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Proximal Hamstring Tendinopathy is a horrible condition affecting athletes and non-athletes alike. If you fall victim to the misguided information that is circulating the internet, symptoms can persist for months, sometimes years and start impacting your everyday life.
This podcast is for those looking for clear, evidence-based guidance to overcome Proximal Hamstring Tendinopathy. Hosted by Brodie Sharpe, an experienced physiotherapist and content creator, this podcast aims to provide you with the clarity & control you desperately need.
Each episode brings you one step closer to finally overcoming your proximal hamstring tendinopathy. With solo episodes by Brodie, success stories from past sufferers and professional interviews from physiotherapists, coaches, researchers and other health professionals so you get world class content.
Tune in from episode #1 to reap the full benefits and let's get your rehabilitation back on track!
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On today's episode, we have another PHT Q &A. 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. Thank you to all who have replied to my shout out to submit some questions. For those who are unaware or who didn't get notified, I've just been blasting my email audience. Those are people who have subscribed or signed up to the PHT five day course, which is a free five day email sequence. They jump onto the list or if you have... purchased anything from me. Usually you get tagged about being in my PhD audience and obviously unsubscribe at any time if you don't like my emails but particularly using them at the moment to notify people of these questions but also if I release other content like my YouTube videos, putting in more effort on the overcoming PhD YouTube channel and yeah when a video does get released I like to let my email audience know to go to that straight away. Um, so yeah, I did, uh, reach out, I think we're up to about two and a half thousand people on my PhD email list. So, um, as you can imagine the influx of replies, uh, quite substantial. so typically I try to answer about four to five questions here and that covers a nice episode, but the influx of questions. know I did say in that email first come first served. What I have done is ask Chach-ebt to go through my inbox in the first two days of me releasing that request for questions and to sort of condense it all down, synthesize it in a particular way and put together the questions. so apologies if I don't know maybe Chach-ebt is like to slightly tweaked how your question was formed or the context that it gave. But if you look through the volume of responses I got, but also how long some of the emails are, some of them are pages long, you know, discussing detail and the unique circumstances that surround the question, it's just impossible to kind of manage and put together in an episode. bear with me while I tried my efforts just to condense it all and apologies if. I didn't get to your question just purely based on the volume of responses I got. But also apologies in advance if the context of your question is just slightly misplaced, just because I've had to automate a lot of the processes to get this out to you. But like I said, I typically try to answer four to five questions. going my I'm gonna put this into like a two part up, but I'm going to try to attempt 12 questions on this one. maybe a bit shorter, maybe a bit concise, but just like straight to the point. And hopefully you see a lot of value in just answering as many questions as possible as like I say, the volume is quite high and just trying to keep up with the demand. this topic is more about rehab, more about loading, more about return to sport. And next episode is covering more to do with more complex scenarios, something that's a bit more chronic and why isn't my PhD getting better that is kind of like a bit more of a general theme. All right, let's dive into the questions. Miles says, how long should I do isometrics and strength training before I can start running again? I don't necessarily have a benchmark. What I try to do when I work with clients is sort of you gather a whole bunch of data points based on what your running history is like, what your general strength is like, definitely like the irritability of the tendon. And when I say irritability, I mean like, how much does it take to really set it off? And then once it is set off, how long does it persist for? And how long you've had off running. And so it's hard to come up with a really tangible, you need to do this amount of weight, or you need to do these amount of isometrics and you're ready to running. It's not clean cut like that. What I can do is try to help out with some baseline tests and maybe just some case scenarios. like, let's just say for example, Someone comes to me with PhD. They said, all right, six weeks ago, I was marathon training. I was getting into my volume. I guess I kind of peak week of my marathon training. And this is when the PhD started coming on or I had a flare up and I haven't ran since. So it's been six weeks of no running. It's calmed down. I'm not doing any strength training, but my symptoms are back down to like a mild one or two out of 10. I would say, yeah, let's start running. Let's absolutely let's start running. will start very slow, as in like the speed will be slow. But this is a case where someone's obviously got a good history of running, building up sort of like marathon volume and time off. Sure, we'd probably start off with 20 minutes of continuous really slow running. But symptoms seem quite stable. And yeah, we don't need to do any strength like just for me to test just for me to give it a go. Obviously. If I was working for them to rehab this tendon, I would do strength training with them. But this is not necessarily a benchmark of being like, let's add in strength training. Let's get your deadlifts up to 50 kilos and then we can start running. I reckon they'd be able to tolerate running straight from the get go. Whereas like another case would be someone who's done. Maybe they've had a flare up during their marathon training, but that was two years ago and they haven't returned to running since because it's been super irritable ever since any return to running. has flared them up, sitting at the moment for more than five minutes irritates them. They've tried progressing their deadlifts from one quarter range of movement to half range of movement, and that's caused a flare up. That is a completely different scenario and what we would, what I would sort of deem more irritable, not really tolerating any strength and a lot of long time off running. And so yeah, I would say, you know what, based on setting some priorities, I would say let's try to get the right amount of isometrics, the right amount of strength training, let's see what sort of load you can tolerate in the gym, rather than sprinkling in some running and just seeing what's tolerated because my guess is even just like one minute of running, two minutes of walking done five times might still be too risky. And so obviously they're kind of two extremes, but you can see where I'm getting from just gathering a whole bunch of data to be like, what do we think? Do we think we're stable enough to at least attempt some running or not? But I always return to running with a conservative start. So if someone thinks they can dive straight into say 30 minutes of running, I'd say, you know what, I agree with you, but let's start with 15. Or they're saying, oh, my slow run pace is typically like eight and a half. I'd say, yeah, probably, but let's start at nine and a half. I don't like people just trying to hit their mark, trying to hit their sweet spot on the get go, sort of going in blind and being like, this is where I think my adaptation zone is. And then they overdo it and it flares them up and then they're discouraged to ever start again. I just like to dip our toes into it. Just dip our toes into a little bit, slower than you think, shorter than you like. And then let's just know that you can tolerate that. And then let's just slowly. progress those variables. And so that's how I like to do it. When I am more uncertain, I go more conservative. So if there's very, very few data points, so we're not entirely sure about the running, haven't ran for a long time, but things are quite stable. It seems like there's low irritability, there's no strength and no cardio data points to draw from. I say, okay, we can try some running, but. there's a lot of uncertainty around here because we don't have a lot of evidence to suggest you might be able to tolerate something. So let's just do 30 seconds on. When I say on like a 30 second slow jog, followed by a three minute walk. Let's just do that four times. Off you go. Just keep it flat, keep it slow. And like I say, just dip our toes into it. If that's easily tolerated symptoms, absolutely unaffected. Okay, let's do a little bit more next time. And let's just build that up from there. In some cases, if I was to really come up with some sort of benchmark, not necessarily for PhD, but it might be jogging on the spot. It's all right. Let's do three rounds of jogging on the spot for 30 seconds, have a two minute break in between. And let's just see how that feels. If that's okay, maybe we can convert that 30 seconds of jogging on the spot to 30 seconds of forward momentum, i.e. jogging. And let's just see if that's successful. And if it is successful. let's just gradually rebuild. And what that rebuild looks like, doesn't need to make a whole lot of sense if on paper, it's very sensible. It could be volume, it could be doing less walking, could be doing more running, not speed just yet, but just like building out either more intervals or longer intervals or less walking. Whatever that next step that makes sense for you is the direction I like to go. I have my own particular. walk run progression charts, which I'll talk about in a second in later questions, but the concept is there and hopefully you understand that. Danny has in context, well, the summarized context says, rehab is going well. The strength work is pain free during and the following day, but increasing running load still causes a one to two day flare up. So Danny's question, how do I progress strength beyond simply being pain free. So my tendon capacity eventually keeps the pace with my running load. So we have a case here where strength training is going well pain free, but any increase in load causes this flare up of one to two days. I would say yes, we want to just keep progressing the strength. You're obviously tolerating that. That's the cornerstone of tendon healing. So just keep progressing that if that's going resoundingly well. But similar to the last question, it's not exactly of, okay, what can I do in my strength work to tolerate more running? That will just come naturally. But my focus would be more on why, what are these jumps you're making in the running that's causing a flare up? Like you're saying, okay, I increased my running load and that causes a one to two day flare up. What was your run prior to that that didn't cause a flare up and how big was that jump in progression? Write it down on paper and be like, okay, I could tolerate this. I couldn't tolerate this. Let me have the one to two days to let things settle down. Let me just take what I did tolerate, stay there for a few more attempts and let me just create a smaller, shorter jump to like bridge maybe like two or three steps in between what the jump that I previously made that was tolerated. towards tolerated and not tolerated. And this is what we do all the time with physio. If I had someone progress their deadlifts from 10 kilos to 12 kilos, and that caused an increase in symptoms. Okay, settle back down, wait for symptoms to get back down. Let's go back to the session that was tolerated. And let's just expand it out from that 10 to 12. Let's just do two sets of 10 and only one set of 12. Or maybe let's do two sets of 10. and one set of 11. And then let's come up with even smaller steps, because we know we're closer to your ceiling or we're closer to your capacity. Let's just find out additional steps. Let's be more creative just below that capacity line so we can foster that adaptation more often. And so that's exactly what we need to do with the running. And so once settled, we go back to the drawing board. My advice is just like keep everything really, really slow. If you're noticing that you're particularly vulnerable to an increase in load, you'll be surprised if you just take 30 seconds off your pace, how much more volume you can actually tolerate. But some additional options for you Danny would be shorter, like I say, smaller increases. But if it is a volume build that caused the flare up, you can finish the run with like a walk run interval. So let's just say you could tolerate three miles, you've gone, you ran three miles and that was tolerated, then you ran four miles and that flared you up. Let's go back to the three miles, but then let's do that three miles and then finish with a one minute run, one minute walk and do that five times. Maybe that's an option that you haven't yet considered. Another option would just be having more successful attempts at the previous level before making a progression. So instead of progressing every single run, You could say, all right, I do know I need to make smaller steps in terms of progressions, but let me wait until I've had two to three successful attempts at one stage before then progressing to the next phase. That could be done, especially if you found you're particularly vulnerable to increases in load, especially with the running. And just some advice is to keep all other variables exactly the same. So make sure we're not adding in hills as soon as you add in like an extra mile on the backend. make sure we're wearing the same shoes, obviously make sure we're keeping to the same speed. So make sure all other variables are considered so that we're knowing that any small jumps that leads to a flare up is an accurate data point. Sandy had several questions. So I'll list out all the questions and I'll answer them one by one. She says, what would an ideal strength slash cardio routine look like during PhD recovery? How would you progress? How would you progressively advance it over? eight to 12 weeks without continuously, continuously exceeding tender capacity. And when progressing walking, should I increase the duration, the speed or incline first? Okay, let me start off by saying, I think this is where my online course, the PhD blueprint would come in really handy. Because my, my answer is it's going to depend like what's an ideal strength cardio routine? What does that look like? It It depends on your fitness background. It depends on what goals you have. It depends on what cardio actually is. And then what your strength background is like, how heavy are the exercises? If we're talking about 60 kilogram deadlifts, there's completely different scenario from someone who can only tolerate five kilogram deadlifts. So the frequency of the strength will vary very greatly. But the online course that I do have helping people guide people through building out their own programs will address all of those individual scenarios. If you can't lift heavy, this would be a typical week. If you can lift heavy, this would be a typical week. If these are your goals, your running goals, your cycling goals. I have recently put in case studies, which people have found really helpful. The feedback has been great. And so it goes through like a cyclist building out there. progression charts and what their weekly structure looks like. Someone who's just starting running, someone who's like a very experienced runner, all that sort of stuff. I've been very excited to see that over a hundred people have signed up for this PhD online course. It's just self guided, self paced, building all things out and all that content yourself. So Sandy, if you haven't signed up yet, that might be really, really helpful. And I'm getting a bit nervous to answer something like this, but I will say generically. A very, very common weekly structure would be strength training two to three times a week. If it is, but we just want to make sure we space that out. So if you are doing strength training twice a week, you're separated out by about three days. So it might be like a Monday, Thursday. If it's cardio, maybe cardio two to three times a week. So maybe not on those strength days. If the cardio is three to four times, then one of those days will have to be strength and cardio. And then we sprinkle in one to two rest days, but Again, I'm like kind of cringing answering it like that because I know I could give that advice to someone and 20 % of you I'm under loading you 20 % of you I'm overloading you and so 40 % of the people that follow that answer are going to be mad at me. So like, it really just depends context really matters getting a detailed history of your fitness, your strength, your symptoms, your goals, all of that is factored into building out the most effective weekly structure. So just don't come at me, just really disrespect that this is unsolicited advice. This is just like a very, very generic common response that I do have. so, yeah, bear that with me. Okay, Sandy's other question was, how would you progressively advance it over eight to 12 weeks without exceeding tender capacity? Similar to what I've answered those other previous questions, just do so very conservatively, like. we can only let symptoms be our guide in terms of are we tolerating this load or not. If I am doing a four week build, if I have been slowly building for the last four weeks and I'm starting to get a little bit sore, maybe I require a deload week. However, I'm still feeling fresh and motivated and symptoms aren't increasing. Maybe I can push on, but each and every step, each and every progression, whether that's in cardio, running, strength, We need to follow those symptoms. We need to follow that symptoms during are just mild, typically less than a four out of 10 during, returns to baseline by the next morning. If that's all okay, we're putting that on repeat. And best case scenario, if symptoms are improving week by week or every two weeks, despite us doing slightly more, that is absolutely gold standard. That is what we are striving for in every single scenario. Might not pan out that way and adjustments might need to be made, but that's what we're looking. towards. Sandy's last part of the question when progressing walking, should I increase the duration or speed or the incline first? There's no right or wrong. There's just safe. We're just like, there's just ways to mitigate risk a little bit more. My preference is always to bump up the endurance first because that's going to be low intensity. It's going to be slow. If we bump that up from 20 minutes to 3040 up to 60 minutes. creating our base. So that's why I prefer the slower stuff first, let's create the base of the pyramid. After that, I would say then speed would be the next variable. It might be 10 minutes out of that 60 minutes being slightly faster. And then we're just building that out. The last variable I'd say is the incline, only because the incline is a lot tougher to measure. So like it's the the rate of the incline. how long that incline is, how fast we're going up that incline. They're very, very hard to dial in. Whereas speed, I can say, yep, let me increase from this speed to that speed. Let's just say it's on a treadmill. I've got, you know, I'm walking 5Ks per hour. I'll bump it up to 6Ks per hour for 60 seconds. And then I'll go back down. Like that is incredibly precise. But the incline, I suppose if you're on a treadmill, it'd be easier with the incline. But just like out hiking per se is a little bit trickier. So that's where my preferences lie when it comes to changing up variables. I was happy to read this question from Sarah because I hadn't really got this one before. Sarah says, how do weighted step-ups actually help the hamstring? Are they an alternative to deadlifts or are they an additional exercise? Should I go heavy as possible or prioritise form? And is there any PhD specific technique considerations? All right, let's dissect this one by one. How do weighted step ups actually help the hamstring? I would say indirectly for most part of that movement, it isn't really a hamstring exercise. However, it is a single leg variation that I like very much because if you've looked at my other exercises, we're looking at hamstring curls, which could be double leg or single leg, I guess, but it's more like an open chain, which means like the foot is kind of free moving. Deadlift is double leg and closed chain. it's fixated, the feet are fixated to the ground and we're doing double leg. And then we have my third option, which are the step ups or lunges, one or the other. And that is closed chain, single leg stuff. You might find this like kind of mild, minor to moderate compression in the upper hamstring when you do a weighted step up pending the height of the box. I know when I do lunges and I do weighted step ups, if I do it hard enough, heavy enough that I do get doms. I do get doms in my upper hamstrings when I do my step ups. I don't really get doms anywhere else. So like it is, that's proof that is loading that area. In addition to that, it does work the glutes and quads really nice. So like when we do strength and conditioning and rehab, it is nice to work other muscle groups as well. So it does hit the upper hamstring a little bit. The higher the box, the more compression the tendon will be under, but a nice exercise to work the other muscles that is also single leg. So for those several reasons, I like to keep it in. It's not very, very high on the list. Deadlifts, obviously number one. Hamstring curls are probably number two. And then I'd say that single leg variation would be number three for most people. So to answer your question as is it... an alternative to deadlifts or an additional exercise? Absolutely, it's in addition. You will be doing your deadlifts as a part of your rehab. Should you go heavier or prioritized form? In terms of dosage, I'll typically say three sets of six on each side for your step ups or lunges. For the step ups, the box height should be about half shin height or three quarter shin height, somewhere in between there. I have most people starting off at half shin height. So the box height is halfway between the ground and your knee. But then we can progress to three quarters shin height if you feel it's tolerated. And then gradually progress the weight. However, you do need to make sure that your back leg isn't springing you up. And I a drill this into people technique wise, just making sure all the weight is being pushed through that front foot. That's where the focus should lie. And I see a lot of people. Progress go heavier and heavier and heavier, but as they go heavier and heavier, they just push off more and more for the back leg and it's just like defeating the purpose. So yes, progress the weight, but make sure you're not pushing off the back leg. And lastly, any PhD specific technique considerations. Slightly, I would say when you're pushing through your step up, you can press a bit more through the heel rather than the mid foot or the toes that would, I guess, recruit a little bit more of the upper hamstring. On a similar note, Rob asks, are heavy machine hamstring curls useful for recovering for chronic high hamstring tendon pain? I would say yes, like your hamstring curls aren't as potent as the deadlift as I answered before. Hamstring curls are number two on my list. It works the entire hamstring unit. It doesn't bias the upper hamstring. So while the deadlifts provide a technique is adequate, will bias the upper hamstring. I can't think of any other exercise, actually I can, I'll answer that later, mimics, targets, loads the upper hamstring quite like the deadlift. However, it is nice for tendon rehab to strengthen the whole entire unit, the tendon muscle unit, and hamstring curls do a good job of that. So bear that in mind, it just makes the whole unit more robust. I prefer prone, so lying on your stomach and doing a hamstring curl. However, a seated hamstring curl in a gym is always a good next best option. Cause I know some gyms don't have prone hamstring curls. So I hope that answers your question, Rob. Richard for context, his PhD improved considerably while strength training in the gym two or three times a week, then regressed when that routine changed. And his question is, can Nordic curl straps? or a home-based exercise provide enough loading for PhD, particularly when you don't have regular gym access. So it won't be as good. Home setups, a provider that you don't have like a squat rack that we can do heavy barbell deadlifts or something. The home setup, I'm doubtful it can get enough load, like quite like a gym setup. However, we can try to get close. I have recently done a YouTube video on this. Like I said, I've tried to be more active on YouTube with the PhD specific stuff. I did a video titled how to rehab PhD without a gym. And so if you wanted to search that, remember to add that link to this video in the show notes. I talked through a Nordic hip dip, which you set it up like a Nordic drop. So if you have the that the Nordic bar that slides underneath the door and you can secure your ankles in place. It's kind of like a Nordic drop except you're dipping at the hips, keeping the thighs completely vertical. And that loads the upper hamstring almost like a deadlift would. And then we can progress through the range, we can progress with weight, we can hold on to like a plate or like a dumbbell at your chest as you dip forward. That is the next best option if you don't have the gym, that's what I would be doing if I didn't have a gym membership. and I wasn't doing heavy deadlifts but wanted to preserve the load through the upper hamstring. So go check out that video, hopefully you find it helpful. Next we have Helen and for context, Helen previously recovered from chronic PhD for about two years. More recently, she had a partial patellar tendon tear on the opposite side. Her return to running involved shorter, faster running and uphill strides to reduce the load on the knee, but her PhD has returned. She can currently run easy 40 minutes, three times a week and deadlift with 15 kilos in each hand, but prone hamstring curls are still difficult. And so her question, how should I progress from easy running back to toward faster five to 10 K running without deteriorating the PhD? Should I be introducing strides even though I still have significant aching with walking and sitting? So for those who aren't familiar, strides are like shorter, bouts of running where you sort of start off quite slow and you accelerate for the first 10 seconds, leaving the after 10 seconds you sort of reach your top desired speed, typically around 90 % of your maximum sprint and you hold that for about 10 seconds followed by a five second deceleration phase. So it's not necessarily a hundred meter sprint, but it's a slow acceleration, maintaining a speed at certain period of time and then tapering off. So that's what strides typically is. What I would recommend, Helen, if you haven't come across the PHT online course, check that out because I do have how to introduce speed safely. There are certain criteria and things that I do like to follow. And so I'll give it a brief overview now, but if you did want to go into more detail, I highly recommend that course. So typically I'll say you can start with starting strides as the first entry level, dipping your toes into some speed. It is faster stuff, but it is very brief, you could say. And I'll typically do phase one of strides. Once you're tolerating about 20 to 30 minutes of easy running, which I think that's you. However, your last part of that conversation or the question kind of concerned me when you said you still have significant aching when walking and sitting. So I'm a bit unsure whether you are actually tolerating what you're currently doing but if symptoms are stable and settled then you know if you're doing 40 minute bouts of running then potentially we could dip our toes into some strides of which what I do personally phase one of strides would be doing four repeats so four strides at 75 % of your maximum sprint so you accelerate you reach 75 % or thereabouts of your maximum sprint for 10 seconds, then you decelerate. Typically say 75 % is fast, but you feel like you've got two accelerations still left in you, you can still go two gears up. That's what that session would do. We'd see how symptoms behave. If that's okay, the following week or the following time strides come up, we'd do a little bit more. And like I say, the online course talks through progressions through that chart and... Typically, I'll say once we get to phase four of strides, that's when we can start phase one of intervals on a different day. So you'd be doing strides on one day, you'd be doing intervals another day, and that would be 20 minutes, 30 minutes of just a nice, easy warmup, followed by phase one is a one minute effort, followed by a one minute recovery jog, and you do that five times. And that one minute effort is around about a six out of 10 RPE. That's what I typically do for phase one of intervals. And so that's where we need to fall back to what is RPE, what is a six out of 10. It's kind of like a borderline tempo, of comfortable, the borderline between comfortable and uncomfortable, I'd say you can kind of hold that pace or you have the sense that you can hold that pace for 20 minutes. But as we say, within this session, we're only holding it for one minute efforts, one minute jog, doing that five times. And then we progress through that chart. And once we get to maybe phase four of intervals, which are typically about three minute efforts of I think it's like a seven or an eight RPE, then we can say, all right, it's looking like the tendons quite robust to different types of speed. We've got this strides, which are the really, really short, really, really fast stuff. And the intervals, which are not as fast, but still efforts of the two to three minutes range. Maybe we do dip our toes and seeing how a six minute effort goes. That might be a 1K effort. And then we just slowly program towards that so that it looks like it's meeting your goals, which is a faster 5K or faster 10K. So we're slowly building out the foundation. We're sort of getting the right components, seeing how symptoms behave in those challenging moments. And then if tolerated, we slowly progress. So that's typically what speed looks like for me. That's just what I've... gravitated towards over the years of working with people with PhD, but any other direction is totally fine, but just needs to be sensible and we wanna make sure that symptoms are agreeing with you. So just bear that in mind, but I hope that example is helpful. Mintu asked a question, for context, not primarily a runner, but has responded well to the PhD Strength Program and wants to return to sprint training. So the question, how should sprint training be introduced and progressed after PHT? I put this following the other because it's similar to strides. I would start with strides. I'd continue with that benchmark of saying, okay, let's dip our toes into phase one of strides and progress through that, either increasing the amount of repeats that you do with the strides or increasing the intensity, just change one variable at a time. But then it might move slightly more towards whatever your unique goals are because I don't know what sprint training looks like in your eyes, Min-Too. yeah, just sort of casually manipulate the variables. It would be nice to have some slower running as the base of a pyramid, unless you wanted to do some heavy strength training in the gym, followed by some plyometrics in the gym. That might be plyo lunges, that might be box jumps, that might be a sled push or... something that's introducing a bit of power and then you do your strides. So just trying to bridge the gap to meet the demands of strides in the gym. If you didn't want to do the 30 minutes of slow running and seeing if that's tolerated as the benchmark to then add in strides. a bit more, yeah, context-based, but also like kettlebell swings would be a nice plyometric power, not necessarily. plyometric but a power-based exercise that does stimulate the upper hamstring. That could be a nice test if you're doing kettlebell swings quite heavy, a fair few, and tolerating that well, then we'd probably dip our toes into some sprint training without necessarily seeing if the slow, easy running is tolerated. Caitlin said, what exercises slash training should I focus on if I'm preparing for high rocks while still managing persistent PHT? I don't know how many people are familiar, but I am also training for high rocks races have been so for the last three years and got my next one coming up in December. I wish more people asked high rocks based questions. If you're not familiar with high rocks, is a event that requires eight rounds of a one K run. And in between those eight one K runs are workout stations involving ski orgs, sled pushers, sled pools, wall balls. row ask a all that sort of stuff. And so my answer would be, well, if you go back to about a year ago, I was actually managing a PhD flare up while preparing for my high rocks race and managed to tick off both tasks I managed to build upon my fitness and get to the start line symptom free while battling managing recovering from a PhD flare up. for the two months leading into the high rocks race. So I managed to do both. It did take a lot of careful planning, but Caitlin, I'm too sure how persistent and irritated your PhD is. what I would suggest is just keep the running really slow. If don't know how far away race day is, don't know how irritated it is to running, but the faster running would probably be the. most riskiest variable in your training, I would say. So to mitigate some risks, I would say keep the running really slow. And if you do want to try to do speed, just make sure it's extremely gradual, extremely systematic and methodical when layering that in. But you can go harder on the ergs. This is what I've done in the past. And what I continue to do for my sort of harder training days, rather than running hard and risking a lot. I do still run hard, but just very short bouts. But my hard days are very hard on the ergs. So like the ski erg, assault bike, the rower, those sorts of things are something that I particularly are fond of to get my heart rate high and not really risk the loads accumulated with running. So trial and error with the ergs because for example, like the rower sitting down and sort of compressing the tendon could irritate but doesn't irritate some. What I would say is if it is irritated on the rower, don't, just typically avoid sort of the deeper ranges of flexion. So like after you row and return back to the start, just don't return all the way back and sort of keep to those outer ranges. Same with a Ski-Og. Ski-Og should typically be okay, can go pretty hard with that. If it does irritate, again, avoid deeper ranges, kind of like that hinge movement. Wall balls, again, wall balls would be okay, but if you find they're irritating, avoid deeper ranges. And as we get closer and closer to race day, you might wanna slowly work in some deeper ranges to see if it's tolerated. But while we're training and sort of building strength and fitness, that is, you'd be totally fine mitigating the risks by still build a lot of strength and a lot of fitness just by taking say 15 % off your end of range, but. Yeah, closer to race day, you might want to try to work on the range and see if that's tolerated. Find your tolerance with the lunges. If my PhD has been totally fine with lunges in the past. So if you find that is irritating, you can instead of doing walking lunges, you can do step lunges, but reduce the range. So you step forward, do a lunge and then step back to the starting point. But when you step and lunge down, you step down to like a foam pad or a foam roller or a Pilates box or a yoga block or something that's a couple of inches off the ground so that reduces the range and that would reduce the tension on the upper hamstring. But everything else, think burpees, sleds, the pharma, carries, all of that typically should be fine based on what we know about load through the hamstring. But be creative with it. One thing I love about Hi-Rox races is that Despite my various injuries, can, there's plenty of things that you can still modify and work on plenty of other stations you can still work on and you can still be incredibly proactive and build on upon your fitness because you've got so many options while concurrently managing and recovering from an injury. So hopefully you found that okay, Caitlin, if you need help with rebuilding that and helping you get to race day, I'd be more than happy to work together. yeah, I'd like to work on. and with more high rocks athletes. So let me know if you need assistance. Number 10, we have Gil who says his PhD seemingly appeared without an obvious precipitating injury. So his question would be what criteria can tell me I'm ready to return to racquetball? What factors determine a yes or a no? Similar about the return to running, except sports are a bit trickier because they're a bit more unpredictable. Like when it comes to running, we can dial in the variables really nice. We can say, all right, run this distance or this time with this speed, this terrain, keep it flat, like go there. We've got that systematically down pat. But with things like racquetball, pickleball, tennis, even like team sports, it's extremely hard to say, okay, go out there and only do 10 repetitions, only do that for 10 minutes at 15 lunges and that sort of stuff. Like there's a lot of variables at play. So it does become tricky. when we're actually ready. But we can lay down some fundamentals and see if that's tolerated. So like, I would say lunges and a single leg deadlift. We're sort of mimicking that hinge pattern if we're like constantly picking up the racquetball like off the ground. We're lunging in the court, we're doing side stepping. So like side lunges, lunges, single leg deadlifts. If you're tolerating that really well, then I would say we're we've got a strong enough base to then start dipping our toes into some sport specific stuff. We've got the running side of things. So like, I don't know if you want to do some slow, easy running, but quick bursts like strides, that could be something quite nice to see if an uptick in like moving forward a bit quicker, like the sprints. I don't know how much sprinting is in racquetball. It's probably like four or five steps, but like just sort of mimicking that. to see if that's tolerated. So we're going outside the sport itself or outside sort of game day and seeing in the gym or outside the gym, like, can we match these requirements and to see how symptoms behave? And then once we feel like we've got the fundamentals tolerated, then we can just work into drills. So I don't, I'm not familiar with racquetball. So like you could do like skills drills and you can start, you know, just doing some basic fundamental movements to see if that's tolerated. And if you start to increase your confidence that way, this is where it becomes a bit tricky because if I was you, I would return to say, 50 % duration, let's say a typical racquetball goes for game goes for 60 minutes. I'd say, okay, let's do 30 minutes, but at 50 % intensity. So you might want to go with a family member or a friend and just like have a hit around. Why I say it gets tricky is a lot of people can't really trust themselves or I can't really trust my clients to. go out at 50 % because they get carried away, competition, all that sort of stuff, and all of sudden they're doing too much and then they get flared up. So hopefully we can dial in those things and then we slowly pick up the duration. We build the duration from 50 % to 100 % and then we work on the intensity. We slowly just do more and more and just test things out and like all these answers, just let symptoms be our guide, see if we're tolerating it or not. But at least this creates some... groundwork with building on the fundamentals and think, hmm, what is actually required to do the sport? Test it out, get it strong, get it robust in the gym. Then we test it out with drills. Then we slowly introduce more game scenarios. This is sort of what we do with athletes and team sports as well. So principles are still the same. Andrea for context has about 80 % proximal hamstring tear without retraction, meaning that the tendon isn't pulling away. from the attachment site. She's done stem cell treatment three months ago using my program for rehab and reportedly shows substantially more tissue, great. And so Andrea's question, as a marathon runner, how would you know whether and when the tendon is ready for full marathon training cycles? Okay, the umbrella statement, let symptoms be your guide. We're just. dipping our toes into some running, slow running, see how that's tolerated. Definitely if you're not doing any strength work, I would be doing the slow heavy progressive strength training because that's the cornerstone to heal the tendon itself. Otherwise we're not giving the tendon the right environment, the right stimulus to become robust and generate better tendon tissue. So make sure we're layering in that. But every return is just sensible, slow. and interpreting your symptoms the entire time. But what I'd say is don't underestimate marathon training. It is a lot and you probably need to take more time than you probably think. This is usually the scenario where the situation where with clients, I tell them to focus on the long game. A lot of people have like a marathon on the calendar. It's like, it's four months away. Will I be ready? It's three months away. Will I be ready? And they sort of like the timeframe sort of gets ahead of them and they jump back in a bit too quick, a bit too fast and it flares up and they're like, oh, I don't know if I'm ready. Let's just think for the next five years. If you want to be running marathons for the next five years, let's just think what does this next year look like? You've had a significant hamstring tear and we want to really respect that marathon training is hard. Let's just focus on the next 12 months working towards a half marathon or something like that. I need more context to actually, for this to be helpful for you, Andrea, but. Um, then let's focus on the following year, getting to marathon, getting marathon ready and focusing on just doing a slow, easy, volume build. Then the year after that, let's focus on, or maybe six months after that, let's focus on the speed work and trying to, um, race, actually commit to a race for like best efforts. Um, this is what I'm doing for my high rocks races. I'm actually looking. ahead like several years of what my high-rush training looks like. My first race was, okay, let me just give it a go. Let me dip my toes in the water. Let me sort of train hard, but to see where my capabilities and limitations are. First race, noticed there was a lot of limitations with my sleds and like actually being physically strong enough. So I'm like, okay, one of my strengths is the running. Let me just commit, you know, eight months to... building muscle, like actually changing my framing, getting stronger. For that eight months I did that. This was like my goal. did, it wasn't even like a, let me just go next time. Let me just train hard for 12 months and let me try to beat my time. It was no, let me just spend eight months focusing on my weak links, which is building out muscle. So I got, I put on more muscle. I got better with my sled pushes and I feel like I built up so much strength. put on a fair amount of body weight. and ended up getting pretty significant calf overloads and calf strains. And so I just backed it all off and I prepared for the next hyrax race the next year and said, you know what, this year I'm not gonna run fast. I'm going to do the strength stations really hard because I've got this strength but I just can't risk the next two months of race preparation to do faster stuff because I don't wanna risk this. calf coming back. And so yeah, just committed. did a high rocks race last year, last December, keeping everything really slow. Like all my runs were incredibly slow, six minute ish pace, but on the stations, I worked really hard. And so this year, I have been working on volume build for my running while trying to preserve the strength that I made. So I'm going to have another race in December, where this is a year later where I'm working on maintaining the strength. want my strength sessions or all the times I did in my strength stations to be somewhat identical, but I wanna do that and race harder. That's the focus for the next 12 months. Next 12 months after that will just be pending how much time and availability I do have. But I see my next block is maybe hiring a Hirox coach and identify my weak points if I feel like I have... Utilised my potential training myself in terms of the running volume in terms of the speed sessions that I have that's the next year of me trying to develop and become stronger. So I'm looking in blocks of 12 months, which a lot of people don't do. They're like, okay, let me just go hard for my marathon in six months. Let me just go hard for my marathon 12 months after that. And then I want to travel and go hard for that marathon. But they're just not planning out enough and you see people going marathon to marathon or race to race, ill-prepared, because they run themselves into the ground, they get injured, they spend a significant portion of their marathon training managing an injury, then they feel like they get to the start line, ill-prepared, and then that just carries over to the next race, that carries over to the next race. So like, let's just build things out, build out some nice qualities, and then take it from there. Andrea, I think my answer is to... A lot of the previous questions would have helped you answer this question as well. However, hopefully you found that a bit more helpful. Okay, Thomas for context says, I've got several previous episodes of PHT, but now I'm injury free. I've been injury free for a couple of years. My question, if you could just add one exercise to a twice weekly strength training program to reduce your chances of PHT returning, what would it be? Drum roll, I would say the deadlift. I don't think there is much surprise. I would do three sets of eight or four sets of six and with a weight that is with two to three reps in reserve. So if I do a hundred kilos for my deadlift and I do eight and I feel like when I rack the weights a little, I feel like I have three more left in me before I max out. I would say that's a decent weight. I would then give myself two to three minutes rest in between that set and then I do the second and third set. And then if my goal is reached, if my goal is racing high rocks races and I feel like I've got enough robust strength and capacity in my tendon to go hard with those high rock races, then I would just maintain that. Yep, once, twice a week, do that lift and get that tendon the right stimulus. However, if I progress or I demand more of my tendon, incoming in the future, i.e. if I start prepping for a marathon or wanting to really race hard for my high rocks and notice that that demand is going to climb, then maybe my deadlifts do need to pick up. Maybe I do need to go from the 100 to 105 to 110 just to create more of a foundation to layer stronger bass, have a stronger pyramid bass before I start layering if I want those top tiers to increase in weight. So higher demands requires a bigger foundation, which means the deadlifts do need more attention. So that would constantly fluctuate. But once I picked that up and training is tolerated, then I'd maintain that next level up. If I decide to have a year off, then I can probably reduce things back down to the hundred kilos. Like, you know, we're just slowly fluctuating based on demands, but that's exactly what I would do. as a PhD maintenance thing. And that's what I'm currently doing, I'd say. Right now, my PhD is fine. I am training hard. I'm picking up my running distance and my overall training volume. PhD symptoms are at bay. So I do my deadlifts once a week. I do three sets of eight. I do have a fourth, like kind of warmup set, but most of my deadlifts are around about 90 to 100 kilos. I've just realized that's my maintenance. That's what I'm happy with maintaining. And I do, I have the same maintenance for the curls and for my lunges. And I just feel like on top of all my other training, if I try slowly progressing those at this stage, it's just adding on a bit too much risk. So I am in a maintenance phase with that at the moment. So that's what that looks like. Hopefully that helps answer your question, Thomas. And I hope. All of my responses have been helpful for you considering how your PhD is going, how your rehab is going. There's a lot here on returning to running and just increasing load, returning to sport in general. So hopefully that helps address a lot of the confusions and factors that you're currently facing and hopefully you enjoyed this episode. If you are looking for more PhD resources, then check out my website link in the show notes. There you will find my free PhD 5 day course, other online content and ways you can personally connect with me. Well done for taking an active role in your rehab by listening to content like this and together we can start ticking off all of your rehab goals and finally overcome your PhD.