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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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today's episode, navigating the conversation of surgery with Dr. Loopy-Vinrich. Welcome to the only podcast delivering and deciphering the latest running research to help you run smarter. My name is Brodie. I'm an online physiotherapist treating runners all over the world, but I'm also an advert runner who just like you have been through vicious injury cycles and when searching for answers, struggled to decipher between common myths and real evidence-based guidance. But this podcast is changing that. So join me as a run smarter scholar and raise your running IQ so we can break through the injury cycles and achieve running feats you never thought possible. Louise, Lupe, Weinrich. Thank you for joining me on the podcast today. Happy to be here. I would like to start with, uh first of all, like your medical qualifications and your medical background. Can you let the audience know about that? Yeah, of course. So actually, my medical background kind of started or my interest in the body started from the other side coming as an athlete. I was a breaker, so a professional break dancer for about 20 years. I'm still really active, but just not competitive anymore. um At some point I became German champ and was in the German Olympic team for a while. um so my identity is really built around movement and performance a lot. And um yeah, so I know how it feels to be injured. And it's just always been interesting for me to learn more about anatomy and how the... body moves and how to improve everything connected to that. And in parallel to that, at some point I started going to medical school and then eventually specialized in orthopedics and traumatology. I was at quite big sports orthopedic clinics in Germany, including Charité in Berlin, Sportklinik Stuttgart and at last at Weidkrankhaus Erlangen, a smaller one with a very high level sports orthopedic, Dr. Professor Thomas Tischer, one of my mentors. He and also the other chefs at the clinics did a lot of complex hamstring avulsion repairs. And I assisted a lot of them and was part of a lot of them and saw what happens before and after the surgeries and saw a massive gray zone. um A lot of people that were kind of swimming, not really knowing how to recover well from this. And that's basically where I'm coming from. Excellent. Okay. So what. made you decide to branch away from doing that to what you're doing now. Well, basically, um I always knew that my path was more in the conservative way of orthopedics, but in Germany, just considering the specializations you can do, the best for me was to do orthopedics and traumatology, since it just involves a lot of diagnosis and just involves a lot of learning the techniques. um the focus on... conservative orthopedics in Germany is not that big. So it was my best option to be honest. And I've always put a focus on the rehabilitation part anyway. So I knew I was gonna do it and always felt driven more towards the side on how to actually treat the body. Of course, including surgery if it's necessary at some point, but also to use everything else that is possible around surgery. yeah, so. I basically decided after specializing that it's the right point to start now to specialize in this kind of direction and especially for proximal hamstrings I chose this topic um because I saw the huge gap and a lot of missing education in this field and I just thought this was the one most necessary to fill the gap basically for example m uh, cruciate ligaments or shoulder injuries. There are a lot of people that are already trying to help. But with this one, I felt like it's a rather big gap. Of course, obviously people like you, there are some people that are doing it, but it's uh still a very small amount. Yeah. You mentioned the topic around like the gray zone cases, like someone who's listening might not know exactly what that means. Um, and so From my understanding, look, there's some clinical presentations that are very clear. Okay. You need surgery. We're pretty confident that you will need surgery and will really benefit from surgery. And then there's people at the other end who's like, no, you definitely don't need surgery based on what we find. Um, you need to go down the conservative option, but then how would you define what a gray zone case might be? Well, basically, um the gray zone, let's just start from what is really clear and really clear surgery and what is really clear conservatively. I think it's easier from that way. um So what you have to look at are, of course, always the MRI structures that you see. It's a big part, but it's not all of it. And in the MRI, especially, you have to look If it's a full thickness tear or a partial tear, a full thickness tear is always more towards a surgical approach. A partial tear can always be discussed that it might biologically be able to grow back on its own. Then you have the detraction size, meaning how far is the tendon pulling away from the pelvis towards the knee. And um that can range, of course, it can be very close still. a surgeon might be confident it can grow back on its own. That might be like below one to two centimeters and everything above let's say three to four centimeters is something um where people cannot be very confident that it grows back on its own. Although there are certain cases also in uh e-light athletes where father distractions have been seen and still they chose the conservative road and it worked. Even there you can already see there is a bigger gray zone than you would see in most of the papers, um which already shows it's a very individual situation. Then of course you have to look at the whole surrounding m if it's a chronic or an acute situation. In chronic situations maybe the tendon tissue has already changed a lot, which means it might not have as much biological potential. to heal on its own. um And then what adds to the MRI is the person obviously and their goals. So it depends on the age. The older the people are, the less likely they might want to reach their highest peak of potential in sports. So maybe they could live without a surgery and could try at least the conservative pathway for longer. But on the other hand, if you are um an athlete who wants to get quick back as quick as possible, then it might be better to have a surgery early. So here's already, you see, it's not easy to set certain age dates or certain goal limits. It's just also another part of the gray zone. um Yeah, would say these are the biggest parts. And also one thing that is important that would lead more towards a surgical road would be if they are very important structures. involved as well like nerve structures or additional tendons like the adductor tendons em or even um bony evulgens that are further retracted. yeah, there's a lot of things that come into the influence and the gray zone I would say is not that all the criteria are met at a certain specific area, but some are and then some aren't. So it's always important to get to put all of them together and then see where it goes. mean, based on you saying that, like, based on the people I see, it seems like most people would fit in the gray zone, because it's never really that clear. seems like when it comes to proximal hamstring, evulsions and tendinopathy is like, really all in the middle. And so you're trying to consider all factors to be like, okay, let's lean more towards one or the other. Obviously, the surgery is a big decision, it's extensive, it's expensive, it's, you know, a lot of recovery and those sorts of things, but um they're the things that have to be weighed up. You did mention a full thickness tear would be uh sort of indicative of heading more towards the discussion of surgery. Are you talking about a full thickness of vulgian and also like a full thickness tear within the tendon? I think I was, um, I was uh sometimes, I'm also not using the correct words. When I said tear, I meant rupture, which means that the tendon is ruptured very high approximately, so very close to the bone. And then avulsion would mean that the tendon is fully just torn off the bone. And a tear would actually usually be more towards the muscle area. So a um full thickness rupture, I would still say leaning more towards the... um the surgical rod and a tear within the muscle, full thickness tear. em It's a very difficult situation. I don't know if I've um ever seen a full thickness tear like that happening. But if we would say the whole muscle would be torn, I would say most experienced surgeons would still decide that some kind of surgery is necessary because a huge hematoma would be involved and so on. But yeah. Yeah. And you'd suspect that the onset of that injury would be quite traumatic. It would be like someone slipping on ice or doing the splits or doing some sort of high maneuver rather than someone who's just a recreational runner, trains for a marathon and gradually the symptoms get worse and worse and worse. And typical of what we see over tendinopathy, it'd be very rare for someone to get scans and then that show a full thickness tendon tear. It's more unlikely, but of course it can be an acute on chronic situation, meaning, um, yeah, you would chronically have a more and more evolving, uh, like micro tears and then bigger tears and then, but still at some point, maybe they would do a very acute move or fast movement and then it rips off and still an acute situation. So it can be acute on chronic, of course, as well. Yeah. Okay. So you have the tough job of trying to configure all of these variables and then have a discussion with clients about what their options are. Is that sort of what you do on a day to day? um What does a typical day to day look like with you when consulting clients? For me, I'm not only doing that. That is actually some addition I built after what I'm most passionate about, I'd say. um I'm working more with patients after the surgery um because uh that's the first gap I basically closed was to create a post-surgery rehab protocol that is personalized um or can be personalized. And so that's what I'm working with a lot as clients that are actually recovering after having had proximal hamstring repair surgery. um Since people still were struggling a lot with the decision of surgery, I decided to just offer this remote service because for some people it's really difficult to just get a hold of people that know a lot about it. There's a bunch of great sports physicians out there, but since the injury doesn't happen so often, sometimes they won't see a patient like this for many, many years. So they might not be up to date to what is evidence-based at the moment. And I just decided to have this offered so people could actually just have a second opinion in case they were really struggling to find someone. And I've, yeah, I've learned that it's really useful for people, especially since I'm focusing on athletes and have this special approach to really think, okay, for your career situation at the moment, how do you decide? So basically my day to day is both. I'm doing the... rehab side, but I'm also doing the second opinions and yeah. Okay, so someone could come to you after having an operation and be like, I'm lacking direction, things aren't progressing the way I would like. This is my current rehab. Can you just give me guidance on what rehab might look like? But also you might be consulting with clients who aren't sure if surgery is the right option for you. And you review their scans, you review all their all those factors we talked about the start their age, their goals, current level of function, and then kind of guide them through what might be the best treatment path. Would that be fair to say? Yeah, pretty much. Um, I have like what I came to the conclusion after having, um, made the whole program. I realized that for some people, it's not really easy to commit to such a long process because I'm actually offering a six month. recovery program because I think it makes most sense to really start over a lot of the patients with proximal hamstring issues um Just were really unlucky and have some Usually some problems to Technically use their pelvis and the core in a correct way which leads to these problems and I think if you only like give some exercises usually It will benefit a little bit, but it will not really solve the root cause of the situation. So I created this long program, but to understand that from the outside, when you're not really deep into the topic, it's not that easy. So what I started to do is so-called hamstring recovery roadmap calls, where I look at what they're doing right now, what exactly what you said. I'm just going to have a checkup, see everything in detail where they are on their journey. And then... What I'm doing is trying to put it into the different phases post-operatively, if you're still in the release safety phase where you have to be careful and kind of just do simple exercises to uh support circulation and to start um engaging the whole body and the foot body axis and the trunk pelvis stability or if you're already moving towards more specific targeted strengthening training where I involve like what comes later is a lot of unilateral strength training. um Like I said, I'm putting a lot of emphasis on the pelvis, a lot of emphasis on the glute and em yeah, it depends a little bit uh what matches best. And then later on, of course, also more towards return to sports, return to competition, involve more m unpredictable movements to get safer with everything learned in advance. So yeah, that's basically what I do in this kind of call. So people can have a first idea also if my approach makes sense and I'm approaching the situation. Well done. um I thought it might be helpful on this. interview, if I come up with a few case studies to like sort of look through your thinking process. It's always hard coming up with case studies, because there's so many factors that are at play. But there's, there's kind of like a common pattern that I often say, like the clients that maybe might be listening to this podcast. So I wrote down, we have a 45 year old, could be male or female, who's like had a gradual onset of this issue. So it's a slowly emerged marathon training throughout marathon training to slowly built and built and built until they developed, you know, uh, pretty typical proximal hamstring tendinopathy, but now it's persisted for more than 12 months. I'd say it's been, it's pretty much the typical timeframe of by the time like I jump on an initial call with someone, it's usually they've had it for about 12 months. Uh, symptoms are getting worse. They had an MRI. The MRI shows partial tears and like some tendon thickening. There's sitting is really uncomfortable. They can hardly sit and they can't run at this point in time because symptoms getting worse and worse and worse. Uh, they tried doing some light rehab. They tried, maybe they've listened to a few podcasts here and they tried, you know, adding in some strength training they did so lightly, but that increased their symptoms. So now they're scared to do that. And they've just reverted back to body weight exercises or body weight bridges. I'd say that's pretty typical. Their goal is to return back to marathons, ah but recreationally nothing at the elite level. Based on that information, happy to disturb if you want more information, happy to provide with this makeup sort of case scenario. But what would your advice be for this sort of presentation? Where at first I would like at first the fact that it's important to look at is always like we said before, are we still in a tendinopathy in a more acute scenario or more chronic scenario? With 12 months, obviously, it's a more chronic scenario. We are entering already, but this um is also important because this will help us know what to do first and how to approach. Then m the second question we have to ask is what created this scenario? Meaning, especially in runners, typically they do one motion for very long time, meaning they are running. in a certain way for sometimes hours. em often movement patterns with walking and running are just misadapted patterns, some compensation mechanisms that happen. And em I think it's important to look at the error. at the error in the body that leads to this, which also for professionals like you and me, I mean, you know that is really difficult. Like it's not an easy situation where you say, oh, I just look at you running once and then I know exactly what the problem was that led to this. So I think the most important is that you know with the tendinopathy, you brought yourself to an injury that will take a long time to heal because it takes a long time to find out what exactly. the situation with your cases, especially if it's already persistent for 12 months. And em it takes time to find out what it is and then it takes time for you to change your movement pattern, to change your stability so that the body can actually start healing. And the third part is obviously if a tendon is involved, most of the listeners may already probably know um tendons heal over a very long time. So they need at least three months to heal. if we found out or over the time find out what the movement pattern issue is and then start targeted treatment also of course with the classic tendon treatment, then it will at least take three months to heal. When you've had a uh problem like this for 12 months, maybe even longer. because tendons just take such a long time. yeah, that's all in advance. And then I would say obviously glute bridges and just general exercises can sometimes be useful. But at the moment, at least for tendons, are at a, like we are looking at a structured protocol that is usually used for tendon injuries with. starting with isometrics to get you at some point where you can actually use the... like you can bear the pain enough to start heavy slow resistance training, eccentric training and then later on start running again. And I think for runners that's the hardest part to like to accept that running might not be very useful for a while but just switch from working that's... what I always say from working in the body to working on the body, because if you just work in the body, meaning you do like what you always did, your athletic training, you will not be able to heal a tendon like this. It just really needs a lot of rehab work. You mentioned the altered movement patterns that you want to try to identify. Have you seen, cause I don't really spend too much time admittedly on technique and form and looking at someone's analysis, I don't get too technical on those types of things. Do you see any particular common traits looking at a runner where you say, okay, the way you're moving, looks like we might need to change how you run? think like considering, um considering running in general, you can sometimes see it like you can see, um I learned that a lot in manual medicine, actually, to look at just walking patterns, how you swing your arms, if you hear a louder em If you hear a louder stepping on one foot, you can kind of hear he's just using the heel on the right foot or something like that, which can be an issue or you're not really stretching your legs accurately. But still from there, you can see this, but you cannot, or at least for me, em it is really hard from this to understand, okay, this means your, I don't know, right part of your trunk muscles have a problem. So it becomes more easy, I think, when you try out certain movement patterns, like, are you able to do a deep squat? Are you able to do a single leg squat? Are you able to isolate your pelvic movement? Like, you do, can you tuck and untuck your pelvis? How can you open and close your rib cage? Things like that, basically. So, like, really try to isolate those kind of movements and... Also what I found is that mobility is a big topic that can lead to this, meaning if you don't have strength in the end ranges of your movements, even though you don't need that for running, this can also kind of translate into movement patterns that are just problematic. To be a little bit more specific, A lot of the issues are usually that people, especially because we are sitting so much, don't have the good glute muscles. And then the glutes doesn't do what it's supposed to do, help you stand upright and or lift you from from like being in a bent hip position, for example. And then the hamstrings might compensate a little bit more in combination. They might be a little bit more short. And then this can also already be an issue leading to this that I would say in a lot of the cases, it has to do with our pelvic movement. Okay. You mentioned like squats and single leg squats as like functional assessment tools. um Anything else that you might assess functionally to look at? I guess when you're talking about seeing if someone has strength at end of range. as an important mechanism for tendons, are we looking at like the end of a deadlift type of movement or the end of a lunge or a squat? Any examples there? Yeah, during these movements you can see very well how the upper body and the pelvis are compensating. That's what I was trying to say before. Like, let's say you don't even have to go so deep. Like you can do a single leg squat on a rather high surface, but you can see, can I untuck my pelvis correctly to go lower down or am I already crouching my shoulders and leaning forward to somehow compensate? Can I even stay upright and... really isolate my pelvis and use it to use my glutes to do that for example. So for example this movement but also with the RDLs you can see it can somebody really untuck, move forward, have the uh lower belly more towards the thighs. Like it doesn't have to be, often doesn't have to be the full range of motion. um It's more that in these movements you can already see what they're lacking basically. And then especially for example, like in a, in a deep squat, that's what I meant. Like when you sit in this Russian kind of squat, like all the way down, some people can't even do that at all, which has a lot to do with mobility, but you see the, like the problems often even before that. Yeah. So you're looking at doing those functional assessments. sort of looking at the combination of strength, function, mobility, and the sort of relationship between. your posture, your pelvis, the pelvic control, your lower limb strength and those sorts of things. Yeah. And in a more, like in a more advanced situation, um, I would also, for example, involve shoulder blade mobility, shoulder blade movement combined with the rest and like being able to stay upright in these movements. Yeah. So going back to this case study. So we have this runner who's developed this slowly over time through the marathon training. And you said we would go through sort of clarifying a few things, clarifying the onset, clarifying whether in the acute or chronic kind of phases and those sorts of things. um on the information that you know, would you be more talking about conservative management or is there a small possibility that surgery is on the cards for this person? I think that would depend highly um also on the function. So you mentioned partial tears. So the question is how big are these partial tears? Partial tear is still a very wide range. like if it would be a rather big partial tear and the function um already would be much lower, I think there would be still at least you could consider talking about surgical or interventional options like using PRP or dry needling techniques or techniques to just increase the healing in this situation for sure. As a stage is definitely already where it's not only a functional problem but also a structural problem. Meaning m sometimes it's really difficult for the body to go back to a normal tendon from that. um But of course, again, here we are in a huge gray zone. You could still discuss and say just do a very proper conservative approach. Try a protocol once. And at this point, it can get worse, obviously, but what can be worse than deciding for surgery? So you could also argue just to try one proper approach with a protocol. that gives you certain timelines. And what I find always is really important to not just say we're going to start it, but to just have a timeline where you say, for example, okay, we're going to go for three months. This is the protocol. If we reach a certain point on day X, we can stay with it or we can re-argue to go a different direction. I think that's usually em what helps most really have a set timeline and then argue again from the next timeline point. Yeah. If someone does have a significant partial tear, uh not necessarily an evulsion, because I kind of get what surgery can entail when it comes to an evulsion. You take like the retracted tendon and you sort of attach it to the sit bone with switches and help the structural integrity of that. uh Would a similar approach be for a significant partial tear of a hamstring tendon? Would they? sort of stitch it back together or like what would surgery involve in that case? What my leading head doctor always used to say in these situations, are definitely not winner operations. Meaning, this is not a surgery that makes a surgeon or the patient happy usually. So it's like, it's really the last step you want to take because even though you can do the surgery, I'm going to come to what you do, but even though you do the surgery, a lot of the patients, about 50%, are still not satisfied afterwards. Because what you can do, obviously, like you can take away the parts of the tendon that are very thickened, that have very much changed the collagen structure and the structure of the whole tendon. um That's one option to do. You can also just um take the whole tendon off. kind of clean everything that is messy and that is not functional, not useful anymore and then reattach it. But that still doesn't mean that when you do that you have a healthy tendon afterwards. You still have a tendon that needs to heal and you will still have microscopically changed collagen fibers in the rest of the tendon usually. So it won't be like the surgery will automatically just heal the whole tendon. it can still be an influence and effect to let the tendon heal again in a different way. So if nothing worked, I would still definitely say, okay, it's a way you can try. um But it's still, like I said, not a winner operation. yeah, so usually you take out the parts of the tendon that really macroscopically, so you look at it, that doesn't look healthy anymore, usually for like a proper tendon is just white fiber material that looks kind of clean. And the changed parts, they look a little bit more like a yellowish color, very hard structure. Like they're not, not bending as easy anymore. And these are the parts that oftentimes are taken out, like taken away and um yeah, then the tendon has to recover on its own. Yeah. Okay. That makes me nervous because there's like emerging evidence that well, following I've interviewed Keith Barr on the podcast who studied tendons before and he's seen on MRIs, he's seen like really bad tendinopathies, like patellar tendinopathies completely say like moderate to severe degeneration convert back to normal healthy portions of a tendon if met the right criteria with the careful loading and he uses supplements and. vitamin C and collagen, those sorts of things. And he's witnessed with MRI scans, like degenerative tendon portions convert back to normal healthy, like tendons. I don't know how often that happens in the real world. I, it's hard to really know for sure, but taking away unhealthy parts of a tendon when we know that they might be the driver of pain, but also know that we probably can, if done the right way, convert. back to normal, healthy portions of the tendons, how realistic it is to do that or not. But I just think like there's potential there, taking, having surgery and like removing that away, removes that potential to convert back, but maybe it removes the signaling that's producing the pain. Maybe it's reducing, like you're taking away all the really sensitive structures that's producing the pain in the moment as well. So like, I can see the merit for it, but it also makes me nervous at the same time that we're sort of taking away that potential. Yeah. I agree totally and I can tell you that a lot of the surgeons feel the same way about this. It's nothing that you like to do very much and think um it's good to take away parts that might be potentially healing. Unfortunately, we are not at the point where we can say these things for sure. I think that sometimes patients expect this. But unfortunately also we are limited in our knowledge when it comes to this. Yeah. I appreciate that honesty because like our surgeons always come across as very confident people, but like I would be extremely nervous if I was a surgeon with all these gray zones. Like you, there's obviously the case where it's a slam dunk. need surgery. Let's get you in. Let's operate tomorrow. Let's like, you know, expect a pretty good outcome. But because so many are with fall within that gray zone, it's, oh Like if I was a surgeon, I'd do the best I can for these patients, but like part of me would just be like, yeah, like extremely nervous about the unknowns about how the outcome might be at the end. Um, but I guess the same as me for a physio, like, you know, I've seen a lot of success with certain people, uh, but there's other cases where I'm like, I don't know if the conservative option is that, but I don't know. Surgery just comes across with a few more risks and investments and financials and that sort of stuff. But uh nonetheless, one thing I want to spend some time on while I had you here was talking about some common mistakes or errors that someone might make if they were leading into surgery or they have surgery scheduled, they are uh errors they might make pre surgery, but also post op as well. uh Are there any common mistakes or things that you can advise on? pre-op any mistakes that you see. m Well, that obviously depends a little bit on if it's a very planned surgery, like say it would be a tendinopathy or if you have an acute situation. But in either way, um what I often see pre-op is that people kind of stop moving. um So they don't really m strengthen their body pre-operatively. They think they... just wait until surgery and start with it afterwards. And um that's not necessary and probably not the best way to prime the body for surgery. Usually the more muscles and the more musculature you have pre-op will also have an effect on how well you recover and how much potential your body has to have rehab afterwards. That's one thing. And The other thing is focusing on sleep, on protein intake, on hydration. I would say these are the three main factors that influence recovery the most. So just not worrying about sleeping on time, not sleeping enough, um not even eating enough protein, just eating whatever. And also just drinking enough water to have the body hydrated. Pre-op, think, would be... ah big mistakes you can make and then also a topic that is like a little bit more open in my generation but maybe not in the older generations is to prime the nervous system pre-op so obviously it's a big stressor to have a surgery so if you are more mindful in advance to breath work some meditation things like that you can really calm down the alarm system and that would be things that can at least help a bit. Yeah, very helpful. With the strength and like sort of preserving as much strength as possible and maintaining mobility and like you said, try not to rest too much. um Is it just guided by symptoms? Can someone still walk, still exercise, still strength train and just use symptoms to be their guide as to what's okay and what's not. Obviously, disclaimer at this point, educational only and I'm not giving personal advice here, but m in general, listen to the surgeon and what he or she will recommend what is still possible, but usually, especially lying isometric movements, isolated movements of your whole core area, strengthening the areas that are not affected like the healthy leg, the upper body. is still possible to involve without being unsafe. Okay. Yeah. And I guess those restrictions and cautions would be higher for someone who does have more of the significant tears or evulsions or like a, someone has a full thickness of evulsion. Um, I see a lot of questions being posted around, I have this surgery scheduled in a few weeks. Can I walk, can I stretch, can I load it up? Um, so I guess, like you say, fall back on what surgeon recommends. Um, but I guess be more cautious in that state. If it is more of a full thickness, significant partial tear, sort of thing. Not really. I mean, it's, it's like with a, with a clients that I have in my program. because the program already starts pre-op also, so people can prime also before surgery. I put it into levels, so it's pain adapted. It depends on how high the pain level is, and obviously the higher the pain, the less they can use this leg. So the more lying movements will be involved. um like for example, you can still usually do um hip abduction lying down. You can still do movements like this, for example. Obviously you are not supposed to stretch the back side of your leg on a high level because it could increase retraction and it's just painful but em just doing like um easy elevated leg exercises to at least have some nerve gliding for example is still possible if the pain allows it and some really don't have that much pain surprisingly. I don't know how it's possible usually, but some are really not that in pain, even though they have a full um avulsion. And then they can do even movements that involve more glute work, standing up and so on. So it really depends on how, yeah, how your pain level is. And then obviously if a surgeon really, really not allows certain movements because he prefers, then that too. Yeah, I guess so the overarching message would be okay. Don't rest too much because that just fosters deconditioning and weakening and more sensitive structures. And then it's leading to poorer outcomes post-op when you are in a more weakened state, you're starting from a strength level you could say. Okay. And good note on the like giving your body the right conditions to heal. So sleep. Nutrition, protein, hydration, those are the things that are really helpful tips. Was there anything else pre-op mistakes that you see before we move on to post-operative? No, I think we covered, I mean, some will overdo it before, know, they'll just kind of stress and feel like they have to try so many things. Of course you can also overdo it before, but yeah. Okay, great. What about post-op? What mistakes do you see? Post-op, that's why I just thought about the overdoing. um I think you have kind of like two groups, the fear of underdoing and the fear of overdoing. So some will really worry about not doing enough and not getting back on track quick enough and might not um really respect the healing timelines and just try to get back as fast as possible to what they were doing before without realizing that the body just needs time to heal. that there are going to be necessary changes to strengthen the areas to even be able to go back to where they were before. And then on the other hand, the fear of underdoing to just have this traumatic experience in your mind and just not being able to overcome this, which is often a mental block. And yeah, they just fear to load at the point where they would be allowed and just don't strengthen enough. And that is kind of just stopping them from getting back as quick as they actually could. So these two sides I would say which both come from this huge identity hit actually that you kind of feel like damn I used to be an athlete, I just used to do my sport like a lot of the people have sports identities usually and um this can go these two directions I would say. Yeah, I think there's a lot of mistakes that can happen if you don't have like a proper, proper laid out plan and kind of rules within which you can move. Yeah. Do you have any like generic guidelines in place? Like you have guided people through post-op routines and protocols and those sorts of things. How does someone know whether they are overdoing or underdoing it? Well, um, What we are usually doing is I'm working with a face based system rather than just working with weeks post-op. So obviously you can be eight weeks post-op and yes, with a weight bearing usually this works. But other than that, you just have to look more at the individual timelines on pain, on healing of the whole scar tissue and um like... uh if whatever, somebody is sick for three weeks, for example, I had one client who was sick for six weeks in between, of course, the whole rehab phase will just prolong because they couldn't train for this amount of time. So I rather see it as uh a phase-based system where after the phases, we do certain checklists to advance and then you do certain exercises and it's really difficult and... I'm not gonna dare to just say generic advice here to be honest because yeah, it's just too individual. But what I can say is if you find the phases for yourself, where I say you have a protect and prepare phase in the beginning where you can kind of prime the body to start any kind of strength training, then when you're at the end of this, meaning you can actually weight bear on both feet, you can stand on the one foot. kind of at least without pain, like we'll go with the pain levels here. Then you can advance to start strengthening in general without targeted hamstring strengthening for a while. Then for the next phase, like you can say, you can at least do single leg squats on a high elevated surface and small jumps. Then you can start going into the next level with em further more unilateral strengthening. um Yeah, and always look at the pain levels in general, look at swelling. em And at some point we introduced the impulse system. So you kind of have these 24-hour rules. That's a rule that usually helps that if pain is gone after 24 hours, again, that increase after training, the swelling is gone after 24 hours. If it increased, then that's usually a good sign you can progress. It's already not green, but it's yellow. And then if it stays longer than 20... four to 48 hours and just regress, take a break. That's usually some, some, some of the guidelines we work with. So if a surgeon gives someone like a timeframe of like, Oh, you're back to sport in three months or you're back to running in, you know, six months, like you'd kind of be skeptical of that based on the individual healing basis and the fact that like your particular approach is like outcome and function focused. um knowing that people's timeframes do take a while? Well, it depends what we agree on, I would say. um For example, if somebody would say, I want to do the high level ELITE protocol conservative, they didn't do surgery, they returned within eight weeks and they did this and this and that. And we look at the protocol and we say, okay, let's do it then. It's still possible, but you just have to know what your personal risks are, what the pros and cons are to do that. So it's still like, it would still be possible. That's what I mean with individual. If you know yourself, okay, my risk is I'm going to rip this thing again, but I'm, I'm willing to try it because I want to go back to some competition. Okay. But if you say no, I want to be really careful. And my main goal is not that anything happens again, that I have surgery again or whatever. Then of course you can. you will take a different approach and look more onto the timelines that safeguard this. So it depends individually on what somebody, what some person's goals are, if they want to just stick with a certain timelines mainly. So it has so many individual factors, I would say. Okay. Yeah. Good answer. I think one question I really want to ask was, If someone's sitting down or got a review call with a surgeon, or maybe this is their first introductory call with a surgeon to see if it's an option, if they're eligible, if so, what does it look like? Are there any questions you feel like these people should ask their surgeons? Yeah. I mean, are we talking, they had the MRI already and everything? Can you tell me? say all the pieces are there. Let's just say that. the they're they're in the gray zone, they've had a MRI and it's kind of either small avulsion or it's a significant partial or it's, you know, something that's heading towards the discussion of surgery. um And let's just say the surgeon says, All right, yep, you're eligible for surgery. Let's book a book a consult or let's book a time to schedule this in. What do you think, are there any questions that usually go unmissed that leave people a bit confused? I think in general, I always like it most when people come a little bit prepared because it just satisfies the patients and the treating doctor usually the most. When you just took the time before to think what are actually the questions that I need answered for myself personally. like specific questions that are usually important is like considering my personal situation, what are the biggest risks and what are the biggest limitations for me. If we would do or wouldn't do this, then definitely something that is important like how is the time after what's going to look like for me, what am I allowed to do, what am I not allowed to do and Like be more specific about it. Like am I going to be able to drive? Am I going to be able to bend my hip to whatever degrees and what ranges? Ideally ask for the post-op protocol in advance to be able to get ready before surgery and know how to set up the home, for example. um Or if you decide, okay, maybe surgery is too much in the gray zone, we agree on a conservative path. How is the time from here on going to look like? Like what exactly are we going to do? Be more specific about what the physio should focus on, for example, things like that. em I think, yeah, I think... In general, like if you bring three to five questions that you really thought of, not like a 20 question list, it's insane, but like a three to five question sheet where you really thought what questions are most important for me personally. I think that can really help to just, yeah, feel more secure in the way from there on. Yeah. I think the post-op protocol is really helpful as well, because I have seen a couple of cases where they have the operation, they're recovering in bed and they just. a bit unsure of what to do moving forward, they sort of get the suggestion, okay, go see your PT or go see your physio. Now it's time to do some rehab once you've recovered like, or like once the wounds have healed or something like that. And they're just left in the dark a little bit. um Whereas like, I think preop asking the surgeon, okay, what does a post op protocol look like? Do you have it? Is it a handout? Can you provide it for me? Do you have recommendations of PTs for me to see? ah guidance in terms of that. So you're not just like getting pushed through, have the surgery and then left in the dark thereafter to go and find your own PT or those sorts of things. I think that's ah really important. Would you say that's typical? Should a surgeon or someone who's working closely alongside the surgeon be providing patients with a post-op protocol immediately after they've had the surgery? Yeah, 100%. I think it's really important and necessary to have a postal protocol like that, especially with an injury where the variety is so big on how you can treat it post-operatively and especially with an injury that I would say I don't want to exaggerate but maybe 90 % of PTs might not even have seen. um Which means they don't know exactly how a classic postal protocol looks like and we all know... A classic PT doesn't have time to just read into a case for I don't know how many hours to find out what is appropriate and what's not appropriate. So I think it's actually really important and necessary. The problem I see and the deeper I get into the whole topic is really there are so many different posts of protocols, which are also confusing for people. They exchange in the groups and they're like, my protocol looks like this. The other guy's protocol looked like that. I actually prefer this. What does this mean? Is my surgeon not up to date and so on. So I really think there's a big gap between or actually there, there doesn't exist like a first line post-op protocol treatment. Yeah. Which I hope is going to be something to develop in future years. Which you've obviously created your own or like you've, you've, you provide that resource for some people. Did you just. extrapolate from the surgeons that you've worked alongside or did you use a bit of, bit of everything? Did you pull that from research? Like how did you create your own postdoc protocol? I have to clarify, I don't have my own post-op protocol. The whole rehab system I built is actually built around all of the post-op protocols. That's why it's face-based, so everybody can basically enter. So it can be entered from all the sites because I would never dare to go over the guidelines of a surgeon who actually did the surgery and knows exactly what he or she did and how it is attached and if it should actually need more security. and be within a brace for a while because it's just too dangerous to move early on. So that's something that only the surgeon can always say. em But I still provide education and guides, that's true, but they are more about the whole pre-op situation to educate people on what path they are on. And there I used, I would say, the most recent and most important papers. around 40 to 50 papers put all together, kind of like in a personal review written in patient-friendly language to understand. Actually, by now it's more than one guide because I realized the first one was very detailed, so I have one that is more an overview guide, the Proxima hamstring avalgen 101 guide, then the understanding Proxima hamstring avalgen, which is much more in detail already what routes there are and providing the whole like the whole scientific database. And then I created just a pathway to see where error moments are. um also one guide that is more focusing on identity. So I have these four guides, but they are not plain. Like you would not be able to create your own rehab post or protocol with this, um since they are just very individual. And I would say that that's also the situation right now, like the latest review papers say both extreme versions having a quick return and not doing any brace and having almost immediately weight bearing on both feet and the very conservative approach where you have a brace for sometimes even up to 12 weeks, they seem to have similar outcomes at least after a while. So it's difficult to agree, agree on anything when everybody just has so many different opinions. really hope it's going to change at some point to not be so confusing for everyone. Likewise. Yep. Well, you're doing a great job of trying to bridge that gap while identifying the gap, first of all, with your clinical experience, but then trying to try your best, make it a bit more clear for people, which is a nice segue into like, where can people go if they want to learn about more of the resources that you offer? They can go on my website, it's athletetransitionlab.com and from there you can find all the free resources that I created also specifically for uh surgical repair. For athletes I created a community and within this community basically there's a whole ecosystem you can find everything there specifically for post-op people to exchange more in depth who want to get back to athleticism. And also, like we said in the beginning, I offer the HSCAA, the Hamstring Surgery Clarity, order to um get a structured telemedical opinion if surgery or conservative treatment is appropriate. Then on there you also find the Hamstring Recovery Roadmap Call, where you can get a kind of get a phase setting for the next 12 weeks. What would be the next appropriate recovery block if you had surgery already? Or you can decide to do the full route 24 week phase based recovery system with personal navigator with weekly check ins for safe recovery, which I recommend, but I know also it's sometimes not easy to commit to this so quickly. Very good. Well, I'll be happy to add your website into the show notes so people can click quickly, find it, click on it and see what resources are available. And yeah, just want to thank you. Thank you for. identifying the gap, like we said, trying your best to educate as many people as possible, provide the guidance in a condition that's fought with a lot of confusion. And yeah, it's, it's good to see, it's good to see people like you out there doing that. So thank you for sharing all the information today. Thank you for providing your online resources and, um, coming onto the podcast today. Thanks for having me. It was really nice to have all these questions and was really nice for me to talk to you. It was my first podcast actually. Excellent. And I really enjoyed it. If you are looking for more resources to run smarter, or you'd like to jump on a free 20 minute injury chat with me, then click on the resources link in the show notes. There you'll find a link to schedule a call plus free resources like my very popular injury prevention five day course. You'll also find the Run Smarter book and ways you can access my ever-growing treasure trove of running research papers. Thanks once again for joining me and well done on prioritising your running wisdom.