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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, we're investigating how we can heal tendons through light, ozone and immune therapy. 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. Welcome back everyone. have three different research papers that have come out this year that I've wanted to discuss and kind of stack them into one episode because I feel like there's relevance in each topic. So I'm going to cover them briefly and I will, I guess, warn you to start with a lot of these are preclinical in terms of their design. And so very, very early days for these attempts of treating tendinopathies. But I always say on this podcast, I'll keep my finger on the pulse and let you know ASAP if there are any emerging researchers or different ideas around tendons. And so yeah, I've gathered three of those papers that kind of meet that criteria. So we're going to discuss them today. I'll be upfront. A lot of these papers are not really being tested on humans as yet. Some are still mostly animal research. And some kind of sound a bit futuristic, but. I aim to question on this episode today, could any of these realistically help someone with PhD now or in the future? So we'll cover each paper, we'll cover the basic concept and any interesting findings that they do find, how strong the evidence actually is and whether we think is actually relevant for PhD. So the first paper is titled, recent advances in immuno... regulatory biomaterials for tendon healing for immune remodeling to functional regeneration. So a lot of fancy words out there, but essentially, can we manipulate the immune system to improve tendon healing? So the basic idea, this is a 2026 review, and it looks at what we call immunoregulatory biomaterials, which sounds complicated, but it's quite simple in terms of its concept. researchers are developing materials that can be placed around the injured tendon to do two things, physically support the tendon and also influence how the immune system behaves during the healing process. So if someone is listening and they are more on the science side of things, we are looking at things that involve say, hydro gels, scaffolds, stem cell products, exosomes was mentioned a lot in this paper. or materials that release certain substances depending on what's happening inside the tendon itself. Based on like, it seems like the different environment of the tendon, whether it's like change in inflammation or change in acidity will actually manipulate how these materials behave. And so the key idea from this paper is that the immune system is helping direct the entire repair process. Because when Tendons undergo healing, they sort of have these overlapping stages. The first is the inflammation phase. So if you really overdo things, if you go for a run too far, too fast, and it's a bit irritated later the day or the next day or the next several days, we are undergoing some process of inflammation. Then we have a proliferation phase followed by the remodeling phase. So think of it building... Rebuilding a damaged house. First you have the demolition crew that comes in and clears out all the damaged material. Then the builders come in and they lay down new tissue. And then over the following months, that tissue gets reorganized and strengthened. So the immune system is helping decide, okay, when does this cleanup start? When should that cleanup process stop? And then when does that rebuilding phase begin? And so we often hear like the inflammation is bad because it's causing pain, it's causing this redness, hotness, all that sort of stuff. in the early phases, early inflammation is actually supporting and important for the healing process. And there is a certain maybe overreaction of the inflammatory system. So I guess that's where people sort of market as bad. Sometimes there's too much inflammation or sometimes there is prolonged inflammation so that process just doesn't switch off appropriately. But the authors of this paper describe how the early immune activation helps clear this damaged tissue, whereas prolonged inflammation provides fibrosis or like scar tissue. And that forms kind of poor quality scar tissue, you could say. So a useful way for framing this is like the future processes may not be about eliminating inflammation. but about making the inflammation behave better and have the response more appropriate, you could say. So where does this implementation, this futuristic part actually come in? So the researchers are now designing what they call smart scaffolds. And so for example, they inject like a gel and it goes and sits around the intertendon and it senses an inflammatory environment. It slowly releases helpful molecules. It encourages the immune system to shift towards repair. It supports collagen formation, which is primarily what tendons are made of. We call this this collagen turnover, this breakdown and buildup of collagen. That's what is required for tendon healing. And it eventually breaks down once it's no longer needed. Sounds magic, sounds futuristic, but this is what they're working on at the moment. And some of these materials are often designed to respond, like I say, to different environments, like different acidity levels, oxidative stress, different electrical signals, or even mechanical loading when the tendon itself gets the signal to, or gets a signal through your rehab exercises, that is a mechanical load that the tendons have to respond to. And this smart scaffold that surrounds the tendon will then respond to that and hopefully help the repair process when they get that signal. So the paper includes examples of pH or acidity responsiveness, the oxidative stress responsiveness, hydrogels that release therapeutic substances when the injured environment changes. Like I say, sounds like magic. And like I said, they mentioned these exosomes a lot, and it's another interesting example. So exosomes are like tiny packages of cells. used to communicate with each other. And the researchers are investigating whether you can take those signalling packages, put them into hydrogel and deliver them directly around the damaged tendon. Animal studies reviewed in this paper suggest these combinations, they may reduce excessive inflammation, encourage more regenerative immune cell behaviour, improve collagen deposition. improve blood vessel formation and improve mechanical recovery. So how close are we to saying, all right, let's put this in someone with PhD. Unfortunately, we're not very close. The authors are very clear that most of these technologies are still preclinical, but there are still major questions around long-term safety, the manufacturing of it all, how consistent is it, the individual immune differences. and how these products behave in humans because like I say, a lot of this testing has been done in animals. So what's my level of confidence when it comes to the immune, I guess concept and healing the tendon, fairly confident. Are these technologies going to be involved in the future of tendon treatment? I'd say plausible. How useful is it for PhD clients right now? Very, very low, very low confidence. But like I say, this is, I'll keep my finger on the pulse. We'll see if this starts emerging in human trials. We'll see if it starts working its way up the chain and then becoming available to the general population. Okay, the second paper I want to talk about is titled, Oxygen Ozone Therapy in Tendonopathy Management, a Comprehensive Review. Okay, so the one word in there is ozone therapy. What is ozone therapy? So we have, Normal oxygen is O2, but ozone is O3. So I think there's an extra molecule in there somewhere. And medical ozone therapy uses a carefully controlled mixture of oxygen and ozone, which can then be injected around musculoskeletal tissue. And the theory is slightly counterintuitive because ozone causes a small amount of oxidative stress. Some people might think oxidative stress is bad, but in low doses, it may trigger the body's own antioxidant and anti-inflammatory system. So the idea is almost like a small controlled stress stimulates a protective response. When I was sort of doing my research on this kind of made me think about how we deal with immunizations. You know, we inject a small part of the virus and that triggers the immune system to be like, Oh, I recognize this or let me recognize this for the future. In case I encounter this and then I have the right amount of antibodies or my body knows how to respond to this in the future. guess it could be said for this sort of preparing the body and triggering that stress small amount controlled and then getting that protective response. So the paper describes low dose ozone as potentially reducing inflammatory signaling. while activating antioxidant defense pathways. So what might this do for tendons? The proposed effects include reducing excessive inflammation, influencing pain signaling, increasing local circulation, stimulating fibroblast activity, improving collagen production, and potentially improving tendon strength. Now that all sounds impressive, but what does the evidence actually show? Like I say, this. this paper in particular is a comprehensive review. looking at other studies and seeing how strong those studies are and what they've actually found. So only four studies that when they scoured what papers have been, actually, the research has actually identified, I think it was 161 papers. But then after screening all of them, they only come up with four studies that were actually included. And this included tennis elbow, included Achilles in rats. It included the rotator cuff, which is a tendon in your shoulder and also shoulder impingement. And so the most interesting, I guess we could find in these human studies, one study looked at 80 people with chronic tennis elbow. So that is still a tendinopathy and they compared ozone injections with a corticosteroid injection. So you can think of those two groups and at nine months, so a fairly decent sized followup. the favorable outcomes for resting pain was 92.8 % in the ozone group compared to 39.5 % in the corticosteroid group. Similar differences were reported for pain with compression and activity, but this was a retrospective study. So didn't have a strong randomized control trial. So interesting, absolutely. But is it definitive? No, but I'd say like if we're looking at resting pain was improved and favorable in 92.8 % of the people in the ozone group and only around about 40 % in the corticosteroid group, that's a significant difference. So it raises eyebrows. When we look at other human studies that were somewhat less impressive, a study of 44 people with chronic supraspinatus tendinopathy. So that's the rotator cuff in the shoulder. They found again, they did two groups, ozone group and corticosteroid group. They found improved pain, function and quality of life over 12 weeks in both groups. Another small trial involving the shoulder impingement found that the corticosteroid group worked better initially, but symptoms continued improving over time, better in the ozone group. So a bit more of a longer term benefit. And there were no meaningful differences in ultrasound findings or range of movement compared to those groups. We did have an animal study. I said, there was an Achilles study looking at rats. So this was somewhat interesting. They had 60 rats that were looking at, well, they had Achilles injuries and the ozone treated tendons showed less inflammation at two weeks, more fibroblast activity, better tissue remodeling, greater tensile strength and higher failure load later in healing. So again, interesting. But where does this stack up in terms of current relevance? I'd say, does it have biological effects? I'd say likely. Can it reduce pain in sun tendinopsies? I'd say possibly. Does it regenerate human tendons? I'd say still unclear. And does it work for PhD? We don't know yet. But the authors themselves conclude that ozone should still be considered experimental until larger and better trials confirm its efficacy. safety and ideal protocol. So I guess very, very similar to the first paper. The third paper, the third weird and wacky intervention that managed to come across my desk is a paper titled photo bio modulation enhances tendon regeneration, a systematic review and meta analysis of preclinical studies. So this is using light. And I guess that's where the photo bio modulation comes in. The question being, can light actually improve tendon healing? And this is probably the most impressive paper out of the three of the experimental results. But it does have a big caveat being that all the included research was preclinical. So we're talking animal studies, we're talking laboratory research, not in humans. So what is photobiomodulation? You may have come across terms of red light therapy, low level laser therapy, LED therapy, this sort of fits into that particular bucket. The theory is that specific wavelengths of light can be absorbed by structures inside ourselves, particularly the mitochondria inside ourselves. And so different wavelengths can penetrate different depths and interact with the cells of that particular structure. And so that may increase cellular energy production and influence things like inflammation, fibroblast activity, collagen production, and tissue repair. And so the authors describe photons being absorbed by the mitochondria and increasing ATP production, which is just energy production, which is basically your energy cells being put to work. And so how much research was included? They scanned 5,000 papers and eventually included 36 animal studies in this particular paper for review. And that included 20 acute injury models and 16 chronic tendinopathy models. 12 were similar enough to combine into a meta-analysis. And so if we're crunching the numbers, there were four... kind of subcategories within this meta analysis it's worth considering. So compared to untreated animal tendons, photobiomodulation produced approximately, now there's I guess, measures in here that I don't fully understand, but inflammatory markers were 40 % lower. They had this associated level IL-10 or IL-10. which is typically what they say associated with inflammation resolution. It was 65 % higher in the photobiomodulation group. So we want inflammation resolution to be higher and it was 65 % higher. We had 1.7 times better type 1 to type 3 collagen ratio, which I'll explain that in a second, and approximately 20 % greater tensile strength. So actually putting it in a lab actually putting load through the tendon and seeing where its limitation is and it being 20 % greater. So those are interesting findings. Back to the collagen type. So type three collagen is commonly associated with earlier more immature tissue repair, whereas type one collagen is stronger and more representative of mature tendons. So when we're looking at a 1.7 times better type one to type three collagen ratio, that's healthier, more mature, better functioning tendon, you could say. So essentially just having more collagen. So better collagen maturation and organisation. And then the strength side of things was very impressive. Researchers actually pulled on the tendons until they failed. And the treated tendons, like I say, with this photobiomodulation, was approximately 20 % stronger, could tolerate 20 % more load. So should we be buying red light devices for PhD? Not based on this paper. But like I say, this is not human trials. Kind of takes me back to Keith Barr, what Keith Barr is doing. He's in the lab creating synthetic tendons and like subjecting it to different conditions, applying different loads, different rest periods into seeing how the tendon behaves. This is sort of what they doing in the labs with light sensors and seeing, you know, how things react. So when it comes to animal tendons, I guess you could say like a rat Achilles tendon is extremely superficial compared to like a proximal hamstring tendon, which is much deeper. So if we're looking at light penetrating tissue penetrating skin, fat, muscle, all those sorts of things, we would have to bear in mind that it's gonna have to be a different wavelength, it's gonna have to be a different dosage. But yeah, I guess the limitations here, one, not in humans. Second is the depth of the proximal hemorrhaging tendon to what was compared in these rat studies of the Achilles. And third is the dosage. So it appears like there is a dose response relationship where too little may produce nothing, but also too much. can also remove benefit. They had to look at one experiment where the dose was a little bit higher than usual or higher than what was tested in other tests and that had negated a positive response. So more powerful isn't automatically better. And amongst these different studies that they found, was the protocols all over the place in terms of the wavelengths that we used, along with different powers, treatment types, the dosages, the frequencies, all that sort of stuff. So. The authors identified this variability as one of the major limitations. So nowhere near able to say for PhD use this wavelength for this amount of minutes for this many times per week, we are nowhere near there yet. But looking at the preclinical data, it is promising and we may see this come forth in the future. So does this particular mode modality change tendon biology in animals? Yes, quite convincingly. Does it improve tendon healing in animals? I'd say probably. Does it help human chronic tendinopathy? Still uncertain. Does it help people with PhD? Unknown, not entirely sure just yet. But like I say, maybe in five to 10 years time, we start to see this becoming more and more robust. I know that I did a podcast episode a while ago looking at other methods, interventions, procedures, particularly around high volume hydro dissection, which is, I hadn't heard anyone have that done, but now I'm starting to see it. I've got a handful of clients that are starting to see the outcomes of those, even though it is very, very early days, it's still being rolled out. So maybe these are getting rolled out in the next couple of years. And I start seeing a handful of patients doing this and we can start looking at the effects. So hopefully you're enjoying these as We can't take action right now. We can't look at the practicalities of it, but at least it's hopeful that there are engineers, scientists, researchers out there doing the weird and wacky stuff that hopefully we do find some really nice effective treatments. And yeah, hopefully it's making you hopeful for the future and for your tendonopsies. But right now keep to the basics because that still works. And I hope you enjoyed the insights in this episode. 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 5 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 and finally overcome your PhD.