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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, what to do before and after surgery with Dr Alex Hardy. 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. If the name sounds familiar to you, Alex Hardy was on the podcast. He has been on the podcast before alongside his colleague, Dr. Lefebvre. And today I want to do something slightly differently and dive into the specifics around prehab. Any exercises, do don'ts, precautions. There's a lot of questions around, I strength train? Can I do my cardio? Should I stretch? Should I rest? And then switching gears into the rehab phase. So once you've had your surgery? What are the expectations recovery, appropriate exercises and precautions? Do we need to redo scans? Can we stretch all those sorts of things? And Alex was great at answering all of these hard questions I threw at him. He does talk about his medical background at the start of this interview, but he is a surgeon. He specialises in operating on the hamstring. He operates out of Paris, France, and he's kind enough to share his email at the end of this interview. If you So want to reach out and contact him and his team. But right now let's dive into the specifics about what to do before and after surgery. Alex Hardy, thank you very much for joining me on the podcast today. I'm very happy to be there. Yeah. For those who aren't familiar with you for the first time you are on this podcast, would you mind giving us an update on your medical profession and your day-to-day work? Yeah. So I'm Dr. Hardy, I work in the Clinique du Sport in Paris and I've been doing some hamstring surgery for quite a while now. I've been taught by Dr. Nicolas Lefebvre who's been running a court hamstring surgery for almost 10 years now and we've got about 1,200 people who have had hamstring surgery in our facility. those 10 years. So we are very focused on this specific pathology. So I'm very happy to be on the podcast to discuss it with you. Excellent. And while you are focusing on hamstring tendinopathy and evulsions, there, what sort of procedures are involved in your day to day? Like does it vary a lot in terms of the actual surgery itself? Yeah, for proximal evulsion, it's always the same type of procedure you tend to reattach the proximal tendon. You can do it uh in acute cases, it's pretty easy so you just put some anchors depending on the amount of tendon that uh is available. So if it's a full abversion you tend to put four anchors so we use absorbable anchors and with the needles attached to them to reattach the tendon after freshening the bone to make a a good healing capacity. When there is only uh one tendon that is oval, so either the conjoined tendon or the semimembranosus, we tend to put only two anchors. What can happen when the aversion is chronic is that we're not able to bring it back all the way to the eschym. So we tend to use allograft. We can use a... So the gold standard would be uh Achilles tendon. which we do have in France. The other issue that you can have is uh bony abusions. So we tend to treat chronic bony abusions. So bony abusions are mainly touching kids or adolescents. And so when you're an adult and you have the bony abusions in your youth, you can have big uh bony growth that can be a pain when you sit. So we tend to uh either freshen the bone to fix it or remove the bone and fix the tendon. And the last pathology that we could treat is uh tendeopathy. So we tend to be pretty cautious about the surgery and only do it in case of, uh in case if all of the treatment has failed. So we normally use, we could use a physio shockwave therapy and are conducting currently a study on the PRP injection. So we tend to do them CT guided. And if the PRP injection has failed, we can do surgery. so we'll just, so we will like open the insertion of the hamstring tendon, freshen the bone, remove all the small, chronic little bony part that you can find in the. inflammatory tendon and then fix it back using two or three anchors. You probably don't have the space to put four anchors. One thing I really wanted to spend time on on today's discussion was getting your experience around leading into surgery. So if someone's booked in for surgery, what can be the best steps forward in terms of prehab? And then we'll have a chat about post-op. restrictions and instructions from what you've seen, but we might start off with the prehab side of things. um I get a lot of questions around, do I need to rest? Can I exercise? Can I do my strength training? Can I stretch? um If we have someone who has a hamstring avulsion and is lining up and awaiting surgery, what sort of advice do you provide? around the exercise domain? Well, I guess there is a big difference between chronic and acute. So in an acute cases, I would say maybe avoid uh exercising because you know, we're talking about doing surgery during the first 30 days. So I would say just live a normal life, no stretching or exercise, just do the surgery as soon as you can because As we discussed during the first podcast, I guess it's really, I would say probably the the main message that we should be uh giving people is that in uh hamstring evulsion, there is really like a big question about the timing of surgery. So we do know now that the functional outcome and the rates of rupture are far worse if you have a surgery. later on. So we published a paper in the AGSM giving this cutoff of 32 days. So we tend to operate before those 32 days. And so I would say for an acute cases that you're able to operate between those 32 days, I would say live a normal life, no stretching, no exercise. You you're going to have surgery quick, so it's going to not going to make a big difference. On the other hand, for chronic cases where you get surgery, I would say, after six months and you had your pathology that hasn't been treated for some reason, either uh misdiagnosed, which is pretty common in this type of injury, especially if you have a sonography, which is a terrible exam in this type of injury because it can lead you to wrong diagnosis. uh So in those chronic cases, I can say... to whatever you want, it's not going to make a big difference. You can exercise, stay fit, do whatever you can without having any pain and it's not going to change anything for our surgeons, so might as well keep you uh fit and do your exercise that you're able to do properly. And lastly, for the chronic hamstring tendinopathy, I would say do as much as you can, but try to stay under the guidance of a physio because You know, as I was telling you, uh so for those chronic, uh, hamstring tenopathy surgery is really the last option. So it's a good option, but it's the last option. So if you haven't tried everything before going through surgery, if you can exercise, exercise to whatever you want surgery will always be there to fall for the last try. Have you seen any detriment to someone who says. who like completely rests and maybe deconditions themselves if they have say surgery in, you know, several weeks or maybe even several months. And they say, you know what, I've got surgery booked in. Let me just, you know, drop all my exercises, drop all my activity. And they do get deconditioned in that time. Do you see poorer outcomes? Yeah, I would say that for sure. We currently don't have the data because obviously proximal hemorrhagic aversion are... bit less frequent than what we could see in ACI reconstruction. For example, we do know now that uh pre-habism is one of the main things that you can use to have good outcome after ACI reconstruction. For proximal hamstring evolution, it's more difficult to say. But yeah, for sure, I recently had a patient who had a proximal hamstring evolution and I even treated her acutely. But from the day she had the diagnosis, she rests on her bed, like very scared about what's going to happen to her. And we know that for those anxious patients, everything is going to be far more difficult. They're going to have more pain and that's, you can see it on every surgery that we do. If you're more fearful about the surgery, if there is anxiety, then the pain after the surgery is going to be bigger. So I would say... We can reassure you there is no big risk about doing anything. Surgery is going to come and there is nothing that you can do to worsen the outcome of the surgery. So just live a normal life, exercise as you can and no worries to have on what you can do to your hamstring after it's been evulsed. Great. And I appreciate you answering it in the way of, okay, acute evulsion. chronic avulsion and you know, chronic tendinopathy as well. Cause I understand a lot of these will just depend on the presentation and I should probably clarify. So when you talk about acute, you're talking about someone who was playing sport or did the splits or slipped on ice or had a traumatic incident where they felt a pop up in their hamstring with bruising. And it's just like one instance that managed to cause that that trauma or that evulsion, whereas the chronic evulsion would be someone who may have had a gradual onset of proximal hamstring pain. They just kept doing their activities, sitting got worse, activities got worse, their level of function got worse. And then just gradually over the period of weeks and months, they have a scan and the scan shows that they do have a hamstring evulsion. Would that be fair to say? Yeah, that's fair to say. and that's, think what you're saying is really true. So I would say another message that you can uh put out there for everyone, would say the public, the physio and the doctors and even the surgeons sometimes. So I would say if you do a split, if you uh fall forward doing some water skiing and you feel a pop, which is And I think it's one of the important part, uh bringing you a very intense pain. Sometimes people will faint when they have this type of pain. And then you've got a huge hematoma that appears on the back of your thigh. Then I would say it's probably a proximal hamstring injury. So go and do an MRI as soon as you can and do not go to a sonography that can bring you a reassuring message. but a false message just goes straight to the MRI because you probably have lost your proximal hamstring insertion. yeah, so this is the acute case where you can, I would say, live a normal life and try to avoid exercise for a while, try to seek medical attention as soon as you can. For the second type of patient that you mentioned, you have had hamstring pain for a while. your uncomfortable sitting and you can have also a sciatic irradiation of your pain with the sharp electric pain going down your foot. This has been a symptom for more than six months. You can keep on training and just book an appointment. But there is no rush and there is nothing you can do bad for your hamstring. What's understanding of those who do experience like that shooting pain down the leg into the foot? um What's the mechanisms behind that? Yeah, so that's, that's, would say not so common, but this is honestly, and this is not so good news because what it will tend to reflect is that Probably the ovals tendon has been scarred on the sciatic nerve. So that's a bad news because obviously it's pretty uncomfortable for the patient. But that's a bad news for us surgeons because it will say that you will have to debride and detach the tendon from the sciatic nerve, which can be a bit tricky. Like I would say honestly that if you're a surgeon, And it's not saying that I'm the best surgeon. It's saying if you're a surgeon and you have this type of injury and you're in common with the hamstring pathology, I would say try to avoid to do those cases because you can do uh worse than what it is because it's quite difficult to detach the tendon from the sciatic nerve. So it's definitely the worst case that we treat. nightmare for us. Gotcha. Going back to, you know, for the chronic avulsion, just doing what you want, exercise what you want, because you're going to be having the surgery anyway. I think a lot of fear for people is that it's going to make the avulsion worse or whatever tear they might have, and doing more damage if they were to stretch or if they were to exercise with that damage. Is there a warrant for that? Or Does it just not matter anyway? I don't think there is any one for that. in our experience, when you operate on those guys after six months, the tendon is always caught somewhere, you know, so you're not going to detach the scarring that you've done in six months. So you can do whatever you want. It's not going to change anything for the tendon. would say anatomically, you know, it's not going to move the attachment of the tendon. Honestly, it's possible during the acute case because the tendon is basically floating in the hematoma. So if you stretch it a lot, can probably retract a bit, but in the chronic cases, it's not going to change anything. Gotcha. Okay. Um, are there any specific exercises that someone should do leading into surgery that might better enhance their odds of success or better outcomes, or is it just generic strength and conditioning. It's a good question. I would say uh there is no data to support it, but I would say to keep cardiovascular fit, to keep on exercise, you can do the upper body or everything, but losing your cardio is always a problem in the second part of your rehab. I think you can try, and especially in hamstring tendinopathy, on focusing on eccentric loading and really uh getting... these hamstrings strength back. It's sometimes quite difficult because it will bring pain to the patient, but if you should try to focus on, on, on exercise that will not bring you too much pain, it always good. And, uh, and stretching of course is always good of the hamstrings. So stretching is for me, not a problem, even in chronic cases. Okay. So sort of maintaining my ability by stretching the hamstring. loading up the hamstring with some, you know, specific hamstring exercises and just being guided by pain and symptoms, and then maintaining some cardio in whatever is comfortable for you. So it might even be like swimming with a pool buoy in between your legs. So you're not really kicking too much, but you're, you know, using the cardiovascular system quite drastically. Yes, I would say that. Great. um I had written down here any like precautions that you suggest people awaiting surgery have. We may have covered it because you don't seem too fussed about what people can and can't do, but anything come to mind if we talk about precautions? That's a good question. So I would say... So the main thing is to have a recent MRI. So even if you seek attention from a surgeon or medical doctor, you might have an MRI that has been done six months ago when you ruptured your hamstring and you didn't do surgery for some reason and then you got pain six months on the night. You need to have a new MRI because the situation of your tendon, the situation of your muscle might have changed a lot. That's another issue that we didn't discuss, but it's interesting as well, is that we're currently looking on the amount just for, just like for a tier, we're looking at the amount of amyotrophy and the... fatty degeneration of the muscle that can appear especially in chronic cases and we're currently looking if it has any impact on the functional outcome after the surgery. So that's another thing that you can discuss and to keep uh exercising your hamstrings if you're in chronic cases is that if your muscle is basically resting for six months, then you're going to have a lot of fatty degeneration and a lot of amyotrophy and it's going to be very difficult for you to bring those hamstrings firing again. that's another uh anatomic consideration that you can take into account. So keep exercising those hamstrings in chronic cases because it's going to help you after surgery probably. So apart from a recent MRI, I don't think there is, of course, the question of if you have anticoagulant, that's a big part of preparing the surgery. So if you have anticoagulant, it's important to discuss it quickly with the anesthetist, especially for acute cases, because if you have anticoagulant that will need five days stoppage before surgery, can change a bit the surgical program. But apart from that, no, no real problem for me. If a client consults with you or any surgeon about the possibility of surgery or what the outcomes are like after surgery, or let's just say they're just meeting their surgeon for the first time. Are there some questions you would like them to ask? Are there things that might be useful for them to help guide them and navigate this sort of tricky scenario. So I would say the question that you need to ask are. uh Honestly, it's a bit of an uncomfortable question, but I would ask for the number of surgery that the surgeon does. It can be a tricky surgery. As we mentioned earlier, there is the sciatic nerve that's running pretty close to the tendon. So it's not a main issue in acute cases, but it can be quite tricky in chronic cases. So I would definitely ask the amount of experience that the surgeon has. uh The other thing that is pretty variable in uh surgeons is the postoperative care. So some surgeons will put you in hip splint, some surgeons will put you in a knee splint, some surgeons will put you in no splint. So that's something that you can ask. I'm not saying it needs to be a decision. uh And so if it puts you in a hip splint, it's not like, oh, it's a bad idea, I a knee splint or I need no splint. I don't think it changes anything. There are a few studies that we might discuss afterwards targeting the subject, but we don't have clear data for now. So would say the type of postoperative rehab. And so there is also the question of endoscopic reattachment, which is starting. There are some teams that starting to do it endoscopically. So that's another question that you can ask. I would say that's all. For those who are unfamiliar, because I know there's a lot of technical terms, like an endoscopic reattachment would be sort of not open surgery, not like a big opening there, just more keyhole surgery where they um sort of minimally invasive where they reattach the tendon that way. So yeah, so we'll use a camera and some small instruments with a bit like what we could do in the ACI reconstruction. oh we do only small holes, then the camera will put some water to make some space inside your thigh and we will use the other hole to put inside some small instruments to reassess the hamstring. The only issue with the endoscopic treatment is that it's pretty difficult for uh retracted tendon, so we intend to use it only in a... put some enhancing telepathy or very acute cases with a small amount of retraction. Gotcha. And yeah, I agree. I think it's very important that patients raise the number of patients that are their level of experience. But also if they do, the patient does have symptoms further down the leg and it might indicate there is some sort of sciatic nerve involvement. Definitely raising that with the surgeon and raising their uh information they've heard how complex that scenario can be and what the surgeon's response is to that for addressing that particular scenario. I think ah that could get a good gauge as to the direction people want to move in. So yeah, I appreciate ah that honesty. Is there anything else on the prehab side of things before we switch gears and talk about post-op rehab? oh I don't think so. I think that the issue that we have, especially in France, is sometimes the access to MRI. So there are some regions in France where it's pretty difficult to get an MRI and the average time to get it will be one month and a half or two months. So it's a bit tricky because for those type of injuries, it's an issue. So what we do advise patients from this type of area is just grab a trade. go somewhere else, do the MRI, come back to your hometown. Because once again, the timing of the surgery is such an important matter that you need to find a way to get a proper diagnosis. Okay. With the rehab side of things, do you, I know you mentioned that some people might favor using a splint, like the whole entire leg or maybe just a knee splint. Do you favor doing one or the other or none at all? Or does it depend on the patient, their presentation? Yeah, so historically we've used a pre-standard knee brace, so articulated knee brace. I think that the fact that hamstrings are a B-articular muscle, you've got the opportunity to either lock the hip and the knee or just the hip or just the knee. I would say the knee brace in the markets are probably easier to find than the hip brace. So that's one of the reasons why we moved to knee brace, which are pretty easy to find. And so it's pretty easy to use as well. There are some studies, especially from Australia, that I've seen in recent Congress focusing on using a splint or not using a splint. the study could have... There are some limits with the study that could be underpowered, there is not a lot of patients that are involved. But in the patient that they involved, and I think it was a randomized control trial, so a very strong study, they didn't find any difference in the rate of re-tiered preparing knee brace to no knee brace. So... We haven't changed our post-op yet, but I think it's definitely a vapor to uh keep in mind and to follow in the future to see if there is new studies on the matter. How long would people stay in a knee brace for post-op? So classically what we use in our facility is a knee brace. So we lock the knee brace in extension. So you're lacking extension, meaning you're, you're, you're, you're You can weight-bear but using crutches because if your knee is flexed, your leg is going to be a bit shorter, so it's a bit difficult to weight-bear properly. But you can definitely put some weight on your foot. So we tend to lock it depending on the amount of retraction of the tendon. So if the tendon is far retracted, then we might lock it around, let's say, 60 degrees of lack of extension. But on a normal case, we would go around 40 degrees. And so we do not touch the brace for the first three weeks. And then we will have free 10 degrees of extension every week, starting with three. So normally, when you see the patient in six weeks, you are either in full extension or lacking 30 degrees of extension. And we remove the brace at this time point at six months, six weeks. Six weeks. So are you, can they do any exercise in that time? Can they take the brace off and do some exercise lying down or anything, or is it brace 24 seven? Yeah. So for us, uh, in our experience, we tend to be pretty cautious during those first six weeks. So you can do upper body. can do cardio with the upper body, but we tend to advise the patient. not to remove the brace for these six weeks. So the physio that you can do is mainly focusing on the scar and maybe do some... Drain? Draining? Like a massage and draining? Why we do that is that in our whole cohort, we looked at uh the re-rupture that we witnessed, which is pretty low. It's around 5%, but still, it's a catastrophic uh event because the functional outcome after the re-rate, the re-rupture, sorry, are really not so good. So when you do the surgery, you might want to do it uh correctly the first time. And so what we do is we tend to be very cautious because all the rupture that we witnessed are mainly occurring during this first three months and especially in the acute post-operative phase because that's basically when the tendon is uh healing to the bone. And that's when I would say I'm a big I'm a big rehab guy and love rehab and I'm very happy to discuss with the physio, but that is for me the timing. What I would say just rest, just, you know, a bit like a fracture. would say do not do much with the, with the hamstring rehab during those first six weeks. Okay. And then after that six weeks, what do you advise in terms of returning back to exercise? What would be the best exercises and yeah, any guidelines around that? Yes, so I love, so what I like is first to get the mobility back, so I would say some light stretching. It's not a very uh stiffening uh surgery, uh even when I see patients down the line at six months, 12 months. It's pretty rare to have a lot of lack of motion. It can be a subject when you, when we are talking about distal hamstring evulsion. but for proximal hamstring evulsion, it's pretty uncommon to have a lack of mobility after surgery. stretching is normally pretty easy and the mobility is back quite quickly. I would say around four months, you need to have your full mobility normally. And then when the mobility is back, I quite like some light biking. quite quickly because I like the thing that people are able to move again quite freely. So I do a lot of biking without resistance at the beginning and then move to small resistance. with time, uh, then, uh, we tend to move to, uh, jumping, but I will say around more like around three months and running is normally back at three months and a half or four months. Okay. Do you have any favorite like strengthening exercises for that area once the brace comes off? Yeah. So strengthening exercise. So especially if I had the hamstring, um, the most difficult part is to gain, I would say the strength in the between 120 degrees of flexion and 90 degrees of flexion. How do you call that in English? I guess it's, yeah, it's like most people are familiar with like a right angle. like, you know, 90 degrees flexion, most people are familiar with that, but just, I guess the 120 would be slightly more bent. Yeah, so I would say that it's difficult to have the strengthening uh after 90 degrees of flexion. So when you test the hamstring, what we witness is that normally people will tend to be able to resist more easily after 90 degrees of flexion. So I would say try to not miss the lack of power that they can have after 90 degrees of flexion. So at the beginning of the strength training, I will tend to use a uh close kinetic chain. But after a while, open kinetic chains are OK. And you can also do eccentric loading, which is more efficient to bring back the muscle strength. But it's also more at risk for the tendon reattachment. So I will tend to delay it a bit. OK. So when we're talking about clothes chain exercises, we're talking about sort of the foot planted or fixated on the ground somewhere. So there's a bit more of a stable surface. so like that's where glute bridges would come into it, or maybe they might be doing a glute bridge, but feet are on a ball and then they're curling the ball towards it. guess it's kind of semi closed chain, but the open chain exercises would be like a hamstring curl where they're lying on their stomach, there's a band attached to their ankle and they're sort of curling the leg towards them. So that would be more open chain, which you'd recommend sort of in the latter half of the rehab. uh That's putting more, I would say more tension on the reattachment. I would tend to do it later on in the rehab phase. Gotcha. Okay, so would glue bridges or say like a Swiss ball hamstring curl, would they be appropriate exercises? Yeah. would say if you're doing under the guidance of a physio, that's, that's probably okay for me. Okay. Great. And then just emphasizing that because some of the strength and power is hard to regain in when the knee is more bent than so if someone is doing say a hamstring curl on a Swiss ball, just, guess, having more of a conscious effort to curl all the way towards them so that you're getting more of that hamstring activation in those deeper ranges of movement, you could say. Yeah, I would say that. And also for open kinetic chain, I tend to use a lot of the Nordic hamstring, which is a pretty difficult exercise that you can modulate depending on the amount of strength that you have. that's for me, of my favorites. Great. And so the Nordic exercise most people are familiar with where they drop down when they anchor their ankles to the ground and they sort of lower their body, but can be modified with, you you've seen some people with power bands or resistance bands that sort of control their descent. I've seen some of my favorites is like having a Swiss ball in front of you that you can put your hands on and you just roll the ball out in front of you to help assist that lowering as well. um And so, yep, the Nordic exercise is a good one. um Any others? oh I would say uh swimming is quite nice for me, then running of course is going to help. uh So for the, we were talking about the last degrees of flexion, so you will witness those lack of strength in sprinting especially, when you go all the way through the flexion. So if you don't have proper strength in the last degrees of flexion, it's going to be a problem for sprinting. So that's one thing I want to focus on. One of the exercises that's a, like one of my favorites would be like a deadlift, um just trying to engage and activate the upper hamstring and engage some sort of tendon compression to the, sit bone area. um Is that a worry post-op that that would be a closed chain exercise, but that would entail a lot more compression of the tendon. And I guess challenging that attachment site um any thoughts or opinions on that exercise? Let's say I wouldn't do it right away after the removal of the brace. But yeah, so I would say after three months is okay for me. great. Yep, just starting off with kind of lighter, more conservative starts, reduced range of movement. And then if you find that symptoms are tolerated and everything feels okay, then just slowly progress those exercises. Yeah, exactly. Exactly. And you need to follow you guys, the, the, physio, they know all about this, but you know, you need to focus on the pain that the patient will witness during the exercise and try to adapt the load that you would bring to the hamstring attachment, depending on the reaction of patient. Yep. Is there any warrant for like re-scanning someone? if, provided that they're absent of like a big traumatic re tear or something like that. Um, is it within common practice to, to rescan them after an operation just to see how it's healing? So we tend to do that. We tend to use a systematic MRI. We do not do it anymore because obviously it's a lot of money for the patient and for the society. we don't do it normally. So I would do an MRI for two reasons. First, you feel another pop. which is normally patients will feel it. know, there is like, it's basically looking like the first injury. So that's the first reason. The second reason will be people still having sitting pain after six months or in proximal hypsomotal neuropathy, still witnessing a lot of pain in eccentric exercise or whatsoever. So those are the two reasons that we would get a post-operative monitor. Okay. So if pain persists beyond six months after operation, being with sitting or exercise, um you would consider rescaning and seeing what the area is like. But then if at any stage there's an incidence where they notice a pop like similar to what they had initially, you just MRI that straight away? Yeah, for sure. Okay, great. Any other mistakes that you might see someone make? when it comes to navigating the post-op minefield. So I would say that using the knee brace, it's pretty difficult to, uh, to. walk. The main reason we had re- rupture were people basically using crutches and walking on something slippery and then they just do another sprint and what you need to keep in mind is that of course the knee brace is protecting the reattachment but if you go in a full hip extension like if you do a sprint with the knee brace can still be a problem so I would say when you're uh walking by with the crutches, keep in mind that the slippery floor are a danger for you. And we have like, I would say 10 or 15 cases of the exact same injury. Wow. Okay. Any advice for someone who feels like their recovery isn't quite going as smoothly as they indicated, or as the surgeon may have indicated, um, let's just say it's less than six months because as you recommended, if pain persists beyond six months, it's probably warranted for another scan. But let's just say they're three or four months in and they're not recovering as well as I think they should or could have always, you know, um, talked about any advice for them. Yeah, I would say there is two very different cases. I would say for chronic cases, uh, recovery is much longer. So I would say do not worry and just, you Trust the process and see at six months how it's going. For an acute cases, I would say normally at three months you're able to walk normally. If you're not able to walk normally and you're still limping, that's probably something to worry about and maybe discuss it with either your physio, your doctor or the surgeon. And you might want to discuss to do it before that. The other symptoms that you need to keep in mind is if you have some sciatic uh irritation, meaning you have some pain going down your leg. This is also a big worry for me. So I would definitely seek medical attention right away and not wait for those six months. Okay, gotcha. Any other final takeaways? Anything we may not have discussed um based on preop post op? but also within your given research as well. Anything else you might find the audience might find useful? Yeah. So I would say, uh, to message, uh, I would say if you, uh, feel what we've discussed, meaning the pop in the back of your leg, big pain, big hematoma on the poster aspect of your thigh, seek medical attention right away. Do an MRI right away. do not do a sonography. So that would be the first message. And second message is uh if you do have this type of injury, keep in mind that if you have surgery quite quickly, the rate of return to sports are pretty high. So if you have surgery with an experienced surgeon, you might have some very good outcomes. So do not think or do not be too sad your sporting career is not over. Great. All right. um If people want to contact you and your team, if they're interested in a consult and maybe eventually surgery, what advice do you have for them? Where can they go? So uh we do have a, well, I have an email address that you can get in contact with, is dr.hardy. uh Chirurgie du sport, but I will write it to you.com. There are plenty of infos on this type of surgery on our website. And so you can get in contact with me and I'll be happy to assist you in the consultation or even surgery if you want to. But we do receive people from all around Europe, so it's pretty easy for us to organize. But the first thing is to get a proper diagnosis once again. All right. Great message. Great takeaways there. And I will be sure to leave that email within the show notes so people can find it easily. um And yeah, second appearance on the podcast. Thank you very much again for coming on your expertise and not only expertise in this area, but your commitment to conducting research and learning more about these outcomes is really good. So uh yeah, thanks again for coming onto the podcast and sharing. Thank you very much. oh If you are looking for more PhD resources, then check out my website link in the show notes. There you will find my free PhD 5-day course, other online content and ways you can personally connect with me, 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, and together we can start ticking off all of your rehab goals and finally overcome Ph.D.