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Proximal Hamstring Tendinopathy is a horrible condition affecting athletes and non-athletes alike. If you fall victim to the misguided information that is circulating the internet, symptoms can persist for months, sometimes years and start impacting your everyday life.
This podcast is for those looking for clear, evidence-based guidance to overcome Proximal Hamstring Tendinopathy. Hosted by Brodie Sharpe, an experienced physiotherapist and content creator, this podcast aims to provide you with the clarity & control you desperately need.
Each episode brings you one step closer to finally overcoming your proximal hamstring tendinopathy. With solo episodes by Brodie, success stories from past sufferers and professional interviews from physiotherapists, coaches, researchers and other health professionals so you get world class content.
Tune in from episode #1 to reap the full benefits and let's get your rehabilitation back on track!
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On today's episode, which PHT exercises actually reduce pain with Aidan Rich? Welcome to the podcast that gives you the most up-to-date evidence-based information on PHT rehab. My name is Brodie. I am an online physio, but I've also managed to overcome my own battle with PHT in the past. And now I've made it my mission to give you all the resources you need to overcome this condition yourself. So with that, let's dive into today's episode. Today I'm joined by Aidan Rich, a sports and exercise physio here in Melbourne, who has spent the last several years completing his PhD in PhD specifically. So amazing to have him on as a guest. If you've been following the tendon rehab for a while, you've probably heard the term of isometric exercises like bridge holds and how they may reduce pain, often called like an analgesic effect and maybe the first steps in your rehab. But Do they actually work better than traditional movement-based exercises? In this episode, we're diving into Aidan's latest research study that he's just released, comparing isometric exercises with isotonic or movement hamstring exercises, specifically for people with PhD. We also discuss why an isometric exercise has become so popular in the first place, whether bridge holds really provide pain relieving effects, why some people feel immediate pain relief when loading up their tendons. why some people can get stuck performing the same exercises for months without seeing any progress, the role of heavier strength exercises in long-term tendon recovery, and practical advice for anyone currently struggling with sitting pain, running pain, or a case of stubborn PHT. So if you've ever wondered whether you should be doing glute bridges, hamstring curls, or both or neither, this episode will help you make sense of the evidence and give you a clearer direction moving forward. Here's my conversation with Aidan Rich. Aidan, thank you very much for joining me on the podcast. Thanks very much Brody for having me on your podcast again. Yeah, I, um, I know we chat back and forth quite a bit and keep updated on your studies and publications and that sort of stuff. So thank you very much for keeping me in the loop. Um, would you mind giving people a bit of a introduction of your qualifications and your academic background? Sure. So I'm a sports and exercise physiotherapist. I'm based in Melbourne, Australia. did my undergraduate degree at La Trobe University finishing back in 2004, and then did a master's in sports physiotherapy finishing 2010. And then this year I finished my PhD and the PhD topic was treatment of proximal hamstring tendinopathy. That's been a big part of the last seven or eight years of my life. My day-to-day work, I manage a group of physiotherapy and sports medicine clinics here in Victoria. I'm still treating, I quite enjoy treating. 17, 18 years experience as a clinician or just over 20 years actually. And I've worked with a few national sporting organizations, including Triathlon Australia, Athletics Australia and UniSport Australia. And a lot of your research is focused on PhD. What's the, uh what gravitated you towards that? I had some good exposure with some tendon researchers when I was an undergraduate. spent quite a bit time with Jill Cork and I ended up being a research assistant for Peter Malliaris' PhD. and was taking a PhD on botanical tendinopathy when I was just finishing up undergrad. So I had some time with them. They were enthusiastic and motivating. And it was a time of great change for tenants, know, in clinical practice before the mid to late nineties uh treatment for tenants was rest, stretch, anti-inflammatory medication. And then there was this huge, you know, almost 180 degree turn over the next 10 years where most of those things fell away and it went to loading. advice away from ice, away from anti-inflammatory. With some exceptions, there was a huge change in how things were treated and it was interesting. I can something that we thought we knew so well in the late 90s be so challenged a few years later? So I had some exposure to them and um through my work environment, I had the capacity to do a PhD part-time while I was still working very close to full-time. I ended up getting in touch with Jill Cook again back in 2015 and she was kind enough to answer the cold call and the warm call I guess. And she was happy to be involved as one of the supervisors for my PhD. And why PhD? It was kind of the understudied tendon. I've got an interest in endurance sports, runners and triathletes and this seems to be relatively common in that group. There really wasn't much out there on that. I think we'll talk about that a bit later on there. think there are only two randomized control trials ever prior to me starting my PhD. on this topic, whereas Achilles, tennis elbow, patellar tendon, glute tendon had been studied a lot more extensively and there's a lot more out there. So it was a chance to, you know, really make an impact on what's known about Tregna's condition. I've got the paper that you just published in front of me. It's the title of the effect of isotonic versus isometric strength, exercise for pain and strength in proximal hamstring tendinopathy and randomized crossover trial. For those who are listening and aren't familiar with the terms isotonic and isometric. Would you mind giving us a brief sort of explanation of that and then we'll carry on to the main paper. Yeah. So like isometric, I'll start with isometric basically means a static contraction. So if you walk up to a wall and you push against the wall, unless it's a very, very weak wall, but assuming it's a normal wall and you push against the wall with your muscles, that's an isometric contraction. The muscles are shortening or lengthening while you're pushing against the wall. The same thing if you try to pull a really, really, really, really heavy something, table, and you couldn't move the table. It's an isometric contraction. Your muscles are the same length the entire time. Whereas an isotonic contraction, it's more typical of what you do when you go to the gym. If you grab a weight and lift it slowly up and down with a concentric, shortening phase and eccentric lengthening phase, that's an isotonic contraction. So pretty typical of what people would do at the gym, doing a bench press or a squat or a bridge or a bicep curl, that's an isotonic contraction. Yeah. And if we carry that over to the PhD population, you would say like, say a long lever glute bridge, if you, people are familiar with the bridge, but have your heels quite far away from your hips, like your legs are close to being straight, that would be long lever. As you hold that up position, the hamstrings are contracting and not moving. So if you hold that position, that would be a isometric as opposed to say a hamstring curl where someone lies down on their stomach on a gym bench or uh hamstring curl machine and they're activating their hamstrings, they're shortening their hamstrings as they curl that weight and then they're lengthening their hamstrings as they uh lower that back down. Why? The desire. to create a paper studying the differences in these two muscle contractions. There's a little bit of a history story here and I'll try and keep it brief. It'll get to the answer. So back in the early eighties, there was a book by Stanish and Kuhl and that talked about doing eccentric exercises, which is a lengthening exercises, the treating tendon problems. didn't get a huge amount of coverage. And one of the early papers that people are mostly familiar with is by Huck and Alfredson, who's a... Swedish orthopedic surgeon and he had Achilles pain himself. Asked his boss the time off to get surgery on the Achilles because that was what was done at the time and his boss said no you can't have time off. So he went to the gym and did some very very very very heavy calf raises to try and make it worse um so he could get time off so he could have his Achilles operated on it and then finally I think he got better with doing these heavy eccentric or lowering exercises and that became the thing you know eccentric exercises. had a, you know, they were effective at treating many tendinopathies. And then that was was done. And then over the next 10, 15 years, people continued doing some eccentric exercise, but also went to what they called heavy, slow resistance, basically heavy gym exercise with a isotonic exercise under another name. So a concentric, a short and an eccentric phase. And then there was this fantastic research by another Melbourne-based physio, Ebony Rio, which the data collection was around 2012, 2013, and really complicated and groundbreaking research at the time. She got six male volleyballers with patellar tendon pain, so jumpers knee. And she got them in the lab at Deakin University here in Melbourne and got them doing isometric exercises. So it's a leg extension. we sit and you push out against a weight. Isometric exercise and then a washout here and then isotonic, you know, slightly up and slowly down in a, um, in a random order. So they both got both interventions and the isometric exercise was from a pain point of view, incredible. So the pain with squatting went from about seven out of 10 before they do the isometric. So was down to zero out of 10 or 0.2 out of 10 afterwards immediately afterwards. And then they still had zero out of 10 pain or 0.2 out of 10 pain. 45 minutes later, whereas the isotonic exercise, the leg extensions didn't have the same effect. They had a mild reduction in pain, but not anywhere near what we saw with isometric exercises. So effectively, they abolished this knee tendon pain for up to 45 minutes plus by doing some heavy isometric exercises. And part of the reason this was so groundbreaking was they any measured brain activity with this device called TMS or transcranial. magnetic stimulation to look at the activity in the brain. And they saw a decrease in cortical inhibition that correlated with the reduction in pain. And Evnie hypothesized that these changes were responsible for the improvement in pain. So really quite groundbreaking research rather than just doing the exercise, investigating the mechanisms at the time. even though there was some, Evnie put some limitations in the paper about careful. being careful with interpreting the mechanisms and careful extrapolating it to other tendons. I think everyone, know, took this and ran with it and including myself and we did variety of isometric exercises. 5 odds of 45 seconds are effective for patella tendons. Sure, they're effective for other tendons too. So people do the same exercises for Achilles, for glute tendon, tennis elbow, for rotator cuff, for plantar fascia. um before the research and showing that it was either effective or ineffective. And then by the time I started my PhD back in 2018, there'd been about maybe eight or nine different papers looking at isometric exercise, or maybe if you're less, six or eight, but nothing on hamstring tendon. I thought, gee, it makes sense to investigate, is what we see in male volvulars with botelotenant pain. Is that the same in people with proximal hamstring tendinopathy? Are isometric exercises effective in reducing pain in proximal hamstring tendinopathy? And the other thing from Ebony's trial, was quite interesting is that the strength actually improved in those people after isometric exercise was improved by 19%. So one just took the pain away, they're able to produce more force. So something has all these great implications. know, if you're a volleyballer who's got to go on court at midday and you're worried your knee's going to get sore and you can't jump so high, or maybe you do some isometric exercise at 11.40 and you block the pain for when you're on the quarter. So it has performance enhancing benefits as well. But, um, you know, that was the reason we landed on this, this trial design because it could have been done in other tendons, not the proximal hamstring tendon are tied in nicely with the rest of my research. Yeah. I mean, some of the PhD audience would be familiar with this, what we call the analgesic effect, loading up a tendon and having this immediate short-term, but immediate reduction in pain and improving in performance and confidence just to activate that muscle. Some people do it. before going for a run. If their first half of their run is usually a bit ah unsettling, they might feel more comfortable doing some loading beforehand. uh How would you explain to them, or how do you explain to these people what's actually happening? Why, why is this effect taking place? Could you sort of dumb it down to someone and create a clearer explanation? My explanation's changed a bit over the the last couple of years with the way the trials have gone at it. But several years ago, I'd say doing a heavy isometric exercise or heavy static contraction creates some changes in your brain, which reduces the pain you experience in your tendon. I'd keep it as simple as that. Yeah. So not really improving any quality of the tendon structure itself, but it's changing sort of the neural circuits and how the brain interprets things. Yeah, the tendon structure stuff for isometrics interesting and there's not a huge amount out there. There's some, small amount by a Belgian researcher, Lauren Pringles from Gantt about the pressure within the tendon after isometric exercise. If it's quite preliminary, I'm not sure I'm confident enough to use that as an explanation yet. But we think that the thought was, you know, up until maybe two or three years ago, that the changes were driven in the brain. Um, there has been some recent work by another Melbourne physio actually called Patrick Balance. I think he'd be a good guest on the podcast. He's done some great work together. Patrick and I, he's, um, a very smart cook. He's done some great research on, on neuroscience. All of us completely over my head, but he is more recently investigated some of the mechanisms around isometric exercise. And he thinks it's potentially not in the brain. It's lower down. It's due to lower spinal excitability changes. Um, And maybe, you know, this is stuff that will take 10 or 15 years to tease out, but maybe there are subgroups, maybe there's people who respond better to isometric exercises because of their spinal excitability. I'm not sure we're there yet, but some of my explanations changed a little bit over the last few years. Yeah. I had a chat with Keith Barr on the podcast a few years ago and he was, I think it was him. He mentioned the strong, heavy isometrics and chronic tendinopathies can have some fluid within the tendon matrix itself. And that really strong contraction helps ring out some of that fluid, which might influence the peripheral endings of the nerves and their excitability and those sorts of things. I'm not sure if that's actually studied or just a hypothesis, but um interesting to think about. Yeah, it's similar to Pringle's work, the Belgian. doctor, looked at intratendinous pressure. So I it's an overlap there. that's, you know, it's a hypothesized mechanism for how isometric to reduce pain. Yeah. Does it work with everyone? Like would everyone with a tendinopathy respond equally to these isometrics? Cause I have a lot of PhD clients. say, look, I don't get any warmup effect with my loading exercises. Does that mean I don't have tendinopathy? Well, that's a good question. And it probably leads into the other isometric studies. So look, Ebony's was, was groundbreaking. and the results are incredible going from seven out of 10 pain to zero. But since that one came out, there's been about, it's up to 14 now randomized control trials looking at isometric exercise compared to isotonic exercise, the pain in tendons and it's pretty much every tendon now. So plantar fascia, Achilles, femoral patella, glute tendon, rotator cuff, tennis elbow. And the results, it's fair to say, are mixed and the majority of them. don't show any benefit for isometric exercise over isotonic exercise. And I think there's now two systematic reviews where there, systematic review is where you get all of the randomized control trials and you analyze them and try and summarize the results. And there's one by Clifford from the UK from about three years ago, which the conclusion was basically isometric should be done on a trial and error basis, which hurts a little bit as a physio, you've got more kind of clinical reasoning around that rather than it's a trial and error approach. And there was also a narrative review that came out just a month or so ago actually that had a similar conclusion. But of those 14 trials, I think three of those showed benefits for isometric exercise, A for isotonic, including Ebony's original trial. And then 11, including my own on proximal hamstring tendinopathy that showed no benefit for isometric exercise compared to isotonic exercise. when, I guess my question was like around if someone believes they have a tendinopathy. And if they try either isotonic or isometrics and they still get no analgesic effect from either, does that mean they don't have a tendinopathy or just does some tendons just not respond to that type of stimulus? Okay. Potentially both. If someone doesn't have a warming up effect, particularly with an early stage, I've got an early stage, I've got bit of a sore Achilles. I go for a jog. The first time actually my Achilles is a bit sore and then after five or six minutes I've forgotten about it, that's a warming up effect. That's quite typical with an early stage tendon where someone's got a pronounced, more significant tendinopathy. It might start off sore and just kind of get worse and they start limping and have to kind of hobble home. But if someone doesn't have enough pain relieving or analgesic effect with exercise with an early stage tendinopathy, it makes you reconsider the diagnosis. You know, are we confident with the diagnosis? And depending on the tendinopathy, can be challenging to diagnose or easy, but there's a few kind of... methods to diagnose it. think it's just reassuring for some people to know that if they don't get an analgesic effect and they have a chronic tendinopathy, that still could be a tendinopathy. But like, as you were saying, it seems to be more common in the just acute tendinopathies. Yeah, yeah. I wouldn't rule out a tendinopathy based on having no warming up effects. And that's probably what we've break into that the last few years with the research that's rolled out. Some people get this pronounced analgesic effect. Some people get nothing, you know. Um, and across our study, we generally got small improvements, you know, pain was from fives to fours, you know, so you could, you could say that's 20 % improvement. You could say it's just, uh, you could argue it's just placebo. So they had some small improvements with exercise, but sort of not this from, seven to zero response that we saw with Ebony's original research. Yeah. Talk us through this paper that you. conducted. So it was for PhD patients and it was looking at the effects of isotonic versus isometric strength exercises. How was it conducted? So we recruited 20 people with with PhD and PhD in the situation was diagnosed clinically. We got a history and they're required to have at least three months of symptoms in a localized area, small than a tennis ball in the area of their lower buttock and that onset of symptoms was associated with doing more, more running, more hills, more fast running or variations of that. And then to form a clinical diagnosis we did four things. One was looking at their sitting symptoms. If you had pain with sitting within 30 minutes, the second one was stretching the tendon with a modified bent knee stretch. The third one was contracting the tendon with a modified bridge. And the fourth one was doing an Arab, a modified arabesque exercise. contracting the tendon with some compression. If they had reproduction of their symptoms on three or more of those four things, that formed a diagnosis. They were the main inclusion criteria. There were a few others. We excluded people with autoimmune conditions because we were less confident about the effect of exercise on people with autoimmune conditions. We excluded people who had recent injections or shockwave therapy. And we excluded people who had surgery on their tendon previously. But we landed on 20 people. And they came out and saw me at La Trobe University in the lab there. And they were randomized to an order. had isometric exercise first or isotonic exercise first. And then three to seven days later they had the other intervention, the wash out, hear it in between. So we got them to La Trobe and at the start we did a few tests. One was the arabesque to see what their pain was like. Two was we asked them about how their sitting symptoms were in the 24 hours. for the testing or the intervention. And the third thing we measured was their strength. So we got them lying on their tummy in the prone position and doing a hamstring curl on this special dynamometer at the trapezoid called a biodex dynamometer that's really accurate at measuring strength. So we measured strength, we measured pain and we measured sitting symptoms. And then we got them doing the interventions. So for the isometric intervention, the static contraction intervention, it was five lots of 45 seconds. of isometric exercise, which was similar to protocols used in other tendon problems with a two minute rest in between. And then for the isotonic exercise, it was five sets of nine repetitions. So two seconds up, three seconds down, which gave 45 seconds of work. So both groups had the same amount of contraction time, five by 45 seconds or 225 seconds of contraction time. So they got the intervention either isometric or isotonic and then immediately afterwards we measured their strength. We got them off the machine and measured their pain with the arabesque. And then 45 minutes later after a bit of relaxing time at La Trobe, we got them to do their strength testing again on the machine and the arabesque again. So we measured strength and pain at zero minutes and 45 minutes. And then the next day with a video call, we got them to do the arabesque again to look at pain 24 hours later. We asked them about their sitting symptoms and then... we analyzed all the data. What was the, what did the isometric look like and what did the isotonic look like in terms of loading up the hamstring? So it's a hamstring curl, so a prone hamstring curl. So think it's someone lying on their stomach. The hips got a tiny bit of bend, about 20 degrees of bend. And then these are 30 degrees of bend and we've got them to pull the heel up towards their bottom with the isometric and hold that contraction. And we gave them some targets to hit between 50 and 65 % of their best effort. And that was based on the strength testing at the start of the session. So I had a visual cue to try and hit a certain target over that 45 seconds. So we gave them some encouragement along the way, two minute rest, a repeat form all times. And that was the isometric intervention. Okay. And the isotonic was just the standard prone hamstring curl. Exactly the same position. So long on the tummy, very slight hip bend. And then they did a curl from zero degrees where you need straight up to 60 degrees of bend. And it took two seconds. then it's a bit of a funny sensation is Vitex machine. It's slightly different to a normal hamstring curl. The machine kind of forces you down as you push up against it. It took three seconds to lower your leg. So nine repetitions, gave one set, two minutes in between, then five sets of nine repetitions. Same as going to the gym and doing five sets of nine hamstring curls. Yep. Gotcha. um You kind of alluded to it before, but what were the results? So I'll just bring it up here. So we had, we successfully recruited 20 people. The average age was 48.3, which was slightly higher than the 45 that we saw in the other big trial that I ran comparing Pesio to Shockwave. It was evenly split male to female, 50-50. People who were at an athletic weight with a BMI in the low 20s. The results didn't show too much. the pain was reduced in both groups, but reduced only slightly. So before baseline testing showed pain of about five out of 10, or 50 out of 100, but five out of 10 for the purpose of this. after testing, sorry, after intervention, zero minutes of pain was just over four, at 45 minutes the pain was just over four, and then the 23 hours of pain was about 3.94. So really a minor improvement across both groups, but neither group had form the other. With strength, we saw a decrease in people's maximal strength after the isotonic strength only, so the five sets of nine hamstring curls. Their strength was suppressed immediately afterwards and 45 minutes afterwards. You think about it, you go to the gym and you do some really heavy bicep curls and then a few minutes later you try and do some heavy bicep curls, because you're going to find it harder, your muscles get tired. That wasn't a huge surprise, but we didn't see the same suppression of strength in isometric exercise. And then sitting symptoms get improved by that one point out of 10 points scale. So it from fours and fives, and then threes and fours, but no difference between groups. So the results across the board were very similar. You saw some small improvements in both groups, but there was no difference at all between the isometric and isotonic exercise response. Yeah. And so it seems like we weren't getting the profound effects like Ebony Ryo is getting with the patellar tendon loading. uh in terms of their significant reduction in pain from a seven down to like a point two or whatever. um It was extremely subtle. Yeah, very subtle and we ran some statistical analysis and not statistically significant. I'm not confident enough to say the differences were due to chance. And I think you also asked what's important for the patients in improving your pain from five to four important. It's better than the opposite, I guess. it's probably not as important as improving your pain from five to one or five to a two. So yeah, the results are more typical of the majority of the isometric studies that have been, have been done since where there was no difference between contraction type. Yeah. And with the, a lot of difference or no difference found between these isometrics and isotonics in the hamstring that you found. Does this reflect the broader findings for what the research highlights? for tendonopathies in general? Yeah, I think we'll see a shift I imagine now over the next few years. You've got two systematic reviews that suggest that isometric exercise broadly is no better than isotonic exercise. And if you look at a lot of practice guidelines around the world, the treating tendons, including the ones that we developed ourselves for our other trial, stage one isometrics, stage two isotonics, and on you go. And I think we'll see a de-emphasis of how important isometric exercises are. probably more important in treating tendon problems is progressing the exercise, making it heavier over time and generally going heavy. The contraction type, whether it's isometric or isotonic or eccentric, is probably less important than we thought a few years ago. There may still be some super responders to isometric exercise, where there's some subgroups that respond better, but I think we're a while away from identifying those if they exist. And the studies are quite difficult to do. know, the recruitment's quite hard. to look at subgroups, probably need several hundred there. They're big and complicated studies to do. Yeah. Cause I see that presentation a lot. see a lot of PhD clients who are told to do bridge holds, isometric bridges, and they do them. It's a bit painful and they say, okay, the next phase is to graduate to movement. So doing some sort of hamstring curls and they don't, they stay stuck on the isometrics because they're too painful or, um, too uncomfortable to do them. They don't feel quite safe to progress to those isotonics. But I guess what you're saying is the, um, I guess the consensus is leaning more towards, it doesn't really matter whether you do the isometrics or isotonics. Um, if anything, maybe leaning more towards the isotonics as it would sort of generate more strength and function, be more functional for the muscle tendon unit. Yeah. And look, the, the isometric exercise, you know, private practice have on it kind of fits quite well into private practice. If you're training someone with a sore tendon, whether it's an Achilles or a hamstring tendon, doing an isometric exercise session one, not like it kind of makes sense. You think it's reasonably low risk of stirring them up, you think it should provide some positive adaptations to the tendon, maybe it reduces their pain. But it's very unlikely to start up giving them something to work on. And then you can see them again in five days or a week or whatever, and progress to an isotonic exercise. It's a starting point that you've got some reasonable confidence when aggravated symptoms, which is aggravating someone's symptoms. You know, when your first sentence, the ideal outcome. then yeah, I suppose I reflect back on the outfits and stuff, and it was pretty simple to it, a truckload of calf raises and when they get easy, add some weight on your shoulders with a backpack and make them a bit harder. And that got a lot of people better, the majority of people better and there's certainly more models out there. I think the general approach is to try and keep it simple, maybe, and maybe a takeaway for people with hamstring tendon pain is to start with some isotonic exercises. If they're well tolerated and you see some gradual improvement in your symptoms, keep doing them and maybe make them heavier over the next few weeks and months. If your random problem is doing isotonic exercise, well, you've got another option. You've got some isometric exercises to try. You can make the isotonic exercise a bit lighter as well, but yeah. I think isotonic exercises are probably a reasonable starting point for the majority of people with sore tendons, including PHT. And I should go with saying like your study in particular is focusing on immediate improvements, like you say in pain, sitting strength, but isn't necessarily reflecting what's a better approach for tendon health long-term, like what helps heal the tendon over the several months following. Um, because Yeah, it's one thing to look at the immediate effects. It's another thing to look at whether the tendons over the long-term is actually healing and getting better. What would you be your advice for PhD clients looking, focusing on long-term outcomes? has been at least one study looking at longer term intervention. It was by Evany Rio actually, a guy called Van Ark back in 2015 or 16, looking at doing isometric or I was trying to exercise over the course of the season. don't think there's any difference between groups. The contraction top probably not super important here, going reasonably heavy with having like a pain ceiling, a three or a four or five pain ceiling there and making sure you're getting heavier over time. And if you've got weaknesses in the adjacent muscles, so for hamstrings, if you've got weaknesses in the glute max, the muscle that kind of extends your hip, I'll be doing some strengthening around that as well. Yeah, I think that's a sensible long-term approach. Don't get too caught up in contraction type. Isotonics are a reasonable starting point. Mild pain is okay and make sure you're strengthening the muscles around the affected tendon. Yeah, great. I had written down here, what scenarios would be appropriate for isometrics. You mentioned, uh if the isotonics, if the movement based exercises are a bit too irritating, then we've always got something to fall back on being the isometric holds. Are there any other scenarios that you think might be useful? where the isometric holds might be more relevant? There's a few, but potentially if there's a lot of, you know, called kinesophobia, but fear of movement, someone's worried that movement at ten and will hurt, that this might be a gender way of introducing them to rehabilitation. If they report a profound response to isometric exercise, you don't want to interfere with something that's already working. So you say, if it works, keep doing it. And the third one's probably a little bit cheeky, If the patient believes that isometric exercise will help them, let's keep them doing it. don't want to believe that expectations probably be part of the results we see. So if someone thinks isometric exercise will help them, I'm not going to tell them not to do them. Yeah. And some people can, can respond well to isometrics. It's just like when we put them in a randomized control trial with other participants, like the generic outcomes might not be as favorable, but if someone reports their own unique, um, benefits with isometrics, we're not going to tell them not do them. And I guess it's worth saying that it's not that this paper is showing that isometrics are bad. It's showing that it's just as good as the isotonic because there wasn't much difference. Yeah, that's right. And we've just got no ability at this stage to predict who responds to different contraction types. It reminds me of ACLs a bit. you rupture anterior cruciate ligament in your knee and you don't have surgery, some people will cope with that surgery and they'll be able to return to running. social basketball or whatever. And some people won't cope. there's copas and non copas, we've got very little ability to pick you'll become a coper and non coper. It's kind of no better than flip of a coin. So I agree. Yes. Yeah. One thing I thought I'd ask you before, like while I've got you here, you mentioned that there wasn't a lot of studies on PhD when you first got into the game. Why do think that is? Why is there such a low attention on this condition? I think the few things, one, it's a relatively new condition. Like the term PHT didn't exist until the mid-90s. The first one was ever documented was by these two Finnish orthopedic surgeons in the late 80s. em one whose name escapes me, but in 1998 they caught the hamstring syndrome, whereas Achilles tendon pain has been around since the dawn of time. of runners have had those and patella tendons, a common injury in basketball. So it's a newer condition. I remember saying a few of my first few years of clinical practice, I would have missed them. I would have thought it was something else like piriformis syndrome, which was popular back there. So I knew a condition and it was unknown how easy it would be or how difficult it would be to recruit people for these trials. And we successfully recruited 100 for the bigger of our two trials and then 20 to this one. So we actually had a reasonable run with recruiting. wasn't as bad. could have been. And ironically, COVID may have helped. COVID caused a running boom. What happens when people increase their running? They often get PhDs. So we're in a big city. Melbourne's got 5 million people, but we were able to find 100 people. So that's part of the reason. It's condition with unknown prevalence and unknown ease of recruitment. But we managed to get around that and got the studies done. We might've touched on this and feel free to repeat yourself, but like I say, a lot of the common cases that I see are people who may be diagnosed with PhD assigned glute bridge holds. They've been doing it for several weeks or several months and not really seeing any improvement. What would your advice be for this type of person? uh Consult with a physio who's experienced in treating this condition and get a bit more of a big picture overview about what you need to change in your rehab. There might be a few things, maybe their exercise program is too simple. Maybe it's not heavy enough. Maybe it's not working on strengthening the supporting or agonist or surrounding muscles around the hamstring tendon. Maybe they're pushing too much into pain. So maybe they're running on a Thursday and then limping around until the Sunday. And generally if they've got a pain response that severe, we'd normally pull them back a bit from their running. So it depends around what their goals are. they've got a big event coming up, you might try it bit differently. So look at the pain response, you might look at their sitting setup. You might consider shockwave and their other trial was comparing shockwave uh exercise, sorry, shockwave therapy to exercise and show the groups had similar responses. And we've got a little bit of subgroup data out now, which is kind of under peer review and having to be published in the next month or two. But there might be some early evidence of different responders to different treatments. We suspect that males or people over 50 may respond better to shockwave therapy and... females and those under 50 and people who more physically active may respond better to an exercise based approach. So if in the example you use that they've got a good exercise program and then not finding any progress and particularly if they're a male over 50 who's kind of moderately active and not highly active, they may be a good candidate for shockwave therapy. like a counterpoint if they're female under 50 and highly active, it doesn't mean they're not. Um, a kind of shockwave therapy, just maybe it's less likely to help them up. You'll leave a little bit later. So I think getting someone who's experienced in treating the condition and getting a holistic overview of, um, your treatment approach would be a good idea. Yeah. I know there was a recent paper from Peter Maliaris and his crew come out about, uh, Achilles mid portion and insertional tendinopathies, uh, around shockwave and where the papers land on that. doesn't come across as that positive for benefits. ah I want to ask, if you have someone that's going to get shockwave, do you have a way of explaining to them exactly what's happening to the tendon when they do receive shockwave and what the evidence shows around it? I'll just have that systematic review. was a systematic review by think, Kora Karkas out of Qatar was the first order and Peter Maliaris was another author as well. And it was a systematic review again where they combined all the randomized control trials on shockwave for insertional and mid-portion Achilles. In this systematic review, they only compared it to sham shockwave or no treatment at all as opposed to comparing it to exercise. That was a bit different to previous reviews. But you're right. Yeah. In the systematic review, they showed no benefit for shockwave. But in two previous systematic reviews where they separated them out and they either analyzed mid-portion Achilles only or insertion like these only the results are a bit different and it seems to be that shock waves more helpful for insertion like at least tendinopathy, but not as much for mid portion tendinopathy. In terms of how I would explain shock wave to a patient, it's tricky. When I wrote at my PhD thesis, I think there was seven or eight hypothesized mechanisms about how shock wave therapy is supposed to help. And some of them are quite complicated, you beyond my... beyond my understanding to explain easily, but some neurochemical and biochemical changes, but the patient explanation would be that shockwave therapy provides a mechanical stimulus to the tendon and may cause some immediate pain improvements. It provides a mechanical stimulus to the tendon, which we believe is helpful. There's several mechanisms by which we think it might be helpful. We know it's safe. There's some reasonable data to show it's effective in several tendinopathies. And you may experience some early pain improvements or you may experience some improvements from the shockwave that takes several months to play out. So it's a little bit. But, um, I can't with confidence, give a really specific, tight explanation about exactly how shockwave works. I just don't think we're that far along yet. I agree. Yeah. We've I've had several different explanations that it's like, well, which one is it? It could be a combination of a few things, but, um, placebo being one of them as well. It's a very, um, highly technical and advanced procedure or however we want to call it. But, um, sometimes that has real effects as well. Agree. And, um, look, if we had unlimited resources for that large trial, but I ran on a hundred people with shockwave and exercise, we would have added a third arm to it. And the third arm would have been sham shockwave and the trials can be done. get a machine that makes the noise and it's a of pain when you push on the tendon. We didn't have unlimited resources, so it didn't happen, but it's a good way to work out whether there's a big placebo in shockwave or whether there's, there's more specific effects. Yeah. With the attention, popularity of eccentric muscle tendon contractions with say Achilles tendinopathy. Um, you mentioned Alfredson protocol. Um, was there any thought or ideas about doing like a purely eccentric loading? regime for the proximal hamstring and seeing if that elicited any pain benefits? oh Not really. It's another scope of what we looked at. think one of the things, I remember one of the doctors I used to work with, he was on your podcast a long time ago, but he said that the brain doesn't know what the contraction type is. And may well have been right. Look, one of the benefits of eccentric exercise, you can go heavier, there's a higher force you can get out of the muscle compared to doing concentric only, it wasn't something we investigated. No. Yeah. Uh, guess that's like one of the advantages with the, yeah, those sort of exercise contractions is yeah, you can just go heavy up, but, um, we did briefly consider including Nordic curls, um, as part of the rehab, which is depending on the way you do the generally a syndrome and we ended up not choosing it. in the future. Uh, one thing you also mentioned that I wanted to touch on when I asked about someone who's been going through the ring of isometric holds and not really seeing any benefit, um, what you advise you'd have for them. And one of the things that you mentioned is you probably like, they might not be lifting heavy enough. And I see that as a big fear for a lot of people who do have a achy painful tendon. They might've had scans to show small tears or degeneration or fraying, and they're really nervous and worried to load up the tendon. Cause that might cause more fraying or more tears or more pain. Um, And it seems counterintuitive. And obviously we need to do it within safe guidelines, but sometimes lifting heavier is actually the safer long-term option. Is there a way that you can reassure some of these people or ways you can communicate the direction of rehab that's required? Yeah, I use this quite a bit with people who I see who've got an achilles' tinnitus. Often people, my experience at least with Achilles, they've got this fear of rupturing their tendinitis, they it on football or netball or basketball or social media and someone rupturing their Achilles and it's traumatic and dramatic and often they have surgery, but not always, and they gee, that going to happen to me? And that probably makes them subconsciously use it a bit less. And there's a bit of data in Achilles to show that the majority of people who rupture their Achilles actually have no pain prior, because it's bit counterintuitive because you think... you've got a sore tendon, it'll be sore, worse, worse, worse, worse, worse, pop. And you rupture, but that's actually really the case. So it's often, not always, but often in Achilles, it's nothing, nothing, nothing, nothing, nothing, So the pain in a way is probably protected. Maybe it makes you offload the tendon a bit more, but you just don't see people rupture their Achilles or hamstring tendon in this case with an exercise program. And most people rupture their hamstring tendon. It's... rapid over stretching and uncontrolled movement, a weird slip on a icy or slippery surface or they're out water skiing or skiing and they have a rapid stretch of their hamstring with their trunk, their torso goes over their over their legs. So you just don't see these dramatic ruptures with rehab in a home or in the clinic or in the gym. So that's the approach I take. Yeah. And can our intuitive to what people believe some people believe but The tendon actually needs a quite a heavy stimulus in order to adapt in order to get a signal to get stronger, to realign its fibers, to rebuild its functional capacity. Um, and so it can be quite a message to tell people that continuing to nurse and do these body weight exercises probably just isn't strong enough of a stimulus long-term. Yeah, yeah, I agree completely. And look, you start, you know, um, a framework that I use. and it's borrowed from a few other papers, but start someone at arousally lightweight. So three to four sets of 12 to 15 repetitions, somewhere around there. And you find a weight where, so they do four by 12, they get to, and they go, oh, I could do a fifth if I needed to, they're not completely exhausted. And then over several months, you gradually increase the weight and decrease the repetitions. And maybe after two, three, four months, they're down to three to five sets of. five to seven reps, something like that. So it's a relatively heavy weight, weight they can only lift five, six, seven, eight, eight times. Still with one set in reserve. So if they do four lots of six, they could probably do a fifth set if they needed to. You don't have to take them to complete fatigue, but gradually making it heavier and more demanding over a several month period, that's typical approach. Yep. Great advice there. As we wrap up, there any other takeaways for those suffering PhD that we may not have covered? Uh, I don't think so. Look, I think the good thing about the internet is there's so many great resources online. You've got a very extensive podcast library now around PhD. There's, some more research from myself and Anthony Nassar in Sydney has done some great research as well. And we're seeing more come out all the time. So, uh, it's good that that's available. Whereas in a 10, 15 years ago, it certainly wasn't. Yeah. Well, I'm grateful for you for committing to this condition as well, and for keeping me in the loop of your publications. So it's, it's been amazing because. Yeah, not a lot comes out there is more I am seeing more and more around hairstring and hair string surgeries and PhDs and those sorts of things. So it is encouraging to see but you know, you're putting a good dent in those publications as well. And so thank you for your time and dedication and for graduating as well. I know it's like very arduous and a tough process. And as you were mentioning, when we're chatting prior getting this paper particular published was particularly tricky. And so Well done and congratulations. Your dedication is just amazing and thank you very much for coming onto the podcast and sharing all of your insights. If you are looking for more PhD resources, then check out my website link in the show notes. There you will find my free PhD five day course, other online content and ways you can personally connect with me. Well done for taking an active role in your rehab by listening to content like this and together we can start ticking off all of your rehab goals. Finally, overcome your PHT.