest thing where there's absolute no compression. So if we think of a glute bridge where, or a hamstring curl, where you're lying on your front, where the tendon is not being compressed in the bone, but you can load it, if it's happy with that. then you think, okay, let's test how happy this is with compression. So you do a free squat, so no weights. You just do a free squat. You see, at what level of that squat do I start feeling some discomfort? And you notice that. And then I usually get my patients to work to that level where they just start feeling the discomfort first until they've got their full range through that. And you can even load them pretty, you know, progressively heavy in that range of movement that's limited. because that often gives us the rest of the range. So if you then want to start a deadlift, I would always test the deadlift first without any weight. And then if it's okay, you add little bits of weight, you know, as you go along. So yes, we want to get to where they work really hard at an eight rep max eventually, but I always start with a 15, 12 to 15 rep max first, preferably get them comfortable with body weight first and then progress onto the rest. But it's a very step. by step program because to be honest, these injuries take a long time to get better and there's no use in rushing into it and progressing so quickly that you flare the pain up because then you not only have the tendon to deal with that sensitive, but you also have the patient who then is in a really low mood because now their pain is worse. I think the running population is the most impatient population out there. And as soon as they get a, an exercise that is now pain free. They want to jump three levels above what they were doing. And like you're saying, as long as you trust the process and you are patient, you do have those expectations laid down. I think a lot of the studies that are out there that do, um, or that are found with the good outcomes, they study it for like three months minimum, uh, when it comes to loading the tendons. So make sure that you're patient and you are building strength. Um, okay. So you've, you've talked about making sure that the tendon itself, is not undergoing too much pain during the exercise. You want to go through a certain range of movement just to that point of discomfort, maybe back off a bit before then, but you might be able to find that you can apply quite a heavy load through that range and get that same amount of discomfort. And that can be quite encouraging for people to start lifting slightly heavier, but it is on an individual basis and it will be on a symptom dependent basis. Am I right in saying that? Absolutely. Yes. Okay, any other points with exercise choice? Um, just that technically there really aren't any exercises that's bad for it. It's just about implementing it at the right speed and in the right way. Um, because I've, I've also, I need to go revise some of my videos because I've had people say, I saw that you said that deadlifts are really bad for it. So I've stopped doing it and you go, Oh, I really don't think I said that, but probably the way that I said it, it may have come across like that. Yeah. So, and it comes down to. Yes, dead lifts compresses the tendon, but you want to make it used to it eventually, but at the right level. Yeah. Some of the, um, like low level hamstring tendon, opethies, if I have a strong runner that comes into the clinic and I have a look at their capacity and they're getting a high hamstring tendon pain, but you look at their strength and they're actually quite strong and symptoms actually really mild. The first thing you could do is probably compress it. The first thing you could do is probably take it through some dead lifts. Um, I like this, I don't know what they actually call it, it's kind of like a Nordic hamstring drop but you're just flexing at the hips and you're just like dipping like a dipping bird, can put a tremendous compression through that tendon but if someone's really mild symptoms and really strong, can be the, can make all the difference and can actually return them back to running really, really quickly. So like you said, it all depends. That actually is exactly what I was trying to say with the last point of my... With my first point where I said that you must make the tendon used to the compression, because if you get those runners who's gone through everything, but they still have that mild pain and you look at their program, they often don't have any exercises in there like the deadlifts that compress the tendon. And that's why the pain is still going on. And if you just make that change, you're absolutely right. Then they get back to running. Perfect. Okay. Let's move on. 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 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. Point number three. Um, it's about dosage. And this is something that I love that the line you used in your second podcast about tendons where you said deciding how many times you should do an exercise and how often, it's more an art than a prescription that you can prescribe to each person. Because it is absolutely an art. You've got to take every person recovers at a different rate. Depending on your age, you're going to recover at a different rate than what you did before. Females, depending on our hormone levels, we recover at different rates. So it's really important to look at where you schedule your exercise. And then also if you're still running and you're running quite frequently in the week, where you schedule your strength training with in relation to the running, that you don't overload the tendon because tendons do take longer than muscles to recover. So if you're doing heavy strength training, they usually need 48 to 72 hours to properly recover from that. So you've got to. think about the training you do after that. Otherwise you'll just add to cumulative overload. Um, so that's a really important point that please don't look at somebody else's rehab, what they're doing and try to mimic that because it will very likely not be the right thing for you. Yeah. And a thing I can add to that is like, when it comes to a tendinopathy, it actually, the severity is on a spectrum and you can have disease, really low load reactive tendinopathy so we can have a really. Um, severe degenerative tendinopathy, someone who's, um, had it for quite some time is really painful. So that will depend or that will affect the dosages as well. And, um, we will talk about Tom Goon before and he has a really nice saying. It's always, um, it's always about reasoning, not a recipe. And so there can't just be one dosage for an individual. Um, and it all just takes a bit of trial and error. I found in the practice we sometimes had newly qualified physios shadow us and then they would ask me, so why did you do that? I would stand still and go, I really don't know. I just felt like the right thing. And then you'd have to stand and think, why did I do that? What was my clinical reasoning behind it? And then you go, oh yes, it's because this person was like this. And then you realize that there are so many decisions that goes through your mind with regards to sensitivity of the tendon and everything like you said. that yeah, there's never two patients that gets the same thing. Yeah. We can kind of through like clinical experience hit like a similar ballpark that you'll want to, um, based on like clinical experience. And, uh, but you do stay to the patient. I don't, I like to give a dosage to a client and say, all right, but we need to pay attention to symptoms during, you need to pay attention to symptoms afterwards and symptoms the next day, because it might need to fluctuate. We might need to add more on. We might need to take a bit off. Um, your tendon is going to not only. be different to everyone else, but it also fluctuates itself. Like one part of the week might be different to another part of the week based on how much sitting you're doing and how much bike riding you're doing, et cetera. So it's, yeah, as long as the client is aware of the symptoms and how to respond to certain symptoms can really put them in that sweet spot. Yeah. And don't you find with your online clients as well that doing the whole process online to get that interaction and that response quite quickly. Because what I found with my patients when I saw them in clinics, that they would not contact me until the two weeks later that they came back in. And then they would tell me about this massive flare up that just escalated and it's like, why did you not call me? Whereas with online stuff, because they're online and they know they can email you, you get a message immediately, you can immediately say, oh, let's just adjust it like this or this and this. And it averts that. Absolutely. So you have to be able to adjust things, but yes, like you said, education of the patient that they actually know to notice that. Yeah. I have been like of late, um, communicating with my online clients, making sure I'm like, please like, uh, interrupt me, disturb me throughout any time of the day, any day of the week, make sure that you are fully informed. And if you have any questions, let me know because if there's confusion or you're not too sure how to proceed, I'd rather, um, adapt on the dime rather than going to a week of them fumbling through symptoms. And yeah, which is why online is perfect because it's just a, um, a text message or an email away. Exactly. And at that point, it's often as easy as a yes, no answer. Whereas if you wait a week and everything's escalated, then it's a nightmare because then it takes a whole session to figure out, okay, where do we go from here now? Cause now we've got a really painful tendon. Yeah. No, I love, I love that. Um, with. dosage as well, one thing I want to add, what are your takes on the speed of the exercise? I tend to be in the, uh, a fan of the slow, really controlled for the quite a long period. Um, until I nearly get them, it's when we start getting back to full running that I start getting them to do faster stuff. But for the first period, especially the first, let's say three, two, to four months, I probably like them very slow exercises. Yeah, I think it's a good thing for the clients to wrap around their head is the load, the like exponential requirements of the tendon once speed is introduced. And you can go really heavy and really slow and the tendon can start adapting to that really quickly and start behaving really beneficially. But as soon as you introduce speed, You want to make sure that's really, really gradual and you're really paying close attention because even as body weight with really fast speed, um, might even Trump something as simple as like a really heavy deadlift. Um, so very, um, very important to keep in mind. Definitely. Okay. Can we move on to your third, uh, your fourth point that you have written down? Yes. So you've actually. semi-spoiled this one already for me as well. Damn, damn, damn. We said at the start of the interview that whether you want to tell me these five points to start with, I said, no, I want to be surprised. But I think just when we talk about these sort of things, I get really excited and want to touch on everything that flows into my head. But anyway, point number four. There's no surprising you, my dear. But it is realistic expectations. And so often I get frustrated emails from people. saying, oh, I'm not getting better. I've got exercise, blah, blah. It's not making a difference. And then we have a session and I listen to them and I listen to where they were. And then you listen to the progress they made over the last three months working with their physio. And I usually end up saying, I think you need to go apologize to your physio because look at where you were and where you are now and how much progress you've made. But the problem is that progress with regards to tendinopathy takes a very long time and it can be really disheartening. if you get a day or two where it feels really bad again. Now, there's a really cool graphic that Adam Eakins made. You must have seen that one about how a patient expects recovery to be, and it's a nice straight line up from being injured to being healthy, and then how recovery really is. And it's this really tumbling line all around, all around, and that's exactly how recovery is for any injury. Just as you think, oh, I'm clear now. you'll have a day or two where you suddenly painful and there will be no reason why you painful and to be honest, a lot of the time it's because that area is so sensitive and it's very easy to kick off the pain signals and you've just done something that irritated it. So it doesn't even have to, one of the big fears that people email me with when they have a flare up in their hamstring tendons is like, Oh, I think I've just injured the area again. I think I've made it worse. I think the tendon is dying off, things like that, because it's all stuff that they've heard. And you go, no, you've just gone and pushed on that bruise basically and made the pain flare up. It will settle down again. And usually if they then just take things easy for three, four days, they're back to normal and they can carry on with their rehab again. So it's quite important to take a long-term perspective so that you, and note down what you can do on a weekly basis so that you can look back. And as long as the trend is upwards, it means that you're recovering. And also to get back to the point of how long you've got to do your rehab for. So we know from research and strength and conditioning that muscles take longer than eight weeks to get proper strength changes that you start seeing in them. Now tendons take longer than muscle tissue to react to strength training. So you need to follow a program for at least 12 weeks before you're gonna start seeing good results. And then we did a study on Achilles tendons where we scanned the, um, the new ultrasound scanners can look at, um, stiffness of a tendon. And what we saw was with the strength training, everybody's tendons improved in stiffness and then they stopped strength training for four weeks and they came back and the tendons had lost that stiffness again. So it shows us that you have to do strength training for tendons probably for a lot longer than 12 weeks to get that. you know, strength to stay. So, yes, I think it's about having realistic expectations about what you can expect, how much better you can actually expect to be at this point. Sometimes it truly isn't the progress you should have, you should be better off. So it is good to seek a second opinion if you feel you're not making any progress. But sometimes you also just need to realize that it is a condition that can take a long time. Very good. And one thing I do want to mention with that is the, with the realist expectations, I see a lot of clients that go through a lot of like mood fluctuations and they'll, they'll hit their management plan to a T for say a week and they feel really, really good. And they're like, Oh, this is it. I've seen it. This is the light, the end of the tunnel. Fantastic. And then they like do way too much. And then as soon as symptoms come back, they're mood shifts to, oh, it's never going to go away. I'm doomed to like maybe running isn't for me. And it really takes someone to talk to them to be like, hey, look, we did a week of really good work and you start to see results straight away. Like there might've been small results but they're results nonetheless. Like let's just stack one week to two weeks to four weeks and make sure that we're not getting too ahead of ourselves as soon as you start seeing benefits. because then again, we're doing too much of a jump and that tendon starts to react. So I think we mentioned timeframes a little bit. So working at how slow the tendon is to adapt and we're looking at maybe beyond three months. And a point that you mentioned when it, once it's deloaded and that stiffness dissipates might set a realistic expectation for once you are better, maybe maintaining some loading. outside of running. So doing some strengthening maybe once or twice a week to maintain that stiffness and maintain a high tolerance to focus on injury prevention. I think it was specifically for patellar tendinopathy that I was reading an article the other day about best management. And as part of that guidelines with the research they've done, they've definitely said if you, with regards to basketball players and those... that lot. If you want this to stay away, you probably have to do one proper strength training session at least every single week, you know, for the rest of your life with it. And to be honest, once you at the beginning, your strength training is the bulk of your treatment. And as you run more and as you build your running mileage, you reduce the strength training to just be a core, you know, high intensity, low volume session. So your strength training doesn't mean that you're forever going to have to do three sessions a week. loads of time on it, it can actually come down to a core set of exercise that takes you 25 to 30 minutes once a week. And that's all you need to maintain it. But the point is it's got to be adapted up and down at the right times. And that's why it's useful to work with somebody who can help you see when the right time is. Yeah. And also, um, what it's good to let them know that once it is very hard work to build up the strength. but it's quite easy to maintain that strength. Like once you've built up that tolerance to, you know, tolerate whatever you're doing, whether it's basketball or running, in order to maintain that strength, we're not focusing on gains anymore. It's super, super easy compared to the effort it takes to build up that strength. Yeah, no, absolutely. Perfect. Anything we'll need to add before we go to our final point? No, I think that's about But right for expectations. I'm not going to be as surprised about the fifth point because we sort of spoiled it, but let's go to it. But I, beliefs is so important and especially with hamstring tendinopathy. So the internet is a wonderful thing because you can get so much support on there from different people. But the problem with that as well, with support groups and things on the internet is that there are loads of people in there who maybe didn't have the best management or maybe have a severe case and who's not got better. So I often get people who are really frightened because of what they've read on the internet, people telling them, oh, it's never going to get better. You always have this. You'll always have that. And honestly, people, you are an individual and nobody else can tell you what you will have for the rest of your life and how you will feel. And often you've got to look at people who's not got better. How severe their injuries was? Do they have other things going on? What was the management they got? What was the advice they got at the beginning? I can also, and you've just, a big belief or thing that people fall into is when people have a flare-up, that they immediately transfer it back to, oh, I'm gonna have this pain forever. And it's not just for hamstring tendinopathies. I see that with a lot of patients with other conditions as well as, I'm never gonna get rid of this. And honestly, you truly will. It's just everybody will get better if you can find the right recipe. And it's just about trial and error. And if exercise alone doesn't work for you, there are always other things that can be tried. That's why it's so useful to work with a sports doc and a physio because the sports doc can add things like different types of injections and shockwave and all sorts of, we know that they aren't perfect cures and that they don't work for everybody, but there are so many different options out there that to say that you won't get better is a very big statement. Yeah. And it starts with a really, really good management program and seeking out the right advice and someone who says, Oh, I've had it for five years, never getting any better. Oh, what have you tried in the past? And they might try like a couple of weeks of strengthening, a couple of weeks of phone rolling, um, years of stretching. And, um, it's, you, you look at their management. It's like, how about if we, uh, follow some really, really sound advice and be really, really diligent with, um, a solid program. Let's see how you're going to feel after six weeks. And, um, it's easy for people to be like, I've had this five years, never going to get any better. Are there any other common beliefs that you've come across when it comes to this condition? Yes. So the other big problem is that people get fear avoidance. And I think you mentioned that under the compression point that they believe certain movements are bad and they believe that certain things should be avoided forever. And the problem with fear avoidance is that. If you then stop doing those things, you actually reduce the capacity of your body to cope with those things even more. What we also know is that the body doesn't like wasting energy. Say, for instance, I want to pick up this book that's on my table. My body only activates enough muscle fibers and nerve endings to actually complete that task. Because if it does more... then it loses energy and it thinks we're gonna starve. It doesn't know that I've got a pot full of food in the kitchen. So if you don't do any exercise and you just rest, your body goes, oh, well, we've got enough muscle and tendon and everything to just rest. We don't need much of that. So it starts degrading and everything becomes a little bit weaker. You have fewer cells becoming a little bit thinner and things, and that's what we get from total rest. So we need exercise to get the tendon strong again. But now if people... believe that doing exercise will cause them more pain, they tend to avoid it. So then the pain actually becomes worse. So for some of my patients, my biggest battle is often to get them to trust me enough that they start doing exercise. And to be honest, it's not a question of mind over matter with this type of thing. Because with this type of thing, your subconscious is now on high alert to try and prevent you from doing anything that it believes is dangerous for you. So... If you with your conscious mind is going to think, right, I'm going to follow Marika, I'm going to do her program, I'm just going to do this now, and you do it to a point that actually scares you, your pain will feel worse because your alarm system will kick off. So the way to break this belief system of your subconscious down is to slowly prove to it that it's okay. So usually we start very gently and we start with movements that just makes you feel bit uncomfortable. And I'm not talking about uncomfortable in the tendon, a bit unsettled emotionally, that it's just on the verge of what you're comfortable with. Because you know what, if we repeat that often enough, and every time that it's okay, and you see that it's okay, you become comfortable with that. And that becomes your new normal. So then we can push that again a little bit, and we can make you do things that you know at your new level a bit uncomfortable with. And it's amazing to see how people grow in confidence and how Sometimes it takes a couple of weeks. Sometimes it can take six weeks for people to just kind of get through that process of what breaking that fear of movement. And once we've broken that, then I usually have the other problem of holding them back a little bit. So many points there that I want to discuss. It ties in really well with, um, this last episode that I had published with Kevin Maggs and we're addressing the beliefs around knee osteoarthritis and how people get so wound up when. They, um, well, a lot of people think, oh, it's bone on bone. It's wear and tear. I can't run. I am doomed for the rest of my life. This is going to get worse and worse and I need a knee replacement. And when they, uh, start an exercise, if they start exercise on their own and that increases pain, they immediately have this belief, okay, pain, uh, well, increase exercise equals pain. Therefore I shouldn't exercise at all. And, um, They say if a lot of exercise causes a lot of pain, maybe a little bit of exercise will cause a little bit of pain, but no exercise is fine. But they're that, um, belief is ingrained and it could be quite detrimental for the prognosis of the condition. Uh, but then you're tapping into like the, the pain science of things. And I did do a little mini series earlier in the podcast around chronic pain and how the brain is producing the pain and certain anxieties and certain fears and worries tend to amplify the pain signals. And like you were saying, we're sort of addressing the same point from two different philosophies, but just trying to calm down and settle down that anxiety can also manipulate pain signals from the brain. And so it's a very delicate approach for those types of people that are very wound up and very fearful of certain activities and movements. But you do need to be very careful with how you approach it and very patient. Yes. Cause especially at the beginning when, um, I actually listened to those podcasts of yours, I think it's really useful. Those topics. Um, I, at the beginning, when I tried to explain to people about how the brain could create pain that shouldn't be there, I often got misunderstood and they thought that I, I thought the pain was just in their head and they were making it up and that's not at all. all how it is. Yeah. It's, it's literally, you do not have control over that. It's your alarm system and your alarm system is distrustful of your conscious brain. So it's, you don't have control over it. You've got to prove to it slowly through proving to it that little things are okay, that it is okay. The amount of clients I have come into my clinic and they're frustrated and they sit down and they're just like, um, you can tell they're a bit annoyed and they say, Oh, the doctor thinks it's all in my head. Yes. pain that's told that is probably they get very defensive. They're like, they interpret that message to be like, they think I'm making it up. Whereas just the way they go about and the way you need to communicate that message needs to be done a little bit more delicately. And I think for a GP just in the quick sessions that they have and the stuff they've been told around chronic pain, just to say that it's all in their head probably isn't the best way. It needs a really patient, like drawing out way of carefully explaining, um, the way that pain actually works. Yeah. And it, it nearly takes about three sessions cause you'll, you'll think, Oh, I did it really well this time. And then they'll come back with questions the next time where you go, Oh, you didn't quite get it. No, cause like those sort of beliefs that they're so ingrained into people. And even like I'll have someone with knee pain and I'll explain that if, um, it's not due to their biomechanics or maltracking of their knee. And like I'll say, look, we're not, I'll try and make sure I dethrate in a lot of the language that I use and at the end of, or at the end of the session or the next time I see them, they're like, yeah, so what you're telling me is my kneecaps falling out of place and the way they're interpreting it is like the total opposite. And I'm like, Oh no, what have I done? Don't worry. We all do that. They are physios, physios kicking themselves 24 hours of the day. That was a very, very good point. And so anything else we need to touch on when it comes to beliefs? Just that even if you don't know how to change your belief, that yeah, just be aware, even if you can just be aware of things that you think may be standing in your way, the first step is to, if you can identify those, then you can start working on them. But yeah. That's, I think I've said enough there. Yeah. And a very good segue to addressing beliefs is, um, finding the right type of information and making sure that you're getting your information from a very sound wise person. And so, um, Mareika, is there any social media platforms that they can go to? Cause you do deliver a lot of, uh, content, a lot of really useful content. I've got your, um, Facebook group here, which is sports injury advice. Oh no, sports injury advice and support. And then your website is spor which I'll include the links in the show notes. Anywhere else people can go to find your content. Um, yep. If you, so the sports were either the Facebook group's quite useful because you can ask questions there and it's not just me answering them. There are quite a lot of other knowledgeable people in there, but yes, you can find all my videos on YouTube. The channel is sports injury physio again. Um, which is quite useful because you can search for the different topics. So if you've got different injuries, I've probably done a video about that. There I am on Twitter, but I'm not very good at tweeting it. It overwhelms me to see so many messages come in so quickly. So I much prefer if you want, if you've got any questions, just email me or message me on Facebook. I'm pretty, pretty good at getting back to those. Okay. I'd suggest like, yeah, Facebook is a very good one because, um, You've got your advice and you can follow some posts and just keep up to date as well. It's a very good way of getting notifications and staying up to date. I want to thank you for coming on. I want to thank you for sharing your knowledge and just for the fact that I wanted to do a topic with you and we chose proximal hamstring tendinopathy and the fact that you had the, the ability to go back to all the previous lessons and say, okay, this is what we haven't covered. this is, this will be new, exciting stuff for your, your audience. For you to actually do that is a testament to, uh, your, the hard work that you're doing, the, uh, the increased quality and like all that sort of stuff that you put out there. So, um, I really want to thank you for taking the time, doing all your videos, sharing the right type of advice to runners and anyone else who's injured, who might be a bit misguided. Um, and so yeah, thanks very much for coming on and sharing. It's a very big pleasure. I really actually enjoyed it, Brodie. Thank you so much for having me. pain-free future and remember knowledge is power.