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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 are diving into hamstring strength, running form and injury risk. 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. As I've mentioned in previous episodes, have a long list of research papers around the hamstring and PHT that have been released that I've been meaning to do some episodes on and so thought I would cover an episode or a paper today. But before I dive into that and the title and exactly what's involved, just an update on me and my PHT rehab. So I guess the past two weeks have been relatively good. um I've had two good weeks with... I guess a decrease in symptoms and a built up of capacity, which is the trend you want to be on. ah I'm no longer using my standing desk um or kneeling. am doing either a combination of sitting with a cushion or sitting without a cushion and feeling really good about it. think as of like Thursday, Friday last week, coming into the back end of the week, uh I just felt comfortable sitting without a cushion. But then that follows on with a pretty intense workout. weekend. um And so come to Monday, which is today, I'm sitting with a cushion, but don't really feel like I needed that much. But I'm just being a bit cautious. But compared to two or three weeks ago, when I felt compelled to stand and kneel for a lot of it, I'm in a way better position. ah In terms of symptoms, I think at the moment, my like after say a long run, my upper hamstring feels a bit tight for maybe a few hours afterwards, definitely back to baseline. The next day though, ah my test retest I've talked about like when I'm putting down my, um my dog's food bowl every night to I sort of do like a single leg deadlift. I sort of do it with the water bowl as well. I'll deliberately do a single leg deadlift to pick up my dog's water bowl, which is just a little check-in about two times, two or three times a day, just to be like, is there any symptoms there? I would say for the most part, it has been symptom free. for the past seven days. depending how much I test it, sometimes it's tight. Sometimes it's sort of similar tightness to the other side, but for the most part, symptom free. So really happy as I keep checking in with that. Last time we spoke, I think I mentioned I tried single leg hamstring curls and that irritated me for 24 hours, which was a bit more than what I would. Would like so that was a little bit too much. I tried that same thing again a few days ago. And again, there was 24 hours of irritation. So I'm like, maybe I need to modify that dosage, maybe make it a bit lighter. I'm doing single leg curls and it was 10 kilos and I did three sets of six on each side. And so that's what I tried, but yeah, I'm not sure if I should do that coming into this race, which you're probably thinking. Uh, listening to maybe the last four or five episodes now that I've talked about my own PhD. Like, why is it taking so long? Why is it taking so long for Brody who knows all of this stuff? He knows the right things to do with PhD. Why is he still having symptoms? How has he not totally negotiated this particular phase that he's in? Um, I would say it's because I'm towing the line because I've got this race coming up. And I think with the current symptoms and my current knowledge, And, you know, my past strength, I feel like I can still give the race a really good go. And so it's been the last two months of me really towing the line of like pushing my limits without trying to really cause a significant setback. And it's that delicate balance that's going to be sort of the perfect balance of optimizing my load or trying to get as much fitness, as much strength as I possibly can to the start line without. getting to set back with symptoms. And I feel like the track that I'm on right now, I am seeing improvements week by week. So I'm not being, it's not like I'm, I'm still being sensible because long-term trends would say, hey, you're doing the right thing. Things are improving. Like I said, my sitting is improving. I haven't really talked much about my running, but that's improving. My strength training is improving, but I still get symptoms, but I'm still on the trend. So I'm doing the right things, but the healing itself is just slower. because I've decided to pile on additional work just so I'm in the fittest shape possible for my high rocks race, which is in about four weeks now, it's gonna come up quickly. And the next two weeks is gonna be like some pretty hard training. And I feel like I'm on that trend. I feel like the way I've been managing this real fine balance right now, as we speak at the time of recording, I feel like I'll get to the start line symptom free. I'll do that entire race symptom free. and I'll be in the fittest shape possible. I feel like I've perfectly executed subject to change, but I feel like I've perfectly executed things so far. I could have taken a real significant downshift and not really towed the line between my maximal capacity and easily got to the start line symptom free, but would have been underdone strength and fitness wise. ah And so that's. something that I could have taken on board if I wanted to, but I thought that I had enough time in place and I was sensible enough and had the knowledge and know how to achieve both sort of rehab and go for performance at the same time. Um, and it's mixed with the complication of my calves. Uh, it would have been nice if I was managing to, uh, one thing at once, but now I'm managing two things, but my calves again, uh, improving week by week. Today I did an AK run. which the high rocks event is 8K running in total. And my calves actually feel really, really good. I'm still running in really supportive high heel drop shoes, which I'll have to race in. And I've just acknowledged that it will be a slow high rocks race for my running side of things purely based on the calves, not based on the hamstring, but the strength workouts I'm going to plan to really give a good, good go. And then next year focus on running speed. Next year, focus on a personal best time. That's what I'm going to aim for. And so, yeah, in terms of my current rehab and function, I'm not doing deadlifts. I did deadlifts two weeks ago and it kind of set me back probably 48 hours, two or three days. And so now at this point in time, I think adding in deadlifts is too risky for not enough reward. The reward on the rehab being like, okay, it will heal my tendon, but I'm already healing my tendon. Um, the risk would be a flare up and significantly disrupting the current momentum that I'm on at the moment, uh, which I love the momentum. I'm not going to lose strength by not doing dead lifts because I'm doing like tons of workouts. So my strength is not only being preserved, but probably built upon, but I'm just avoiding the most riskier movements, which are as I've found out deadlifts. are really, really heavy lunges, which I'll talk about those in a second. And ah probably those single leg curls, which I probably won't do for the next couple of weeks as race day is approaching. Or I'll modify it, we'll see. But in terms of other current strength, like I'm doing my high rocks gym classes, and they're pretty intense high rocks specific stuff, which my body seems to be tolerating really well despite. having to put my ego in the backseat when people just run past me as I'm patiently doing the runs really slow to nurse my calves. But I'm still doing my VO2 max workouts at home. I've now done, I do my VO2 max workouts on the assault bike and the ski erg. And I've now finished, I finished my VO2 max workouts by doing wall ball all out efforts. So I'll do an eight kilo wall ball and to see how many I could do in one go. Uh, and this is like full range of movement now. So up until this point, up until about a week ago, I was doing half range of movement, wall balls, um, just to protect my upper hamstring. But I've now since moved to full range of movement wall balls. Cause I have to do it for the, the event. Um, otherwise you get a no rep kind of disqualification, but, um, I've worked those in my lunges are now at 30 kilos, but they're more high rock specific stuff. I have to do that for 80 meters. I think the distance is for walking lunges. Um, and so instead of me going to do my normal kind of three sets of six on each side lunges, which was quite heavy, I think it was getting to about 50, 56, 58 kilos or something like that. I've now reduced it to 30 kilos, but doing more reps and my PhD is tolerating that, which is nice. Cause previously, every time I tried to reinduced, tried to reintroduce modified lunges, which was about 40 or 50 kilos, it flare up. Um, so really happy with that introduction. And as of last weekend, I did a high rocks kind of simulation where my runs instead of like a one K in between workouts was only 500 meters and it was a slow run, but managed to do most high rock specific workouts. There's eight stations managed to do all eight with slight. Modifications. And I had a good amount of delayed onset muscle soreness and no irritation of symptoms. So that's a really good result for me. Um, I would say calves handled, PhD handled, and then this morning, like I said, this morning, two days later, after doing that high rock simulation, I feel fresh enough to do that AK run having my usual high hamstring tightness post long run, which I have been getting, which I'm fine with, feeling good feeling like I'm now sitting, sitting with a cushion feel okay. Um, kind of feel like the best position I've been in ever since this PhD. re-emerged. So that's the update on me. And uh I suppose like, what's the date now? We've got maybe two more, well, one more PhD podcast episode to record. And then after that, it'll be after my race, which I'll probably give you a debrief on and how that went. um And so, yeah, like I say, that's the update to me. Let's get into the paper. So the title of this paper is hamstring strength and architectural properties. When they say architectural, they kind of mean like the shape and size are associated with running biomechanics. ah One of the authors is Chris Brammer, which is based out of the UK. He is someone that I've followed his research for a long time, really interesting stuff. And I've had the privilege of having on the Run Smarter podcast once or twice, twice now. And so what this paper is doing is looking at athletes with or runners with assessing their hamstring strength, looking at their hamstring size, property, length, running biomechanics, and the forces that are applied within the hamstring, and then trying to associate the whole bunch, trying to associate hamstring muscle strain with different ways of negotiating or ways of running running technique form that sort of thing. And so with this introduction, it sets the stage by saying the incidence of hamstring strain injuries within sport frequently result from performing one of two high risk actions, either kicking or high speed locomotion or sprinting. An eccentric muscle action is proposed to occur during terminal swing phase of sprinting based on 3D modeling. Although this is contested within the literature by Van Hoorn and Bosch referring to a previous paper postulating that an isometric muscle action occurs during the terminal swing phase based on animal models. So this paper is mainly looking at hamstring muscle strains as a topic. And I know hamstring muscle strains aren't proximal hamstring tendinopathy, but you can argue it's the same unit. If we look at something, some sort of running mechanics that influence the hamstring muscle, it's going to influence the tendon as well. And I know a lot of um clients that I have and a lot of injury chats that I jump on. A lot of runners start with a hamstring strain then develops into a proximal hamstring tendinopathy. So the two are often linked. When they talk about eccentric muscle action, we're talking about a lengthening of the hamstring while it's contracting. This is an eccentric muscle contraction. And when they say terminal swing phase, this is a phase that they're gonna talk about a lot in this paper. If you're running, if you can imagine the leg that's swinging in this swinging action. Continue following that pattern until the leg starts straightening out while it's in that swing phase and the heel is just about to touch the ground. That is the terminal or late swing phase. That seems to be the moment in time where the hamstring muscles are working the hardest. And it's been discussed in previous literature that as the swinging leg straightens out the muscle, the hamstring muscle needs to lengthen, but also needs to contract at the same time because it needs to slow down the swinging heel, the swinging shank or shin tibia, whatever you want to call it. So it needs to contract in order to have a really nice controlled foot position for when it hits the ground. But it needs to do that, needs to contract while it's lengthening. So it's been discussed in previous papers that that is the hamstring eccentrically working. But there is contradictory papers coming out saying, you know what, it's probably actually more of an isometric. So it's the hamstring at late swing phase is more just not lengthening, it's already lengthened. So maybe it's just an isometric holding its position whilst entering that late or finishing the late swing phase. It's probably not important in terms of terminology, but this is the debate that occurs that they mentioned in this paper. They continue. However, it is important to acknowledge that these findings may partially reflect methodological limitations based on ultrasound imaging and modeling of dynamic movements and high velocities. Meaning we have some limitations when it comes to what the muscles are actually doing and trying to calculate or reflect or calculate what the muscle's doing when someone's running really fast. So despite the ambiguity on the muscle action during the terminal swing phase, Eccentric hamstring strength seems to be the strongest modifiable predictor of hamstring injury risk and has been shown to reduce the risk of hamstring strain injuries. The results of hamstring strength training interventions have indicated that hamstring muscles adapt rapidly to the training stimulus. Specifically with the inclusion of an eccentric training stimulus, there is a rapid increase in both the eccentric muscle strength and also the muscle fascicle length. There has been a lot of studies done looking at using like a Nordic drop as a eccentric hamstring exercise of choice. If you're not familiar, an eccentric drop is when you tuck your heels or secure your heels under something and you're in an upright kneeling position. Like I say, ankles secure in a position and you keep everything between your knees and your shoulders completely straight as you lower your whole entire body. And your job is to activate your hamstrings or dig your heels up into that fixated position and slowly control your descent as much as you can. You're sort of holding off the dear life as your muscles of the hamstrings slowly lower yourself down. And what it's doing is the muscles are contracting while lengthening. So this is the eccentric training stimulus that this paper is now talking about and has been shown that If you were to adopt eccentric training into your program, you're not only going to get stronger eccentric muscle strength, which has been shown to reduce hamstring strength in other studies, but also improve the hamstring muscle length. It seems to be that if we train it and we train it under lengthening and we lengthen length and lengthen in this training stimulus, the hamstring gets longer or the muscle fibers and the muscle fascicle length actually improve. The paper continues, both of these adaptive responses to eccentric hamstring focused strength work have not only demonstrated reductions in hamstring strain occurrence, but also subsequent increases in performance of athletic tasks such as sprinting and jumping. So not only will you reduce your risk of hamstring strains, but you'll also get increased flexibility and also an increase in performance. Individuals with impaired muscle strength function through either a history of a hamstring strain occurrence, or acute fatigue have demonstrated alterations in running kinematics, kicking mechanics, muscle activation patterns, and lengthening muscle tissue mechanics. Researchers demonstrate that a previous hamstring strain significantly reduced horizontal force production during high speed running. Under fatigued conditions, where it would be expected that the ability of the hamstrings to produce force would be impaired, healthy soccer players displayed significant decreases in swing phase mechanics in comparison to non-fatigued conditions. There is not however, a single driver to kinematic changes in muscular strains, suggesting that potentially an interaction between several kinematic features such as lumbopelvic control, anterior pelvic tilt, forward trunk lean, trunk lateral flexion, maximal hip flexion, and likely the underpinning of kinematic features such as force production, which undoubtedly links to sprinting mechanic characteristics. Currently, many of these findings are based on retrospective studies and therefore further investigation is warranted. There was a lot of jargon in that previous paragraph, but let's just go through it. They're saying that when it comes to the risk of hamstring strains, there's probably a link and an interaction between different ways of moving. They talk about the lumbopelvic control. which is just the ability to control your back, your trunk, your pelvis, pelvic position. uh We generally speak of this in like a single leg movement. So if you plant the foot and if you're in single leg stance while running, how good you are controlling your body. Anterior pelvic tilt is uh something you may or may not have heard of, it's uh when an anterior pelvic tilt is when you see someone with like a a big lower back lordosis, like a big arch in the lower back because their hips are tilting forward. If you're sitting and you sort of tilt your, sit on your tailbone, you sort of like move your pelvis back so you're sitting on your coccyx bone type of thing, that's a posterior pelvic tilt. And the opposite, if you tilt your pelvis, roll your pelvis forward so you're sitting more on your sit bones, that is more of an anterior pelvic tilt. And... They're suggesting that maybe an anterior pelvic tilt when standing and running seems to put more strain on the hamstring. They also talk about a forward trunk lean. So if someone's running and they look more uh bent over that can maybe put more strain on the hamstrings. And so it's probably a combination of a lot of these things that may lead to like say more hamstring muscle strain. Referring to a previous paper, they say Brahma et al highlighted that lumbopelvic control as a parameter has the strongest level of evidence to support the risk of a hamstring strain injury. However, it was noted that no single biomechanical parameter has been identified as the driver for applied hamstring strain or injury risk. Therefore, a combination of parameters including force production characteristics or strain capacity should be considered and monitored, highlighting the need for a combined observation of key features associated with applied strain and strain capacity. The aim of this present study is to observe the spatio-temporal characteristics, meaning, I step length, cadence, step width, running kinematics, looking at how the body moves through space and the forces that are applied to the muscle, and muscle activation were related to relative eccentric hamstring strength and hamstring fascicle length. It was hypothesized that running kinematics would have a relationship with the modified risk factors of hamstring strain injuries. So let's go into the paper design, its methods, its materials and models, and then look at some results and takeaways that you can take away. So the experimental setup, they said participants were observed on two separate occasions within a one week period, each occurrence being separated by more than 48 hours, but at the same time of day. Participants' modifiable risk factors were assessed during the first testing occasion, whereby the hamstring fascicle length and the isokinetic eccentric strength measured for the hamstrings. On the second testing bout, participants performed a submaximal treadmill assessment running at 18 kilometres per hour with a 3D model or 3D camera setup and EMG measurements taken. So the participants, there was 22 male competitive team sport athletes who incorporated high speed running and participated within the present study. The procedure looking at the first uh assessment was looking at the muscle architecture. So they looked at the hamstring muscle architecture through images, they used an ultrasound device to look at the hamstring in a prone position. So the patient lying on their stomach with their legs out straight, and they looked at with the guidance of the ultrasound, they looked at muscle thickness, they looked at they call uh penation angle, which I think is just like the striads, uh the orientation of the muscle fibers, I guess you could call it and the observed fascicle length or like muscle tissue length. They also looked at eccentric strength. So they had after a warmup of doing submaximal cycling, some bodyweight squats, some lunges, some leg swings, they then did a a muscle strength test with a dynamometer. They did three maximal eccentric knee flexion efforts, which were performed of those three efforts that had a 60 second rest period, where the participants were asked to pull with their hamstring a handheld dynamometer and instructed to pull as hard and fast as possible with strong verbal encouragement provided during each task. They then had with the running portion, the treadmill running portion, they had an all 3D motion data capture system with infrared cameras. Alongside that they also had surface EMG um data. So if people are familiar, there's like electrodes that get applied to the skin. Most people are familiar with like EMG sort of heart rate, uh heart assessments where you put those um sticky pads onto your skin and they can look at the heart beat. they can do the same for other muscles. So they had these electrodes applied to the skin of in and around the hamstring to then look at how the hamstring works when running. So this was applied and stuck to the patient while they were running on this treadmill. And so they did a maximal treadmill sprint test assessment. I'm not sure why in the earlier introduction, they said that a sub maximal treadmill assessment was performed because Looking further deep into this, it says that it was a maximal treadmill sprint test. Nonetheless, participants ran at increasing velocities where they were required to maintain a set velocity for 10 seconds with a 180 second recovery between each trial. So they start off at 18 kilometres per hour. They see if they can hold that speed for 18 kilometres per hour for 10 seconds. And if they could do that, they then... dial it back down, have 180 seconds for recovery, increase the speed by one and a half kilometres per hour, and then try to hold that for 10 seconds. And that just continues and continues and continues until they could not maintain the pace or their RPE, their rate of perceived exertion out of 10 was more than nine. So like trying to do an all out effort, that all out effort being uh ranked as a 10 out of 10, or they just couldn't. perform that task. So they do those tests. They take an image of the hamstring. They do a strength assessment of the hamstring. They look at how they run. They do it at different speeds up to maximal speeds. They then have the electrodes looking at the hamstring function, gathering all this data. What did they find? The first thing that they found was that runners with a higher eccentric hamstring strength showed that they also had a higher frequency, stride frequency or cadence. So the cadence is your turnover, uh how the rate, your step rate per minute, which irrelevant of the speed that you're running at. So if you're running on a treadmill or running at the same speed, some people can run it 160 steps per minute. Others can run at 190 steps per minute. But it seems that those with the higher strength also showed a higher running cadence. They also showed that those with a higher eccentric hamstring strength, also had the ability to decelerate the swinging leg before foot strike. They also had less time on the ground. This is like lower duty factor, meaning that it's more of an efficient stride. They also had lower hamstring muscle activation at submaximal speeds. So if you have stronger hamstrings or higher hamstring strength, when you're running at submaximal speeds, you're not working the hamstrings as much. So those are the benefits with having higher eccentric hamstring strength. Those who had longer hamstring fascicle lengths, they showed less of an anterior pelvic tilt. So their pelvis wasn't rolled forward with that uh high lower back arch that I was explaining before. They also had lower hamstring activation. And so it seems like a fascicle length uh was beneficial. The interpretation is longer fascicle length appears to enable the runners to load the hamstring complex more efficiently and safely, especially during the late swing phase where PhD symptoms often flare up. uh But this can go together, this could be like a combined effort, which is one of the effects that they found or one of the things that they highlight in this, it's that there's this two-way kind of relationship. The authors highlighted an important nuance. They said that the stronger hamstrings may allow runners to adopt more efficient or optimal running mechanics, but also more efficient, optimal running mechanic patterns also allows the shape long-term architectural strength adaptation of the hamstrings. What am I trying to say? I'm trying to say that like, if you have stronger hamstrings, you can run more efficiently. And if you run more efficiently, you are stimulating the hamstring in a better way. to then lead to stronger hamstrings. So stronger hamstrings, better running mechanics, better running mechanics lead to stronger hamstrings. And that's kind of like this two-way relationship that can go the other way. Like if you have weaker hamstrings, you're not optimizing your stride or your efficiency when you're running. And so there's this um back and forth the relationship that can be said and which was identified in this paper. So technique and strength training should be integrated and not. treated as separate silos. Another interesting thing that I found, they looked at the biceps femoris long head, which is one of the hamstring muscles. And it's, guess the most PHT suspected muscle that muscle in particular had higher activation in runners with weaker hamstrings or shorter fascicle length. And the opposite effects, they showed lower activation and better load sharing in stronger runners with longer muscle length. So this suggests that there's an overreliance. And if there is an overreliance of the biceps femoris head, which is the uh muscle of the hamstring that's on the outside, this could be a red flag. It's improving the medial hamstring contribution can redistribute the load through and protect the hamstring in total. So if we're seeing that those with that are weaker and weaker and or shortened hamstrings, tend to over rely on the outer portion of the hamstring. It makes sense to then increase the strength and muscle recruitment of the inner part of the hamstring to then better provide more load, provide a more optimal distributed load throughout the entire hamstring to offload just one tendon in particular. We'll talk about that in a second. Let's talk about some practical takeaways that I think of when I start reading this paper. One, Even if you don't have PhD or if you have PhD or if you've overcome PhD, eccentric strength is going to be a real key factor. If your goal is to, I guess, return to running, return to fast running, return to team sports, this becomes ever more important. How do we work on eccentric strength? Nordic drops would be one. That is quite a high level exercise that a lot of people might not be ready for. So we can modify. An exercise, I think doing a sort of bridge slider or hamstring sliders you might see, where someone goes up into a double leg bridge, but their feet or their heels have like sliding some sliders underneath and often on carpet, you can just slide the heels out nice and slowly, usually about four to five seconds, sliding it out all the way until your hips touch the floor. Then you can just passively relax in a relaxed position, curl the legs, go back up into that bridge position. and then slide back out again. You can do three sets of six with that eccentric phase being about four to five seconds. And then progress, still keeping to double leg, but holding onto weights at your hip crease. And then eventually if you've got to 10 kilos or like 15 to 20 pounds at that hip crease doing double leg, you can then get rid of the weight, go back to body weight and do single leg, eccentric hamstring sliders that just... challenges it more and more, then you can do with weights, with single leg and continue progressing in that fashion until you're ready to transition into Nordic drops. If you do Nordic drops, you can do banded assisted or I like to walk out a Swiss ball. So you're still doing the Nordic exercise, but you're taking some load off with rolling out the ball and applying some load there. You can then progress to just. the traditional Nordic, three sets of five, three sets of six is usually a nice sweet spot that I like to assign people. And then just work on quality, work on just trying to hold on for dear life and see how long you can slowly, slowly descent for before you lose control and have to drop and catch yourself with your hands. um And I don't really progress beyond that because you just need to get better and better and better at that three sets of six. But you'll find that as you get stronger, you can control that descent for longer and longer throughout that movement. I did a YouTube video on that and probably about two or three years ago where I just tried to get really good at Nordics. I did them every day for 30 days and saw how much I could improve. And definitely I saw a big improvement in how I could control my hamstrings and how long I could control my descent for. ah And so if running is a part of your goals and your rehab, then This is sort of what we wanna work towards. Your deadlift is an eccentric hamstring exercise. It's not purely eccentric, like a Nordic drop, but does have an eccentric component to it. So if you are doing your deadlifts, are contributing to your eccentric strength. But also, eccentrics, especially if you're really getting to that end range of movement, has been shown to increase fatical length. So all of those... improvements or enhancements that I've talked about earlier about having a longer hamstring flexibility. A lot of people don't like stretching um to try to improve your flexibility. I don't really think stretching really contributes a lot to flexibility, but there's some good research to show if you do your eccentric exercises, sort of lengthening the muscle under load and doing that quite often does contribute to improving your hamstring flexibility or your fascicle length. And so these benefits kind of intertwine or interlock when you do and progress those eccentric exercises. And like we say, if you have an improvement in your strength, your eccentric strength and your fascicle length, you're then getting a more efficient and more stimulating running stride. And so these things all have an interrelationship between one another. The paper does mention like when it comes to your pelvic tilt, try to sort of run and reduce excessive anterior pelvic tilt. I tend to find that's not that helpful just from experience. I like people just moving what feels nice and efficient for them. Those who consciously change their pelvic tilt and try to run at the same time, I find is just really inefficient, really overloads and overworks a lot of muscles. I find it very hard for someone to permanently change their posture and their natural sitting pelvic tilt. uh think it's, I would say like a waste of time. I just find that a lot of people spend a lot of work just doing all this pelvic control and trying to correct their pelvic tilt. I have an anterior pelvic tilt, but the ability to try to eventually get to where the muscles are so strong and so different that your actual relaxed posture changes, I just don't see happening. I find it's an uphill battle that we can't necessarily win, but we can improve the capacity and efficiency in that position that you're naturally born with to then strive and thrive. And so that's what the paper highlighted, but you know, in clinical practice, I haven't really seen that be that effective. So we should also focus on If we find this is the case, I'm strengthening the medial inside part of the hamstring. So like I mentioned before, ah it seems that those who have over reliance on the outside part of the hamstring can sort of overload or have this imbalance instead of those who have a lot of eccentric strength, they tend to have a more of an evenly distributed load through the hamstrings. And so if we find that there is an imbalance, can. kind of bias in our strength exercises working more of the medial hamstring muscles themselves. And so how can we do that? You can do the same exercises. You can do your hamstring curls, those hamstring sliders I just talked about, even kind of your deadlifts, but with the toes slightly turned in, I'd probably start with the hamstring curls. So if you do a hamstring curl, but the toes are pointed in, that should theoretically recruit more of the inner part of the hamstring. ah It'd probably turn the the foot in maybe 10 to 20 degrees. So we're not talking excessive, but just enough to bias the inner part, the semitendinosus and semimembranosus of the hamstrings. And then if they're nice and strong, and then we work on your eccentric strength, we are then combining, we're getting a more low distribution throughout the hamstring. So that can be done. A few other takeaways from this paper. They said that maybe increasing your stride frequency slightly by about 5%. could be beneficial so that's increasing your running cadence. So if you're not sure what your running cadence is, uh check your Strava or your Garmin. If you're out running with a watch, it should look at what your average running cadence is. Increase that by 5%, set a metronome, which looks, if it's say 165 steps per minute, maybe bump that up to 172 and. set a metronome to 172 beats per minute, run at the same speed. If you don't trust yourself running at the same speed, do it on a treadmill where the speed is fixed and then just run to that beat and see if that naturally feels better and more efficient and ease of symptoms for you. And lastly, integrate running as part of your rehab. If returning to faster running is a part, then we wanna be integrating running faster as a... uh general benchmark, I like to have people running at 30 minutes continuous running of really slow speed and making sure the PhD is handling that before then starting to introduce speed. And I typically do that with strides. I typically have people do start with about four strides, which is just like 15 to 20 second efforts at a faster speed, starting at about 75 % of their maximal uh sprint, which is hard to gauge, but I usually say it's like the feeling of it's running fast, but you feel like you've got two gears up that you can go. So just exposing the hamstring to those conditions for a very short period of time. Like I say, we're only doing 10 to 15 seconds at that top speed for about four rounds and then seeing how your symptoms are afterwards in the next day. And if that's okay, then we slowly build up from there. But that is exposing your tendons and your hamstring to meet the conditions of eccentric control, power, speed and overall improving your stride efficiency. And like we say, we've got that relationship of contributors to increase strength, which increased strength leads to better running mechanics and cycle repeats itself. So a few takeaways there, hopefully you can maybe identify some limitations in your own rehab, maybe make some slight adjustments based on this paper and overall just increasing the success of your rehab. So Hope you enjoyed this style of the PhD podcast and we'll catch you in the next 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 five day course, other online content and ways you can personally connect with me, including a free 20 minute injury chat to discuss your current rehab and any tweaks you might need to make. Well done for taking an active role in your rehab by listening to content like this. Together we can start ticking off all of your rehab goals and finally overcome your PHT.