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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, every food hack you need to heal tendons. 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. I am going to be reviewing a paper that was released just a couple of months ago. Really looking forward to delivering this one for you because the title caught my eye. The title is Rehabilitation Nutrition for Tendon and Ligament Injuries from Collagen Remodelling to Return to Activity and Sport. And when was it released? Published mid-July, 2026. So like I say, a few months ago. And this covers a whole bunch of domains where the research lies in terms of its effectiveness, how confident we are in where we currently stand with certain interventions. I think they cover about six or seven different domains. And so let's see if you're up to scratch with your level of nutrition. And yes, we do need to put the basics in place, but if you're looking for the next level up or everything you can possibly be doing to rejuvenate this tendon. then yeah, let's make sure we've got all bases covered. When we do talk about tendon nutrition or tendon recovery, we're essentially talking about trying to enhance the turnover process. Collagen synthesis is what we refer to as the term that's kind of like the buildup and breakdown of tendon material. And we want to stimulate the tendon enough to trigger this breakdown and buildup. And that comes with loading. So loading is essential. But while that rebuilding phase is taking place, let's make sure we have the right ingredients to enhance that process or make that process as efficient as possible. And so let's set the stage with what they include in the introduction. So they say, unlike skeletal muscle, tendons and ligaments are characterized by low vascularization, meaning blood flow, and slow collagen turnover, that's that collagen synthesis I was talking about before. These biological constraints contribute to the prolonged remodeling period observed after injury. As we know, tendons take a really long time to recover. Rehab protocols have traditionally focused on progressive mechanical loading as the primary driver of tissue recovery. However, increasing attention has been directed towards the role of nutritional strategies, as modifiable factors that may support extracellular matrix remodelling, collagen synthesis, and inflammation resolution during the rehab process. In recent years, sports nutrition research has made substantial progress in identifying dietary strategies that support skeletal muscle hypertrophy and recovery. Evidence-based guidelines now exist for protein intake, carb availability, and several ergogenic aids aimed at optimizing muscle repair and adaptation. Collagen is the predominant structural protein in tendons and ligaments, representing approximately 70 to 80 % of their dry weight. The synthesis and cross-linking of collagen fibers are influenced by several nutritional factors, including protein intake, vitamin C availability, and amino acids such as glycine and proline. Furthermore, Connective tissue healing is highly sensitive to systemic energy availability and inflammatory status. Emerging evidence also suggests that targeting nutritional strategies such as collagen or gelatin supplementation combined with vitamin C prior to rehab exercise may enhance biomarkers of collagen synthesis in response to mechanical loading. So they're kind of setting the stage with a few domains that they're gonna talk about and they kind of... prioritize it from one domain to the next. Before I get into that, they just finished off the introduction by saying, therefore this narrative review aimed to synthesize the current evidence on nutritional strategies relevant to tendon and ligament rehabilitation, in particular attention to energy availability, protein intake, collagen related strategies, creatine, micronutrients and omega-3 fatty acids. So let's start off with the first point of call, which is labeled energy availability and tissue healing. For those who are familiar with RED-S, relative energy deficiency in sports, it's essentially looking at, what is our total amount of intake? How much energy are we actually giving our body through our diet in relation to how much energy we are? how much our output is, i.e. how much exercise are we doing, how much stress is applied to our body, how much loading, gym, strength, all that sort of stuff requires energy, and we wanna make sure that our input is equal to or slightly more than our output. If that scale is off and our input is not sufficient enough, i.e. if our energy availability isn't matching what our output is, then that's when the body really struggles to prioritize daily function, prioritize recovery, and all the important steps that we're gonna talk about when it comes to healing tendons and just performing in general. So that's what we're talking about when we say energy availability. The paper says that that energy availability is defined as the dietary energy intake minus the exercise energy expenditure normalized to fat-free mass. This is a foundational determinant of recovery during tendon and ligament rehabilitation. Although training volume often decreases after injury, tissue repair is not a passive process. Immune reactivity, protein turnover, collagen synthesis, and progressive rehabilitation exercise all require metabolic support. Therefore, undergoing rehab may remain metabolically vulnerable even when overall physical activity or sport participation is reduced. The authors of this paper often say that low energy availability can be particularly common in people who are rehabbing the injury because their food intake is less in response to their low training volume, appetite suppression, pain, psychological stress, or concerns about body composition. This is often where red S comes from in non injured athletes, low energy availability is common in sports where body composition is highly favorable or they just want to remain as light as possible or there might be pressure on them to keep their body weight really low and so they train really hard and eat very little and that's when they run into trouble that's where stress fractures can be of risk and just general body function because the body has to prioritize just keeping the lights on and starts redirecting a lot of their resources away from function of their other vital organs. And yeah, they can run into real trouble. And so the paper continues as to identify or what to do to identify a low energy availability or some general signs. They say low energy availability is associated with alterations in anabolic hormones, thyroid function, immune status, and in physical active females, menstrual function, and sexual hormone regulation. These changes may impair collagen metabolism, prolonged inflammation, and reduce tolerance to progressive loading. Obviously, if we see impairments in collagen synthesis, in the ability for the body to process inflammation, and for the body to not really tolerate a progressive loading program, obviously this is gonna hinder tendon rehab. They mentioned individuals presenting with recent weight loss, restrictive eating, low carb availability, menstrual irregularities, persistent fatigue, frequent illness, poor sleep, or stalled rehab processes should be screened for low energy availability. The paper continues to mention that adequate carbohydrate intake is especially important because it supports training quality, and may indirectly provide a supportive environment for connective tissue remodeling by enabling more effective mechanical loading. Thus, energy sufficiency should be considered a foundation nutritional priority that may help support college remodeling and tolerance to a progressive rehab program. So essentially, let's just make sure we're eating enough. If we're putting the priority number one, we just need the right of energy, once we've got that ticked off, we can then focus on a lot more specifics, which the next specific thing that they talk about is protein intake and amino acids. When we ingest protein, it gets broken down into amino acids. So that's just the difference between the two. They say protein intake is a fundamental component of rehab nutrition because it supports the skeletal muscle preservation and connective tissue repair. During tendon and ligament rehab, individuals must maintain muscle mass and strength despite reduced loading, while also providing amino acid substrates required for collagen synthesis, extracellular matrix remodeling and tissue maturation. So it's important that we remain strong. If we are injured and not lifting as heavy, we sort of want to preserve the muscle mass that we have. We want to preserve the strength that we have. And that comes with maintaining our protein intake. Not only that, but protein plays a key role in that process that we're talking about earlier, that collagen synthesis, the breakdown and buildup of collagen. Very, very important process and proteins needed for that. However, connective tissue recovery should not be viewed simply as an extension of muscle hypertrophy, whereas skeletal muscle adaptation is strongly influenced by essential amino acids and leucine mediated protein synthesis. Tendon and ligament repair depend more heavily on collagen deposition, collagen maturation, cross-link formation and structural reorganization response to progressive mechanical loading. What they're saying here is like, the body needs the signal for the collagen synthesis in the first place. You can't expect to, okay, I'm injured, I'm not exercising, I'm not lifting heavy, but... I should probably just increase my protein intake to heal the tendons. It's not going to work unless you have that progressive mechanical loading that triggers the adaptation, the body gets a signal, oh, okay, let me get my tendons stronger. That's when you need the protein. You need the signal first, need that loading response with your progressive mechanical lifting, and then the protein on top of that. individuals recovering from ligament or tendon injury may require higher protein intake. And they suggest between 1.6 and 2.2 grams of protein per kilogram of body weight per day. So if you weigh 60 kilograms, you are looking for about 140 to 150 grams of protein per day spread evenly throughout the day. These recommendations are derived primarily from a broader sports nutrition and skeletal muscle literature, rather than tendon specific rehab trials, reflecting the limited availability of direct connect tissue evidence. So when they talk about this 1.6 to 2.2 grams per kilogram body weight per day, that is heavily researched, but more on the muscle or the skeletal side of things, not necessarily for the tendons, but it's a nice guideline to fall back on. Importantly, protein strategies are most effective when energy availability is sufficient. Under conditions of low energy availability, amino acids may be oxidised for energy rather than directed towards repair and remodelling. So this is like a pyramid. We need the mechanical load as the base. On top of that, we need the right total energy availability. And then on top of that pyramid tier, we also have your protein. You can't have You can't expect your rehab to be effective if you are getting the right amount of protein, but not meeting your energy availability demands. Cause it'll take all that protein that you're taking and try to convert it into energy. Cause the body's just constantly trying to keep up with keeping the lights on. And so it's not going to go to the right things you want it to. Like I mentioned, they recommend spreading your protein throughout the day. And so that's typically around 25 to 40 grams of protein per meal. And they say that although this approach is often discussed in relation to the skeletal muscle, it may also support connective tissue recovery by enhancing consistent substrate availability during the prolonged remodeling process. For examples of things you should take, they say leucine-rich, high quality proteins such as whey protein, dairy, eggs, fish, and lean meats are useful for supporting muscle preservation. and strength recovery. So that's when we're talking about one of the aims of being to maintain muscle mass and strength. That's when we lean on the leucine rich quality foods, like I just mentioned. In relation to collagen synthesis, they talk about collagen rich foods such as collagen rich proteins, gelatin and collagen peptides. They have higher types of amino acids called glycine and proline. which is very, very helpful in the collagen synthesis process, which takes us to the advice on collagen. So this paper talks about collagen supplementation. I've done some YouTube videos and episodes in the past on collagen with vitamin C with a very well designed protocol, but they do outline it here. So let me just go through it now. They say collagen or gelatin supplementation combined with vitamin C is one of the most relevant targeted nutritional strategies for tendon and ligament rehabilitation. Unlike skeletal muscle, which adapts primarily through protein synthesis, tendon and ligament recovery depend on collagen synthesis. And so this is where collagen itself redirects, sort of directs the amino acids to the right area. The collagen is required for the build up and breakdown. and the vitamin C is what takes the digested collagen and directs it straight to the tendons essentially. So traditional high quality proteins such as whey, casein, eggs, fish and lean meats remain essential for whole body recovery, for muscle preservation, but they provide relatively low amounts of collagen specific amino acids compared to gelatin or collagen peptides. Thus, collagen supplementation should be viewed as a targeted substrate rather than a replacement to complete dietary protein. Vitamin C is central to this strategy because it acts as a co-factor involved in collagen synthesis. Although severe vitamin C deficiency is uncommon in athletes, suboptimal intake may occur during periods of reduced appetite, restricted dietary variability, travel, or intentional energy restriction after injury. Combining collagen or gelatin with vitamin C therefore provides both the amino acid substrates as well as enzymatic support required for collagen formation and maturation. If I was just to briefly cover the protocol for this, we are looking for about 30 grams of collagen in the form of a supplement with around about 50 milligrams of vitamin C. And you take that 30 to 60 minutes before any of your rehab that requires a sensible amount of loading that triggers adaptation. Unfortunately, that's not your body weight or banded exercises. This is where it's really important that we hit a strong enough stimulus that requires tendon adaptation. So we're looking at something a little bit heavier than just body weight exercises. Essentially just however heavy you can tolerate if your injury is really sensitive right now. maybe you're not quite stable enough to lift heavy. I don't encourage you lift heavy if it's gonna encourage or like trigger a flare up. But once the tendons are stable, once you can start poking into those heavier lifts, that's when we wanna time 30 grams of collagen with 50 milligrams of vitamin C and do that 30 to 60 minutes before you start loading up these exercises. So collagen. Combined with vitamin C, really crucial part in this. The next thing they talk about is the role of creatine, which is big, big recommendation for a lot of people right now. It's been recommended a lot on a lot of the podcasts that I listen to. Creatine essentially just draws water into the muscle. It doesn't really have a direct role in terms of tendons, tendon turnover, but its indirect role, it plays a big role in maintaining muscle mass and maintaining muscle strength, all of which can carry over into a more effective rehab for you. And therefore, it will have indirect responses to a good tendon rehab. So the paper says, although creatine does not directly target collagen synthesis or tendon ligament remodeling, it may have functional relevance during the rehab process by supporting skeletal muscle preservation and training capacity. After tendon or ligament injury, immobilization, reduced activity, pain or altered movement patterns can accelerate muscle loss and strength deficits, which may limit the rehab process and compromise return to activity. Creatine though may help attenuate disuse related declines in muscle mass and strength. Like I say, we're indirectly helping preserve a lot of your strength. These effects, may be particularly relevant as rehab processes from early isometric to low load exercise towards resistance training, plyometrics and sport specific loading. In this context, creatine should be viewed as a muscle supportive strategy that may help support the individual's capacity to perform higher quality rehab work rather than its connective tissue specific interventions. So if you are taking creatine or if you're now convinced that it can help in this process. The authors recommend that people take about three to five grams per day. Some research does show that you can have a loading phase of a bit higher than that. It'll just depend on your urgency, but also your tolerance. Some people can't tolerate a lot of creatine up to 10 to 15 grams per day. So maybe start low and gradually build up if you haven't had it before. But five grams per day. can be a good starting point. And then like we say, this can help build or like draw water into the muscles, effectively making them bigger, effectively making them stronger. So like we say, this can be quite helpful when it comes to your tendon rehab and starting to lift heavier. After that, so we've discussed like the energy availability, we've discussed creatine, we've discussed the protein, collagen, all those sorts of things. Fairly robust in terms of its level of evidence. Energy availability, very strong in terms of its level of support. Protein intake, very strong. Collagen and vitamin C, the level of support of evidence is like moderate at this stage. But I would say I've just read a systematic review around it. I'm very, confident with that particular protocol. The creatine is limited in terms of its support to tendon rehab, but. Like I say, it's a bit more of an indirect theory and yeah, it can have its benefit. Now we're sort of getting into a bit more limited to moderate level of evidence when it comes to directing the healing of a tendon and has a bit more of a, let's just call it like supplemental support. So let's just make sure we're covering the basics really well. Whatever we've discussed so far, making sure we're covering that off. Everything up until this point, everything else that we discussed is kind of like a bit more of a one percenter, you might say. Okay, the first micronutrient that they talk about in connective tissue recovery is vitamin D, or vitamin D and calcium. They combine this by saying vitamin D and calcium are also important within the broader musculoskeletal recovery framework. The vitamin D status may influence immune function, muscle function, bone metabolism. and potentially connective tissue remodeling pathways. Deficiency or insufficiency may be more common in individuals with limited sun exposure, indoor training, or winter season rehab. They say calcium supports bone remodeling and mineralization. Micro nutrient adequacy is closely linked with energy availability. So individuals who have intentionally reduced their energy intake during injury downtime may also reduce intake of fruits, vegetables, dairy products, fortified alternatives, or other nutrient-dense foods. This can increase the risk of suboptimal vitamin C, vitamin D, calcium, and broader micronutrient status, potentially compromising the rehab process to tolerate progressive loading. A food-first approach should therefore be prioritized with targeted supplementation used selectively when dietary intake is insufficient, deficiency is confirmed or other risks such as low energy availability, restrictive eating, indoor training, winter season or previous history of bone stress reactions. So just a message out there that while we're talking about vitamin D, vitamin C, calcium, all these important things in the process, a healthy diet usually helps tick these off. We're not looking to supplement these straight away. And we wanna go with the food first approach rather than just directly going to a supplement. And also if you are going to a supplement, we wanna make sure that it is confirmed that it is insufficient or you've got a deficiency in one of these metrics that isn't, that can't be ticked off with your adequate or like normal diet. They also talk about omega-3 fatty acids and its process in the inflammation side of things. So they say inflammation is a necessary component of tendon and ligament healing. And they say therefore the goal of nutritional support should not be to aggressively suppress inflammation. Instead a more appropriate framework is to support a timely transition from inflammation towards repair and remodeling. This is where Omega-3 fatty acids come into it. These lipid mediators are involved in regulating the immune activity, and promoting the resolution of inflammation. In this context, omega-3 fatty acids should be viewed less as a non-specific anti-inflammatory agent and more as a nutritional substrate that may support inflammation resolution and recovery environment optimization. In practice, omega-3 intake should be integrated into a broader rehab nutrition strategy rather than treated as a standalone intervention. Dietary resources such as fatty fish may be encouraged and supplementation can be considered when habitual intake is low. Common practical strategies, they recommend approximately two to three grams of omega-3 fatty acids per day that combines EPA and DHA. They do say though that the current evidence remains limited with respect to direct tendon or ligament specific clinical outcomes. But as I mentioned earlier, it plays a pretty vital role in resolving inflammation that just creates a environment, environmental optimization, they call it, for supporting inflammation resolution. And just as a final word, they say finally, rehab nutrition should be individualized and coordinated within the multidisciplinary team. Injury type, surgical status, rehab load, body composition goals, sex specific considerations, dietary preferences and GI tolerance all guide implementation. Nutrition should not replace progressive loading or return to activity or return to sport criteria, but it may help support an individual's capacity to perform rehabilitation and may help support tissue remodeling and may help reduce barriers to a safe and durable return to activity or return to sport. So if I was just capping this off, because on this... in this paper, they've got a nice little table. We're looking at the nutrition strategy, we're looking at energy availability, making sure you're giving yourself enough energy for the body to do the tasks it's willing to do. Protein intake, we're looking at 1.6 to 2.2 grams per kilogram of body weight per day, spread evenly throughout the day. For collagen, we're looking at around about 30 grams of collagen with 50 to 100 milligrams of vitamin C consumed 30 to 60 minutes before adequate tendon loading. When it comes to creatine, we're looking at three to five grams of creatine per day. When it comes to vitamin D, they do talk about bringing your, if deficient, then bringing it back up to sufficient amounts through sunlight and through normal healthy diet. They didn't talk about specifically about how much to take because I guess it just depends on your deficiency. When it comes to calcium, they do say that 1,000 to 1,200 milligrams per day from your dietary sources and or supplementation if your intake is inadequate. And then when it comes to omega-3 fatty acids, we're looking for approximately two to three grams of omega-3s consisting of EPA and DHA daily when dietary intake is insufficient. So other things to consider, consider it's not just all these episodes that I'm doing about make sure you're doing heavier stuff, making sure where increasing the capacity of the tendon. There are other things we can do to help support the process and also keep your body nice and healthy while we are in this rehab phase. Hopefully you've learned a lot. Hopefully you've either confirmed that what you're doing has been on the right track or it's prompted you to reconsider changing your diet of which consult a sports nutritionist first. I think that's a pretty wise move or get your bloods checked to see if you are deficient in anything. and yeah, hopefully you found this episode very valuable. If you are looking for more PhD resources, then check out my website link in the show notes. There you will find my free PhD five day course, other online content and ways you can personally connect with me. Well done for taking an active role in your rehab by listening to content like this and together we can start ticking off all of your rehab goals and finally overcome your PhD.