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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, I'm covering the latest to PhD research papers. Welcome to the podcast that gives you the most up to date evidence based information on PhD rehab. My name is Brodie. I am an online physio, but I've also managed to overcome my own battle with PhD 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. been meaning to do an episode like this for a while, I have been gathering research papers on tendinopathies, PhD specific, um a bit on hamstring surgeries as well proximal hamstring evulsions and hamstring surgeries, which I plan to do on another episode, but thought I'd cover today, some really relevant research papers that have just been released, talking about rehabbing and managing and understanding tendinopathy and so thought you might be interested in as I just go through the list and mark them off. The first paper that was released just a few months ago was titled Exploring Molecular and Cellular Signaling Pathways Unraveling the Pathogenesis of Tendinopathy. It sounds very scientific in terms of its title but I want to try to disseminate some of the evidence and some of the research that they've uncovered trying to develop our understanding of what tendinopathy is to date. And so the purpose of this paper was to review the latest research on what's actually happening inside a tendon when a tendinopathy happens. And the authors wanted to better understand why tendons become painful, why they get thickened, why they're so slow to heal in some instances, and how that knowledge might be applied to future treatments. And so this wasn't like a clinical trial. This was a systematic review or a review paper, meaning they analyzed and summarized hundreds of lab testings, both animal and human studies on the tendon biology and tendinopsies in general. And so the key findings relevant to you who are listening with PhD is that one, tendinopsy is much more than just wear and tear. For years we were told that tendons were just like cartilage or arthritis where it just like wears out. But this review shows that the tendinopsy actually is a combination of mechanical overload, We know that inflammation, is something that's popping up more and more on my radar, which I'll talk to in a second. Oxidative stress, which is kind of like the stress on the cells, kind of like cellular rust, you could say. Age related changes and metabolic health factors like diabetes and cholesterol levels. I'll talk about that in a bit more detail in a second. But why does this matter to you? So it helps explain why two people with PhD might be rehabbing the same and getting two different outcomes, two different levels of pain, different symptoms and different responses to a standardized treatment approach. But we're also gonna talk about your overall health, like your recovery, sleep, stress, would say metabolic health, all these are gonna be influencing your rehab and your response to rehab, you could say. Let's just quickly go over what we already know if you've already listened to episodes of this podcast. They found that tendons need load, but they hate the extremes. one of the strongest themes throughout this whole entire paper was that too much loading can trigger tendon pathology. We tend to know this for the vast, vast majority of cases when your tendons emerged. It was, you know, training for a marathon, increasing speed work, sitting on a hard surface way too much more than your capacity could handle. Maybe stretching going from one yoga session per week to every single day for three weeks straight, like those sort of The review highlighted research showing that excessive repetitive loading can create inflammatory changes and tendon degeneration. Prolonged unloading, however, can also weaken the tendon and even encourage abnormal tissue changes. This is why complete rest doesn't help. So the key takeaway here is that resting indefinitely isn't the answer. Continuing to hammer through things like painful runs isn't the answer either. And the sweet spot is somewhere in the middle with progressive loading fostering within that adaptation zone. That's exactly what most successful PhD rehab plans revolve around gradually increasing the tendon capacity. This paper also mentions the tendon continuum model that and say that this model still holds up in the research. If you're not familiar, Jill Cook put out a research paper decades ago, and it's this famous continuum model that we always refer back to. The tendon, when it undergoes its first reaction is what we call the reactive tendinopathy. These are the early stages where we do see some tendon thickening as a protective response and potentially very reversible, like in these acute early phases. But as we go further and further down this continuum, we start to get more and more tendon, what we call disrepair, and there's more structural damage that develops, there's collagen, it becomes less organized. So instead of the collagen fibers of the tendon being nice and straight and well aligned, they sort of become a bit mucky and messy and tangled up. And this still has potential to recover with appropriate loading. But then we get further down the continuum where we have this degenerative tendinopathy with more extensive. tendon changes, less capacity for spontaneous healing. I think that's a nice phrase, uh less capacity for spontaneous healing. We do know that even the most degenerative tendons can revert to healthy tendons once again, research from Keith Barr has shown us that. ah But I think it's suffice to say that the further down the continuum you are, the harder it is to work your way back up to normal healthy portions of a tendon so that 100 % of your tendon reverts back to those normal, healthy, well aligned collagen fibers. And if that is you, and there is still some pre-existing tendinopathy there, my reassurance to you that you still can be symptom free. You can be symptom free for 20 years and be completely strong, smashing out races, but still have a mild tendinopathy. in there. And so it's not that you're just doomed and symptoms are going to linger on forever. Just simply reinforces while long standing cases usually take longer and require more patience and symptom free is always going to be the key. The inflammation, the role of inflammation is something that's a bit different that I didn't expect to come out of this uh research paper because for years I've been trained that we moved away from the term tendonitis, because itis means inflammation. We know that inflammation isn't the primary driver of a tendinopathy. So we referred to the more accurate term, which is tendinopathy. And I guess some people go as far to say is tendinopathy is not inflammatory. But this review suggests that reality is a little bit more different. So research found evidence of inflammatory signaling molecules, immune cell reactivity, and ongoing inflammatory processes inside a diseased tendon. So the authors suggested that inflammation may contribute to persistent pain, tissue changes and failed healing responses. So important for you to know, this doesn't suddenly mean that anti-inflammatories are the cure for tendinopathy, it simply means that there's more going on, there's more pieces to this puzzle that we need to uncover. Aging changes, they talk about in this paper a lot. The review highlighted Several age related changes, including the more advanced in age you are, the more matrix breakdown that we see the matrix displaying the makeup and structure of the tendon itself, reduced ability to resolve inflammation. Now that we know that there is inflammation present, the older you are, it's harder to buffer and negotiate that inflammation, reduced regenerative capacity and less effective tendon stem cells appear like when you are like I say, more advanced in age. So the practical takeaways from this is that recovery often takes longer as we age, we need to just respect that as reality. That doesn't mean recovery isn't possible though. It simply means that we need to be more patient and more and progress through our exercises, progress through our loading phases more carefully. The other thing I've talked about in the podcast once or twice or four is the metabolic health. when it comes to tendon recovery and tendon health in general. One of the more interesting sections looked at diabetes and cholesterol. And this paper suggests that high blood sugar can negatively affect tendon cells. Diabetes can increase tendon degeneration. High cholesterol may impair tendon cell function and healing. And so for you, the listening. maybe worth considering these sort of factors beyond just exercise, it may be worth getting just a general health checkup, looking at your blood sugar control, cholesterol levels, body composition, and like I say, just general health. And this is going to be crucial when it comes to overall recovery, if you're really struggling to recover from a tendinopathy, but yet we uncover a whole bunch of things to do with your metabolic health. This is another thing that we can add in to increase the odds and accelerate your healing. They did also touch base on future treatments. They say there is some exciting emerging ah realms of tendon rehab, but they're not quite ready yet. So the possibilities that included were stem cell therapies, gene therapies, molecular targeted treatments, regenerative medicine approaches. And these all sound exciting, but the authors repeatedly emphasised that most of this research is still experimental and that we don't yet have strong clinical evidence showing these treatments outperform a well-designed rehab program. So in conclusion for this paper, if I were to summarize in one sentence, tendinopathy isn't simply a damaged tendon, it is a complex interaction between loading, inflammation, aging, recovery, metabolism, and cellular biology. For you listening who may be struggling with PHT, my biggest takeaway is that pain doesn't automatically mean that there's ongoing damage, rest. is rarely the solution. Progressive loading remains the foundation of a successful recovery, which is reassuring for me to know because that's what a lot of the previous released podcast episodes are on. But also factors like sleep, stress, recovery, your overall health. These may influence how well your tendon responds to the rehab. Once we layer in and understand more about that progressive loading, let's look elsewhere and have a broader whole person approach to your recovery, as well as staying patient, gradually building that capacity. Once we start having a greater understanding of tendon health in general, this can overall help our success when recovering from PhD. The next paper I stumbled across and was really interested in is around shockwave therapy. The title is Shockwave Therapy for Mid-Portion and Insertional Achilles Tendonopathy. It is a systematic review. and meta analysis. I'm like, Oh, excellent. But turns out it wasn't open access. I'm like, Oh, damn, tried to get access to it. Couldn't, but found in the author list. Dr. Peter Maliaris was in there and I'm like, Oh, excellent. Let me just email him. Cause you know, we've converse back and forth over the years. He is the guru, one of the world's leading gurus in tendon treatment and tendon management. So uh emailed him and kindly next day I got the PDF in front of me. So, reviewed this and I think you'll find it really interesting. I know shockwave is very popular. um Is it overhyped? Let's find out. In the introduction, they start off by saying, among numerous treatment modalities, shockwave therapy has gained popularity in treating Achilles tendinopathy, despite conflicting evidence. While shockwave can be applied as a monotherapy, or just by itself, It is typically incorporated into a multimodal treatment approach, including exercise, eccentric loading, stretching, medication, heel lift, orthoses, dietary supplements, et cetera. Clinical trials have reported inconsistent outcomes, potentially due to the variations in shockwave parameters. You can have radial shockwave, you can have focused shockwave, and different treatment protocols and patient selection criteria. Shockwave can be delivered as focused or radial energy, i.e. sound waves. The focused shockwave targets deeper structures, while radial shockwave generates lower amplitude pressure waves that mainly affect superficial tissues. The precise mechanisms of shockwave action in tendinopathy is still uncertain. Like, even when we're talking about shockwave, shockwave, shockwave, it's still unsure of actually what's happening and why it's... proposed to work. It's been argued that shockwave produces mechanical and biological effects through mechanotransduction and may improve tissue healing and alter pain responses through central or peripheral mechanisms. Until recently, no consensus has been established regarding the application or the procedure parameters directing shockwave in musculoskeletal and sports rehabilitation. Considerable differences across the literature including differences in modality, the density, the flux density, I guess these are just the settings, the impulse number, the frequency, the overall treatment dose, as limited compatibility between studies and contributed to the inconsistent evidence regarding the effectiveness of musculoskeletal conditions. Although a recent guideline provides preliminary non-validated recommendations, meaningful standardization of clinical practice is yet to be achieved. While some systematic reviews suggest potential benefits of shockwave in Achilles tendinopathy, their conclusions are limited by methodological shortcomings, including the pooling of different tendinopathy subtypes and inadequate assessment of clinically meaningful outcomes. The primary objective was to estimate the effects of shockwave, whether as monotherapy or in co-interventions compared to no treatment or sham shockwave on function and pain in patients with mid-portion Achilles tendinopathy or insertional Achilles tendinopathy. The secondary objective was to describe adverse events associated with shockwave. So mid-portion Achilles is more classic, more common, and it's sort of two inches above where the attachment of the Achilles is on the heel, whereas insertional Achilles tendinopathy is more at the insertion point around the heel region. Like I that is less common and a bit more stubborn, unfortunately. um So they're looking at both of those and seeing if shockwave has any benefit. um But as the introduction alludes to, there's been a lot of inconsistencies with, first of all, the understanding of shockwave, what's actually happening, but also how many sessions do you need? How intense does the the shock waves need to be, how long does the session go for, do you do focal or radial pulses, all those sorts of things are just, ah it's disappointing and even shocking that we don't have the consistent results, because there's a lot of shockwave papers that do get published. ah So yeah, let's see what this paper shows. The systematic review pulled together nine randomized control trials. So in combination with all of those papers, a total of 557 patients were analyzed. Like I say, this is a meta analysis as well as a systematic review. So they need to have trials that are consistent enough to then pull all the data together and present it as one big finding. And like I said, good enough that they separated the insertional and mid-portion Achilles tendinopathy because they are treated differently. They're treated as different conditions. The advice is overlapping, but yeah, some key differences. First, I guess it's important that I do explain what shockwave, I guess, kind of is. uh I was trained in this like back when I was working in clinics, we did get a shockwave machine in our clinic and we had these two, what I would call marketing guys. They weren't trained. therapists, but they were uh selling us this shockwave device and they're like, Oh, yeah, it's the best, know, people need five to seven sessions this intensity for this long and I don't think they were going off much research but shockwave essentially delivers sound waves into the tissue. And like the paper said, the focused shockwave tends to penetrate deeper, the radial more superficial and it the proposed mechanisms are stimulating healing, don't know through what means, but improving blood flow, mechano transduction, like the paper suggested, and also altering pain sensitivity. tend to, whenever I have my various tendinopathies, respond really well to isometrics. Like I feel like my power returns and I feel less pain for several hours if I really load up with isometrics. I feel like the shockwave tended to have that same effect. But that being quite short lived, but that's just my personal experience. It does somewhat hurt during the shockwave. It's meant to hurt. You dial up the intensity so that you do feel uncomfortable during that session. And then throughout the one session, if your pain reduces, which it was for me, then they just kept dialing it up until it became more more uncomfortable. And then after the session, like I say, it felt better, but that was just my personal experience. and they're the proposed mechanisms. So let's dive into the findings of the paper. Biggest takeaway, shockwave probably doesn't do much. For insertional Achilles tendonopathy, the findings were remarkably consistent. Shockwave did not outperform sham treatment in a meaningful way. Not for pain, disability, function, short-term, medium-term, or long-term outcomes. And that was whether they used radial, focused, or both. radial and focused shockwave. And the differences were tiny. They were often like one point out of a hundred or two points out of a hundred, which is confounding considering the cost of shockwave, the marketing, the hype, like I say, all those sorts of things and how commonly it's recommended. I probably should have mentioned as well. It's very clever that some of these studies that they included had sham treatments because shockwave is one of those treatments where Um, the effects, the expected effects can be huge, but the effects can be a very powerful placebo as well, because you go into a clinic, there's a machine that looks pretty high tech. It's noisy. It hurts. It's, ah you know, you hear a lot of hype about it. So all of these can have a pretty powerful placebo effect and increase your belief or perception that this is going to help. And so that's where the, um, placebo effect does come in and the authors specifically discussed how difficult blinding is because you know shockwave hurts whereas if you do fake shockwave it doesn't hurt. So if the patients can tell it that they're in the treatment group if you do have some sort of sham ah it can be quite obvious that people do know what group they're in so it can be hard. But they did try, they did try their best to in some of these papers create a sham condition, but purely based on the intervention and the circumstances around it means it is hard to completely rule out placebo. ah In fact, the only low risk of bias study that they had with the best quality showed no benefit of shockwave over sham. So that's important. What about mid-portion Achilles and compare it because All of that was just around the insertional stuff. What about the mid portion Achilles? Results are a bit muckier. So this is where there were a few studies showing benefit, particularly radial shockwave combined with exercise in some shorter term outcomes. But the evidence quality was extremely low and the results were inconsistent. Some studies showed good effects. Others showed absolutely nothing. So the authors basically concluded, we still can't confidently say it works, which I think is a fair interpretation. They can't say it doesn't work because there are some studies that are promising, but obviously vice versa. The exercise comparison is also interesting. So like one older study compared shockwave versus eccentric loading and found they performed about the same. But here's the key detail, when shockwave was added on top of the exercise, it usually didn't improve the outcomes further. So that's a pretty big clinical point because if exercise is already doing the heavy lifting, then what exactly are we paying for with all these shockwave sessions if it's not adding anything clinically significant or meaningful? uh So this paper repeatedly enforced exercise-based rehab remains the gold standard for mid-portion. tendinopathy treatment. The other thing that the paper found, so shockwave sometimes looked beneficial when compared to basically doing nothing, like the wait and see group, wait and see approaches. But when compared to sham treatment, proper exercise rehab, active management, the advantage just disappeared. Because it suggests maybe shockwave is better than no treatment, but not necessarily better than good rehab. And clinically, those are really different conclusions. As I mentioned, the secondary outcome of this study was to look at any adverse events. And so most people think shockwave is harmless, but two Achilles ruptures were actually reported after using the shockwave treatment. So the authors were careful with their wording here. They said that uh they can't prove that the shockwave caused the ruptures, but it's still worth mentioning, especially when the benefits are, as we mentioned, are uncertain. and the costs are high for these sessions. I know when I was in clinics, we did charge an additional fee on top of a standard, like the consult fee for doing shockwave. And as I talk with a lot of my clients, they agree shockwave isn't cheap. So with those findings, it's probably worth helpful to remind you that Achilles tendinopathy along with a lot of tendinopathy is probably not just about damaged tissue. The authors discussed this and said that a lot of the outcomes are actually influenced by expectations, contextual effects, pain modulation, the nervous system changes. ah So this is what I took, like one of my big passions is around modern pain science and our understanding of pain science and how multifactorial it can be. um And so. Shockwave doesn't address any of those. I suppose in the benefits of the placebo effects, maybe there is some newly developed reassurance or confidence, but ah chronic tendinopsies do have nervous system changes, changes in the brain, changes the way we perceive pain and shockwave wouldn't necessarily deal with that. And so even though shockwave has become incredibly mainstream in tender rehab, we do need to... strip away the marketing, the machines, the technology and all that sort of stuff. just have a look at what the evidence does show. And I think it's worth reminding ourselves that while there are some studies that are promising, there are just the equal amount of studies that show that it's not really that worth it. And so uh if you are considering shockwave and yet haven't executed on really nice load management, eccentric loading, functional restoration, Um, would definitely, definitely do that first. Um, another thing that I constantly remind myself of is shockwave isn't doing anything to rebuild the capacity of a tendon. You know, strength training does that progressive strength training does that. And if the research is leaning towards progressive strength training is, uh, the gold standard and shockwave on top of strength training doesn't really show any additional benefit. Why not just give the strength training a really good go. and find a good clinician in your corner to help build that out for you. This next paper I thought would be helpful for those who have listened to the first paper that I just talked about and looked at the role of inflammation for tendons and thinking that maybe ice might help heal a tendon as well if there is inflammation. Maybe this can help settle down the inflammation if we use cryotherapy. uh And so, Unfortunately, I could only get the abstract for this article, but the title is, is cryotherapy effective for tendon health, a systematic review of evidence and methodological limitations. Like I said, I'm only just gonna be reading the abstract here, but I think this might be helpful. So cryotherapy is just a uh cold therapy, you could say. This paper did include things like ice packs, but also cold water immersion. uh Let me just read through this abstract because I think it might be helpful. So cryotherapy is widely used in managing soft tissue injuries, but its scientific foundation and clinical application remains inconsistent. Human evidence specifically concerning tendinopathy is limited. Understanding the effects of cold exposure on tendon structure and function is essential for safer and more effective clinical practice. So like I say, this is a systematic review. They scoured the research that was out there and they concluded or they found 12 studies, which had a combination of using ice, three of them, nine studies used ice and three used cold or ice water immersion. Some of them had just the cryotherapy as a standalone treatment. Whereas other studies included things like exercise, ultrasound. or taping as a in conjunction with the cryotherapy. And so in conclusion, which is just a very brief conclusion, unfortunately with the abstract that I can find, they say that current evidence does not support cryotherapy as a standalone or standard treatment for tendinopathy. It may serve as an adjunct strategy for long-term symptom relief, but its long-term structural and functional benefits remain uncertain. High quality randomized controlled trials are required clarify its therapeutic role. And this has been the advice I've generally used for a lot. Like you can use it if you are having a particularly painful day, and you want to use ice to settle down your symptoms, kind of just like a numbing effect. Give it a try. uh Doesn't work for some works for others, a heat pack might work just as well for others in terms of that short term symptom relief. Try out one or the other if you are having a particularly bad day, but just realised that it isn't doing anything to help the long-term structural healing or functional benefits of the tendon. Another useful paper that I came across looks at hamstring injuries in general, not PHT, but still has some pretty key takeaways. The title is Risk Factors and Injury Prevention Strategies for Hamstring Injuries, a Narrative Review. The purpose was to review the latest evidence on what increases the risk of hamstring injuries and which prevention strategies actually work. Another reason is because a lot of pH, well not a lot, I'd say probably 10 % of the pH T clients that I work with actually start off with a hamstring strain that eventually morphs into pH T. And I would say the management for that, you know, you really need to get very strong hamstrings, like the hamstring muscle as well as the tendon. But for people with pH T, I would definitely suggest or definitely highlight we are working strengthening the tendon, but we are strengthening the muscle as well. It is the same unit. And like I say, there's a lot of crossover benefits and takeaways from this particular paper. So this was a narrative review. So the authors were summarizing the findings of several different papers investigating hamstring injuries and prevention programs, and then sprinkling in, like I say, their narrative. And so key findings of this paper, number one, previous injury is the biggest risk factor. There's no real surprises here. We know this with running related injuries as well. The strongest predictor of a future hamstring injury is having a hamstring injury in the past. And this matters because tendons often remain sensitive when it comes to managing an injury, even though their symptoms settle. So someone might have a hamstring strain and then all of a sudden they do their rehab work and they're symptom free. They're returning back to sport symptom free. but that tendon lurking in the background still might be vulnerable, which is why it is a strong indicator. Also, like many runners return to normal training, but never really rebuild the capacity that's required to meet their demands. All it takes is one harder session or two hard training block weeks and they're back with the same injury. And then like it's a vulnerability. We need to accept it as I've had this injury in the past, except this as a weak chink in my armor. Let's strengthen up as much as possible. So just remind yourself that just because pain is gone, doesn't mean the rehab has finished. Okay, very, very important. The other thing they found was the neuromuscular control matters more than people realize. So one of the more interesting sections looked at, when we talk about neuromuscular control, we're looking at... uh your ability, your stabilizers, you could say the nervous system is coordinating the muscles and stabilizing the muscles and joints around it to so it can execute that task. So the researchers found that poor control around the pelvis and the trunk may increase the hamstring stress. They talk about excessive anterior pelvic tilt. And this is like if you were to sit up as tall as you can, you'll notice that your pelvis rocks forward, that is what we call anterior tilt. They said that excessive anterior pelvic tilt may increase the tension through the hamstrings and that poor movement control can alter how the hamstrings are loaded during things like running and sprinting. I'm a bit skeptical or like to see more data on this in terms of what we do to address it. If someone naturally has an increase anterior pelvic tilt when they run per se. I find it very hard to do some mobility exercises and strength exercises to correct their natural posture. um There may be through retraining, I guess could be done, but I haven't convinced, I'm not convinced that I can see it routinely enough or effective enough, but it's worth pointing out that sometimes the way the entire system moves does influence how much load ends up at the tendon. So for you who may be rehabbing your own PhD, doesn't mean that everyone needs to do endless core stability exercises, but it does reinforce that some runners may benefit from improving their single leg control, their pelvic control, their running mechanics, hip strength, those sorts of things. The good thing about the exercises we prescribe is that say like a deadlift does work on glutes and lower back. And we always, not always, but we like to at least put in one single leg activity. My usual go to is a lunge or walking lunge or weighted step ups. And that can help challenge the stability of the core, help workouts if there's much of a difference from right leg to left leg, those sorts of things. And so always helpful to know. The other thing the paper came across was the hamstring often compensates when there's problems elsewhere. So there may be regions where the whole unit isn't working properly and the hamstring actually tries to step in and work harder. They used examples like lower back issues or pelvic control deficits or weakness elsewhere in the whole kinetic chain, which can be as anywhere as far down as the calf, foot, ankle, all the way up to the lower back, upper back even. And so researchers suggest altered muscle recruitment patterns. can increase the hamstring load, potentially increasing their risk of injury. Think of it like, know, if three people are carrying a couch to when they're moving house, and then all of sudden, one of the people stops working, the other two need to really work harder, pick up the slack. And sometimes that person that's picking up the slack is the hamstring. So just bear that in mind. They say the strength still matters, like the review found that strength deficits continue to be an important risk factor. particularly eccentric hamstring strength. So this is loading your hamstrings while it's lengthening. If there is a deficit in that eccentric control of your injured side compared to your other side, that's definitely opening you up as a risk factor. They talked about the strength balance between the hamstrings and the quadriceps. If the quadriceps is really strong compared to the hamstrings, you're opening yourself up for more risk and the ability to just tolerate forces, large forces through greater lengths in general. So a large component of successful rehab often involves gradual building. So we're talking about strength, building strength, raising tendon capacity, increasing tissue tolerance, all that stuff that we propose is just setting a better stage and addressing these imbalances and larger forces. They also talk about flexibility. Now a lot of people with PHT think they lose a lot of flexibility just because it hurts and it feels tight when I just bend forward a little bit. Oh my god, I've lost all this flexibility. ah But I've talked about this a couple of times on the podcast, but my interpretation is that things aren't getting tighter. It's just that your onset of symptoms occur earlier and earlier in that movement cycle. And the more your tendinopathy becomes painful, the more sensitive it becomes. the more those signals or those alarm bells ring into that movement. And so I frequently see people have the perception that they've increased their flexibility when they don't do any stretches, but they just start lifting heavier and load managing themselves better. All of sudden their flexibility returns and there's nothing that's changed about the properties that the hamstring muscles slash tendon unit aren't actually improving their flexibility. Those alarm bells are just ringing. later and later and later through that movement. But they do bring up the topic of flexibility. This paper says that while flexibility may contribute in some situations, it appears to be only one piece of the large puzzle. This is talking about hamstring strains or like the risk of hamstring strains. They say that it more involves strength, neuromuscular control, the previous injury history, load management and movement patterns rather than the flexibility of the hamstrings. leading to an increased risk of hamstring strains. They make a special mention to the Nordic hamstring exercise when it comes to preventing like a injury prevention strategy for hamstrings. I think this is one of the key things for a hamstring strain. If you're looking to return to especially sprint based activities and you want to reduce your risk of hamstring strains, I would highly recommend having the Nordic hamstring exercise. introducing gradually and sensibly. ah This was a part of my review that I did when I was studying back, I don't know, when did I graduate? 15 years ago. I did a paper or I did my own systematic review on the effectiveness of the Nordic hamstring exercise on preventing hamstring injuries and found how effective it can be. And the paper says that these programs consistently reduce hamstring injury strains or hamstring injury rates while athletes actually perform them regularly. This was another thing that I found in the paper that I wrote. ah They give them a tour, a lot of say football players and rugby players, and they get them to go through this Nordic hamstring exercise and they record the rates of hamstring strains. And it helped, but also what didn't help was a lot of the athletes didn't comply. And they only did say like 25 % of the dosage that was required. And we're very, very inconsistent with doing their exercises. Although like the ones who were even inconsistent only did it say 20 % of the time actually still reported a reduced rate of hamstring strains but if you do that regularly it works wonders but this isn't pht though i will preface by saying this we're not really loading the hamstring the proximal hamstring effectively with the nordic exercise it is making your hamstring muscle really really robust with that exercise But we need some sort of compression, which is why the deadlifts come into play. And like maybe the combination of the Nordics with the deadlifts can be a nice combination of the two, but it is a lot of load. Nordics create enormous tendon load and enormous muscle load. So you do need to be very, very careful with, if you've never done them before, introducing them very gradually and don't progress too aggressively, you could say. ah But like I say, this paper does give a nod ah to the Nordic exercise. as an effective injury prevention strategy. So in conclusion for this paper, if I was to summarize the paper in one sentence, it'd be like hamstring injuries are rarely caused by a single factor. They usually develop when the capacity fails to keep up with the demand. And for someone struggling with PHT, your practical lessons would be don't stop your rehab the moment the pain settles. A lot of people fall into this boom bust because they're like, yes, I'm back. They ignore the rehab. They build up their... return to sport way too quickly. They get into a bust and then they're just repeating that cycle. Build the hamstring strength and the tendon capacity. Consider the role of the pelvis and trunk control like we talk about that neuromuscular component. Don't obsess over stretching. It's nothing that's really crucial or important to as a risk factor for hamstring injuries nor prevention strategies. Progress your running loads and your return to sport really, really gradually. and just try to be consistent. Consistency beats perfection. And there is hope, like many runners spend years chasing the wrong thing, but this review reinforces that successful recovery and prevention usually comes back with the fundamentals. So it's a sensible loading, progressive strengthening, good movement quality and patience. So like I say, just a handful of papers that have been released in the last couple of months that I thought I would share with you. So you get, better understanding and an up-to-date understanding of what's happening with tendon rehab and just tendinopathies in general. Hopefully you took away some key lessons 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. Well done for taking an active role in your rehab by listening to content like this. we can start ticking off all of your rehab goals and finally overcome your PHT.