Q&A: 2 + Brodie’s PHT Rehab Update

On today's episode I am answering all of your PhD questions. Welcome to the podcast that gives you the most up-to-date evidence-based information on PhD rehab. My name is Brody I am an online physio but I've also managed to overcome my own battle with PhD in the past and now I've made 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. Let's start. Well I'll get to your PhD questions in a second. We have about five or six questions to answer but before we do that if you were listening to my last episode I mentioned that I have had a resurgence of PhD and thank you for everyone who's sent me some messages about the scenario and wishing I get better. I appreciate those kind gestures and thoughts but yeah I thought it's important that I be transparent about my current experience and what I'm going through because I think it helps you realize that it's a scenario that happens to all of us and I guess from my knowledge and understanding of PhD might be helpful for you to at least see some insights into what I'm doing to help negotiate it. So if you're not familiar maybe just go back to last episode but I'll pretty much just kick off where I left things last recording. So the real main aggravating factors that I found over the last couple of weeks definitely sitting for some reason sitting is one of the big contributing factors and things that I have to modify and lunges. I'm not sure why lunges well I know why lunges because of the load on the up hamstring but I didn't think they would be as aggravating as they are but need to follow, listen to my body and follow my own signs and symptoms of where I am in this moment and the lunges were particularly aggravating. No I wasn't too sure about the deadlift so I haven't really ever since I worked out how urgent this PhD thing actually is and how much I need to prioritize it. I have been more cautious on the deadlift so I haven't really tested out a lot but did test out the lunges and found out that was quite irritating and running running volume like I'm mainly just keeping to slow treadmill stuff at the moment but the running volume which I'll talk about my experience in a second seems to be I'm trying to find my limitations there. What is okay through trial and error squats seem to be fine a few weeks ago I tried squats with reduced range of movement that was fine then I tried squats pretty much at like pre flare up stage just taking maybe like 15% off the bottom of my squats and that was fine so seems to be controlled. I did some hard rowing and hard ski work and that seemed to be fine. Did my burpees that seemed to be fine and did wall balls with reduced range of movement that seemed to be fine so I was just constantly as the last couple of weeks have gone on test out all these different things and PhDs unaffected by those so great I can then continue to stay fit and continue to maintain my strength with these exercises that doesn't affect my PhD so good that through experimenting I've sort of found that the do's and don't saw the the do's and be cautious with and modify. I'm still unsure about the sled push though although I did do the sled push on the weekend and things were no worse and so I think I'll put that in the do list and also like what my test retest has been like typically it's been like a long leave of bridge a single leg long leave of bridge where I'll just get down the floor do my bridge see what it's like see what it typically is at baseline and then do about of exercise do run do some exercise and see what it's like at night see what's like the next morning to then see if I am back at baseline but I know I'm kind of worried about it now since it really fled me up and fled up my knee as I talked about last episode so the knee is completely fine now I don't know if I've mentioned but I suspect it might have been some sort of burst up but it was really really bad for a few days and not getting better and then I think day three it was about 70% better just out of nowhere and then the next day 100% and I've never felt it since and so that was a relief because that would have hindered a lot of my exercise options but now I'm worried to do that as a test retest to see if I'm back to baseline every time so now I'm just doing like a kind of like a single leg deadlift one of the symptoms or moments in the day even like three four weeks ago when this thing was slowly starting to resurface and I didn't really prioritize it I didn't really just show up higher my radar was actually feeding my dog putting the bowl the food bowl down onto the ground when I was feeding my dog and I kind of do a side lunge slash hinge movement to step out of my back door to put down the bowl and that was slowly getting worse and worse and worse and so now I'm using that similar kind of single leg deadlift side lunge kind of action just to see when I wake up in the morning what does that movement feel like before I go to bed what does that move and feel like and if I'm ever noticing an uptick in symptoms that's when I know that I might have overdone things but if I do that and I'm relatively symptom free with that then I know that I'm back to baseline and whatever I've done the day before has been tolerated and so what was my action plan if you recall like I decided to take last week or the week before at the time of recording as like a D-load week which I think was really good mentally for me to know that I'm still on the right track I'll just count this as a D-load week give my body some opportunity to get fresh legs again while concurrently managing this injury because I usually take a D-load week every five weeks anyway so let me just bring it forward and I've still got purpose in the training it's not like a big disruption of my training so that really helped and then in that D-load week I made several modifications to the especially those aggravating factors that I mentioned so sitting I then changed my office environment to a stand desk while I always have a sit stand desk that moved into the standing position I did a lot more standing typically made sure I walk comfortable shoes because I don't want to develop plan a fasciitis like I have in the past and I know it's a pretty increased risk of plan a fasciitis if I just stand still for a long long period of time so I was probably standing for about 20 minutes and then I kneel so I would just get my office chair turn it around kneel on it while I'm on calls or doing some work and do that for about 15-20 minutes and then I'd sit I'd sit for 15-20 minutes and I'd just put that on repeat and that seemed to be okay for my body to handle especially when I stand still and kneeling as well my lower back was getting a bit stiff so I wanted to make sure that constantly changed things up after Mackenzie went to bed and my girlfriend I would watch TV on the couch I'd make sure to not sink too much into the couch either lay down or sink all the way down so that my sit bones were sort of hanging off the edge which with the with the right amount of pillow arrangement was quite comfortable so had to make the those adjustments into sitting my squats like I said I reduced the range of movement a little bit my workouts they just I for the de-load week I didn't do any running I just did the rowing the ski-erg and some upper body stuff I could still do some really heavy like VO2 max workouts I've been doing a VO2 max workout on the ski-erg after listening to Dr. Will on the Runsmarty podcast or interviewing him and he discussing the VO2 max workout of 30 seconds on 30 seconds off do that eight times that's one set and do three sets I've been doing that on the ski-erg and like it's a it's a kick in the butt it's a big big workout and I'm enjoying to stimulate my cardiovascular system so much yet not irritating the PhD so I was doing that during the de-load week and I think I did it once because you know you can still do workouts in the de-load week just the overall volume is to reduce and then what was I doing some isometrics here and there I think I was doing isometrics just occasionally like maybe once a day and that would just be like a single leg deadlift nice slow easy very similar to that test retest pattern that I do and throughout that de-load week symptoms improved symptoms improved really well and so took that as a de-load week went into I guess week one of my next training block and I was back into running I was running four k's that was fine I did a five k run that was fine so from Monday to Wednesday feeling great doing my squats that felt fine and I was starting to do more and more sitting I was really important to me that I slowly introduced more and more sitting and so I was just feeling confident to do that and I was I was feeling back I was feeling really good and so then I kind of felt like I was back in a typical training week with some slight modifications like the hamstring curls I took 5 kilograms off that. My deadlifts were still at 90 kilograms so it's still quite heavy but that's pretty flat. That's like my warm up weight and I got my high rocks ticket as well that went on sale on Wednesday and I hear in Melbourne tickets sold out in five minutes but I managed just to log on the right time. Got my ticket so had a fresh new motivation but then it didn't all go smoothly because Thursday was my first kind of setback like I said Monday to Wednesday was great. Wednesday night I decided to do some lunges again. This is me not realizing like I knew lunges were an aggravating factor I just didn't know how much so I decided to do lunges because I was feeling great. I took 12 kilos off the lunges and only did three sets of five and felt okay during, felt okay afterwards went to bed, woke up the next morning, felt fine but decided to do a run quite early just before Mackenzie woke up and I did 3k slow on the treadmill I thought would be safe. Then Mackenzie woke up I got it ready and then before work I decided to do a 3k run again so two 3k runs separated by maybe two hours and then I was irritated Friday I was irritated all Thursday and Friday and a little bit I think I was back to baseline on Saturday but the 48 hours of a irritation I didn't like what actually caused it I'm not too sure I think looking back on now maybe the lunges were a little bit of an irritant and I needed more time in the day in the morning to sort of it to reveal itself maybe I need to test out a little bit more to be like hmm how am I actually feeling today and then to do a combination of 6k's of a run might have been just pushing it too much which pushed over the edge and so my symptoms were elevated the Thursday and the Friday which was quite a bum up quite a reality check that I wasn't back to my you know typical training week but I'll count it as an experiment I'll count it as gathering data and definitely for my decision making moving forward. So I'd say I was back to baseline Saturday Saturday I did a workout high rocks based sort of stuff I did my sled push I did skier I did rowar did burpees did ball balls for the most part I think that was tolerated really well Sunday back to baseline so I didn't really risk anything in that workout but it was still pretty taxing on my body so feeling like I accomplished a fair bit Sunday I probably shouldn't have done this but I did a VO2 max workout with the ski yoga did that 30 seconds on 30 seconds off workout again and then just rested for the rest of the day come to Monday which is today felt like I was back to baseline again so hitting some pretty good momentum and decided to do my first run my first treadmill run so I only did three k's slow easy on the treadmill so we'll see how that goes I'll see I last negotiated so I'm back to sort of trying to string together some successful days try try not to have too many hiccups this week and build some momentum I'm sitting down as I'm recording this but I'll be doing a fair amount of standing and kneeling periodically throughout the day as I'm jumping on calls and so let's see way too next I think I'll give the lunges a break for this entire week I just don't want to risk anything I'm still gonna keep quite strong with the all the other stuff I've got going on and when I do reintroduce that which might be the following week I'll just do really really conservatively reduced range of movement and a lot less weight and we'll see the runs themselves I think I'll just again not put in too much risk I think I'll just do small frequent runs so I'll do three k run today this morning if I feel great throughout this entire day I might even do three k's two or three k's tonight and then you know just chip away small yet frequent and then just slowly progress everything else progress my curls again progress my deadlifts again back to pre-flare plans in the meantime I'll still maintain my fitness with these fear 2 max workouts and if you listen to this and being like well if Brody's having all these flare ups and setbacks and all these sort of things how I'm meant to manage all this stuff I would say like you know I'm just looking for my own capacity at the moment like this is what I do with clients this is what you should be doing it's like working out what capacity do you currently have how much running can you currently do how far is it how much can you sit like on what surface like all these sort of things are little experiments and I just don't know where I I'm currently at like I have an understanding a bit more of an understanding now as I'm going through two weeks of experiments but we never really know what's too much until we overdo things and then symptom increase like okay that's where it was now let me learn and adjust and compare and so in this like little flare up phase like setbacks are required as we continue experimenting I'm still trying to stay as proactive as possible trying to keep fit and healthy both emotionally psychologically physically and like even though I am having setbacks I'm not regretting any decisions as yet like I feel like I've been very sensible in my decision making but just because that leads to a flare up or a setback doesn't mean that was wrong it just means it was an experiment that I decided to do looked safe on paper symptoms increased let me learn from it I think doing the lunges of the night and then the run times two the next morning was something that on paper seemed okay based on how I felt in the moment felt okay afterwards retrospectively not okay but I'll learn from it and so just dumping my thoughts into this podcast just so you can see what I'm up to where my head's at what experiments I'm doing where my rationale is with my approaches and hopefully this helps you do the same have some reassurance to know that this is the right recovery from PhD has never been simpler if you've been struggling with this condition and you're not sure what to do next I've put together something to help LinkedIn the show notes is a 30 second question air literally just six multiple choice questions and based on your answers I'll point you towards the most effective next step for your situation because over the years I've created a range of resources from free education to structured self-guided programs all the way up to working with me directly all of which are aimed to strip away the mountain of misinformation about recovering from this diagnosis and taking out all the guesswork that leaves people like you overwhelmed if that sounds helpful don't wait until the end of this episode click on the link in the show notes now and I'll guide you from there path that we should be on okay let's dive into these questions one two three four five six seven questions to get through okay the first one comes in from Richard who says a question on progressions I've done step ups with zero weight and I've slowly increased the reps now I plan to lower the steps or lower the step height and add weights is this progression okay also I plan on doing squats but there are many variations I plan on just doing regular squats and progress that too but I'm not sure any ideas okay thanks for your question Richard let's talk about the step ups to start with you could do it like any direction is okay any progression are provided that it's eventually going to be slow heavy load we don't want to progress in the way of getting lighter and just increase in the reps to three sets of 10 12 15 20 tendons don't really like that when done so safely it's good to eventually have that progression chart looking like eventually it's going to be quite heavy and around about the three sets of of off a step ups I like three sets of six on each side is a pretty good frequency but you can go higher reps lighter weight as you just sort of getting used to the movement but your question about do I drop the height of the box or do I and then I increase the weights I'd say that makes sense on paper but we don't know like your symptoms will tell like you can give it a go and then see how it is and then based on how it is readjust or continue on that path um sometimes I rarely reduce the height of the box for some people I just add in the weights but they're just small add-ons of weights and so you could even do the same height you could do two sets the first two sets body weight and then just add weights for the third set if you wanted to and that only be five pounds if you wanted to that's a that looks safe it looks very very conservative on paper um and then you can do it and see how symptoms are or you could go with your approach like I can say there are more there are multiple directions to achieve the same purpose and so um you can do that as well so I get the same question about dead lifts like if someone's doing half range of movement 50 pound dead lifts three set to 10 and they're like what do I progress do I increase the reps do I increase the range of movement do I increase the weights again several directions you could take there's no right or wrong unless there's no right or wrong if it makes sense on paper and eventually has the goal of heavy heavier in the long run. And so yeah, if it's range, you want to increase first. Sometimes I just like to increase the range of movement if tolerated to about three quarter range. So when you start at the top fully extended, you drop the, you lower the bar and the bar goes to about mid-jin, halfway between your knee and your ankle. And that's what I would consider about three quarter range. And then we can just keep that range of three quarters. And now we've ticked off one variable. I don't think you have to do full range. You can if you want to. But I think for some people, it's perfectly adequate to go at three quarters. Just stay there and then just get really strong in that range. And then we've just knocked off one variable. We can keep that consistent. And now we've got just the reps and the weight to play around with. And it's less confusion. So yeah, just my preferences. But then your second question about the squats. Find what works for you. Because squats aren't really a rehab-focused exercise. Yes, they're good to have in just for strength, strengthen the glutes, strengthen the quads. Sure, they do irritate some people, especially in the depth, the deeper ranges. But it doesn't necessarily strengthen the upper hamstring quite like a deadlift. And so we put them in there. But it's just like a non-rehab, just strengthen conditioning, useful exercise to have just for general life. And so because of that, we don't need to be too specific about what type of squat you do. And we just adjust the squat to tailor your goals, what variation you enjoy, what suits your mobility, your range of movement. And that might be a sumo squat. There might be dumbbells. That might be a barbell. Like typically, all our society, if you were starting from a clean slate, I would typically do a barbell back squat, back as a bar is across your shoulders. You go down into a squat to whatever's comfortable for you. Feet slightly wider than hip width apart. Feet slightly externally rotated. And then just go through a depth that you feel comfortable with. I start with three sets of 10 that's relatively lightweight, get used to that, then slowly increase the weight so that eventually it's three sets of six, three sets of eight. Something more challenging in terms of weight, but reduced in reps. Okay, Evan asks, "Hi, Brody, I've noticed that deadlifts using a trap bar just feels better for me than using a standard barbell. It feels a bit easier on my lower back, which can sometimes get a bit sore after conventional deadlifts. But is using a trap bar as effective at loading the proximal hamstring tendons. If people aren't familiar, the trap bar is something where you can just Google it, but something that you step into and it's kind of like a frame that's around you from back and sides. So I sort of hold on to the handles by your side and the weights are on each side. I think I think Googling it rather than me just trying to explain this on the fly. What I've tended to find is people that do trap bar deadlifts, it looks a bit more like a squat. The shins are traveling a bit more forward. The knees are passing the toes just a little bit and it just looks more like a squat. And so if you can do a trap bar deadlift really getting a really nice hinge pattern, then sure, that's great. But if it tends to look more like a squat, we're just slightly less effective with our approach. And I guess biomechanically, the more upper hamstring loading tends to mean you have to hinge more at the hips, which means that it is more load on the lower back. Purely by design, the deadlift does put load on your lower back and strengthens your lower back if you get the right adaptation zone. But yes, strain on the lower back will happen with the deadlifts because you need to hitch, because you need to hinge at the hips, because you need to get load through the proximal hamstring. That's by design. And so yes, there are trade-offs. If you say Brody, I'm doing my deadlifts and like every time I progress it, my hamstring is okay. My hamstring is tolerating it but my lower back just keeps getting sore. Keep having setbacks. I can't really progress my deadlifts because I'm scared of my lower back. Then we might need to do some trade-offs. Okay, sure we might then do a trap bar deadlift knowing that it might not target the upper hamstring just as much. But if we can progress those trap bar deadlifts and progress that weight to better like better load your body, rather than being rather never progress in the deadlift because you're super scared. So if you're scared of the lower back, then that's a trade-off. That's a trade-off we can make. What I would typically do for someone is just do reduced range of movement deadlifts. Half range to 3/4 range will still get a nice stimulus through the upper hamstring but the reduced range means less strain on the lower back. So if you're a trade-off that you might consider but hopefully you're still noticing some load through the upper hamstrings when you do it. If it is looking quite similar to a squat, I would say try to encourage a bit more of a hinge pattern in your trap bar deadlifts. But again, you need to analyze that and see where the clinical justification lies but hopefully that helps you, Evan. The next question is from Susan, who says, "Hi, Brody, my question is about sitting with pHT. What helps and how to manage driving? I've tried various cushions and none of them seem to be good when driving. Often putting me too high on the seat. Many thanks. Thanks for your question, Susan. Sitting can be a tricky one when driving. I guess sitting in general, like I say, typically with what I'm doing. At the moment, I sort of rotate between standing, sitting, kneeling, walking, laying down. But I don't avoid sitting altogether. I think that's really important for people who struggle with sitting. We just need to try to find where your tolerance is and make sure that we foster that as much as possible so that we don't lose our tolerance to sitting. I've mentioned several times on the podcast in previous episodes, but those who really avoid sitting really struggle to get back to sitting. I've seen some stop sitting for 12 months completely, avoid sitting for 12 months and they are really, really tough to get back from. So just try to preserve as much as you can. I think there's a really important step once we find out what you can tolerate. You can nurture that and then even slowly start to build upon it once you're doing all the other right things within your rehab. But this is where driving gets tricky because we need to drive. If your tolerance is 10 minutes and you have to drive for 30 minutes to work twice, two and from every day, that becomes really tricky. We can't always work with the flexibilities that I was just mentioning. But when sitting like we tend to just try to appreciate how much pressure is going through your sit bones when you do sit and seeing if we can manipulate away to offset that. Sometimes when I'm driving, I like to straighten out my legs, still foot on the gas pedal, that's all I think. But when I straighten my legs a little bit more, I recognize that more pressure goes through my female or like my distal part of my hamstring and I kind of see saw my way off. Not completely off, but less pressure goes on the sit bones and more pressure goes towards the front of my thighs. And so that can be helpful to instead of it being uncomfortable after 10 minutes, maybe it's only uncomfortable after 20 minutes. Maybe if I combine that with just ever so slightly leaning towards the opposite side, we don't want to really lean over altogether because that puts a lot of trunk flexion or twists us in an awkward position and then we end up with low back pain if sitting there for too long, but maybe just a slight adjustment can just help tolerate those things. But like I mentioned, if you start getting better at all other parts of your recovery, if you start doing the right strength training, lifting and progressing in the appropriate manner, make sure we're covering everything else off with rehab in general, then sitting does become easier, driving does become easier, but in the moments where it is particularly painful, maybe you can try a few of those adjustments or at least just appreciate what cushion, what adjustments, how do I need to position the chair, how do I need to position my legs that just sort of rocks us a little bit more. Rocks us a little bit off pressure on those sit bones. You know, that might be with padding as well as the straight legs as well as maybe just 5% leaning over onto the opposite side. I like to use cruise control if I'm doing a longer drive and I'm on the freeway because that I can adjust my position a little bit more. You can take breaks if you want if it's a longer car drive and it's two hours to your parents house or something you might want to take half hour breaks that can be helpful as well. These are just many things hopefully one of those things can help you Susan. Okay, next questions from Heidi which is very similar question which is why I sort of sandwich these in together. Heidi says, "Hello, my flare-ups are from sitting. I have not travelled in two years due to this. How do you get to sitting comfortably again?" I would refer to, as above what I just mentioned, but also you know you sort of want to build up your sitting tolerance at the same time as well. One thing I didn't mention, which we don't really have the great luxury of with driving, but with sitting, you can slowly build up a return to sitting plan, pretty much like how you build up a walk run progression chart, a return to run plan or a catch to 5k. We can try to do something similar with your sitting. Once we know what you can tolerate, okay, there's your starting point. It might be two minutes with a cushion. Okay, let's start there and let's do that three times a day and then let's build that to three minutes. Let's build that to five minutes. Let's build that to more times in the day and all of a sudden you're doing more and more sitting, less and less standing. That's with again the flexibility of life. You might try to work on that on the weekends or something where it's you've got a little bit more flexibility, but some people have to sit in meetings. Some people have to sit to get on work phone calls. I don't know, but it's for some people the scenario is tougher than others. But if you do have that flexibility to do a progression chart, a sitting progression chart when it is within your control, then that's going to overall help build up your tolerance alongside progressing everything else, progressing your strength. In particular, exercises that encourage and build up your ability to tolerate compression on the sit bones, i.e. deadlifts would be a great exercise to help achieve that. But one thing I didn't get to, which might help you hide it and also use Susan, is with sitting, there's an emotional component to it as well, especially I've seen with driving, especially with sitting on in meetings or environments where you can't really get away from and they're in your calendar and you're racking your brain about it already. So if you have a lot of pain with sitting and you see in your calendar, you've got this two hour meeting or this conference or this two hour drive that you know is coming up and you are emotionally ramping up your nervous system to, you know, ready for this thing that you know is going to be painful and horrible and uncomfortable. You're gearing yourself up for failure already and then you get in the car, you sit down and you're like, okay, where's the pain, where's the pain, how much is the pain going to be? I hope you're hoping to survive this or you sit down the meeting and you're racking your brain and emotionally you're really, really wound up. That's going to be a bad experience no matter how much you can tolerate, no matter how much sitting you can tolerate, that it's going to be a very, very bad experience. The nervous system is going to really ramp up, pain's going to be really high and like I say, this is why pain is a biopsychosocial construct. We want to consider all of these variables because when emotionally it's really, really challenging and really, really debilitating, we need to address the emotional side rather than just what I mentioned before, unless it's built up your tolerance, let's see how much you can tolerate. If you're freaking out and really fearful, anxious throughout that two minutes of sitting, it's not going to work out well and what we need to do is combat that, almost prioritize calming down the nervous system and then getting you to sit. So that looks different for everyone, but it might be a scenario of just doing some deep breathing, some reassurance, some encouragement, knowing I know that sitting doesn't damage my tendon, I know hurt doesn't equal harm. Sitting is actually quite innocent for the tendon, sure it hurts because you're just poking at a bruise, but you're not contributing to further damage. So know that you're safe, know that it's an okay thing to do and when you just do some deep breathing and do some reassurance, or maybe just some affirmations that you just continue repeating, gets your nervous system in a calmest state, then you sit for two minutes, then it's a lot more successful, that builds on reassurance, that calms down the nervous system, that sort of rewires the brain to be like, "Huh, actually maybe this is safe." You start to change your beliefs about sitting, and then when we build that into 10 minutes, then we build that into a 30 minute meeting or a 30 minute drive, and we calm ourselves down that entire time. This is easier said than done, I know, as I'm talking about this, I'm like, okay, some people require a lot of work to get through this, but right about what you're saying, that we're not just talking about getting stronger, we're talking about calming down your pain signals on top of making sure we build up your tolerance at the same time. So hopefully that helps. Okay, next one comes in from Sandy, who says, "Hi Brody, recently I've heard about PRP, playing the rich plasma, as a successful treatment for sports injuries involving tendons and ligaments. I was wondering if you know anything about this treatment, and if you think it would be helpful to treat pHT. I did an episode about this a few episodes ago. Aiden Rich was the lead author, who produced a paper about pHT recovery, and had this supplementary file accompanying this, and so I've read out that, and it covers through the basics of like patient information when going through this treatment plan, and on that talked about injection therapy. So I'll read that out now. It says in that paper, "There are several different types of injections that have been trialled for tendinopathy. These include corticosteroids, blood injections, which are playing the rich plasma, and injections of substances that damage the blood vessels in the tendon. Unfortunately, there are no strong scientific research showing that any of these injections help, and in fact, some of these injections have been shown to have poor long-term outcomes." And so that's summing up where the current literature is at with injection therapy. We don't really like to inject things into tendons. It doesn't really, it's not really a forefront of our approaches. As much as we'd love to see some quick fixes and some of these interventions play a role, we're not doing anything to build the strength and function of the tendon. That's what's required is to build capacity, restore function, strength, all that sort of stuff, ability to tolerate compression. This is what's required, and unfortunately, an injection can't solve those issues. Joe says, "Hi, Brody. Firstly, thanks so much for all the resources you share on PayHT. I'm finding it all so useful in my rehab journey." Oh, thanks, Joe. My question for the podcast is, how often should rehab be done and what is the best way to schedule it around running? Running doesn't seem to aggravate my PayHT. In brackets, sitting is the main issue, so I'm keen to keep running two to three times per week alongside the rehab. Thank you again. Okay, Joe, happy to help you out here. I find that we kind of need to work our way backwards. First, with your exercises, we need to find how strong your hamstring and tendons are, how much you can tolerate, and then work our way backwards, because the frequency would depend on how much you can tolerate. Some people, when they start their rehab journey, can only tolerate 10 pounds deadlifts. I've said it before. They're so sensitive that anything more than that plays them up, and that's when we say, "Okay, that's not a lot of strain on the body. It's not difficult to lift." And so, let's just foster that stimulus, because we can't do more. We have to work within your level of tolerance. Do your 10 pound deadlifts. Do that morning and night. Two times a day. You shouldn't have a lot of, you shouldn't require a lot of recovery time, because it's not a lot of strain. However, on the opposite side, say someone is tolerating their deadlifts and they're up to 150 kilos. We can't do that twice a day. And so, that's where as the recovery goes on and your weight gets heavier and heavier and heavier, for most who's lifting a modest amount, they might do their strength training three times a week. But when that gets significantly challenging, and you start to feel quite stiff and sore and needing more recovery time, we need to try to find out when that switching point is where you go to twice a week. You change it to twice a week. You start feeling a bit more fresh. You start feeling a bit like you can lift heavy art, and then you can actually start lifting heavier in those strength sessions. Only time will tell your body will tell you need to really listen to your body to know when that switch happens. But typically, for most, two or three times a week for strength training is a pretty good blanket rule. This is where we kind of balance. It's an art. It's a science of rehab. That's when I sort of work with clients to be like, let's try this out. Let's adjust a few things here and there. Let's maybe do two heavy, heavy strength. Maybe just do one light strength. Maybe let's do it on this day rather than this day. Let's move things around and see how your symptoms are, see how your body feels. There's an art to it as well as a science. So it's very hard to provide concrete answers, but in relation to the schedule, yes, I like to have one dedicated strength day with nothing else scheduled in there. Therefore you can control the variables, you can have a nice strong session and see how you feel afterwards. But then if you're running three or four times a week or if you're cross training a couple of times a week, we might pair it, we might do a strength and a run on the same day, ideally separated by several hours, you might do the running, the morning strength training at night. But ultimately, like your symptoms will know whether your schedule is working for you or not. You'll know whether you're doing too many strength sessions or hopefully most people do, or whether you're doing not enough. And if you're not sure, maybe run an experiment, try re-happing less and or try re-happing more and to see. I can say maybe about 10% of the clients I work with, I look at their schedule, they jump on a call with me, we analyze their strength training and I instantly see they're doing too much. They're doing way too many exercises, way too often throughout the week and all I do is dial them down and their symptoms get better and then they can lift heavier and then they just build momentum from there. But listen to your body, see how your symptoms are and gold standard, we want to see improvements week by week. And you sort of plateauing things out, adjustments need to be made, experiments need to be ran so that we continue seeing a long-term trend. I apologise in advance because I'm already going to butcher this name, but Rada Gast from Sweden comes in and says, hi, I'm all the way from Sweden and I have a question that no physiotherapist or orthopedic doctor have an answer for, how can I distinguish P-H-T from ischial bursitis. I've got distinct swelling and dull pain/aic at the sip bone with referral going down higher up on the hamstring. Can't sit and pain is even when standing up. How do I know the difference between them or can I have both? A big thank you in advance. Happy to help you out as best I can. You definitely can have both, there is some literature out there who have gone through MRI scans of people with P-H-T and showing that yes, bursitis can coexist with this population. Bursitis can feel more like a bump, a golf ball, a nut, a bolt or something that someone describes at the sip bone when they're seeing the other, just feel like something's there. I'm unsure of the relevance of people who feel themselves and say, "I'd feel like it's a bit of a ball there because I just know when people are injured." They rub and feel any areas of their injury that they haven't really felt before. I used to work in clinics, people used to have shoulder pain and they used to rub their shoulder and be like, "Oh, this bump here, this flick's over here, this does this." It probably was there beforehand and just didn't really pay attention to it until they got injured and then they start moving around and feeling all these different areas. But yeah, it can be totally present with alongside P-H-T. I would say like in bursitis is typically due to like your initial trauma, like if you fell and landed on a hard surface, let's say you fell back into a chair. If you fell back into a hard surface chair and that caused direct trauma to the bursar, that could swell up and inflame and therefore you have bursitis. The onset of injury can look something like that. However, if it was a gradual increase in running or something that's really mechanical and overload in nature, I would typically say there's some tendon pathology there because that would make more sense in terms of the onset of symptoms. Yes, a bursitis will be tended to touch. In some cases, it would be very, very localized so I doubt that any radiating symptoms into the upper hamstring would be from a bursar. But tendon op please do that. Tendon op please can radiate into upper hamstring. But if you are unsure, like scans would be able to identify it. So an ultrasound can look for inflamed bursar. MRI can inflamed bursar will show up on an MRI like a Christmas tree. And so if you're unsure of one or the other, the management will be different. And so why not get a scan if your health professionals are unsure if it's one or the other. But then on, you know, you can always fall back on treating it as such and seeing if how it responds to the treatment to then have it as a diagnostic tool. I say this all the time, but the response to treatment can be a diagnostic tool. If we suspect this PHA, it fits the patterns of PHA. It, you know, the signs and symptoms and special tests that we do. Even some scans, like if all of it's pointing to PHA, it still might not be PHA. Unfortunately, we never know with a hundred percent confidence. But if we treat it like PHA and it gets better, well, that increases our confidence. And if our calm, if we're wrong, it doesn't matter because you're getting better anyway. But if you treat it like PHA, it starts seeing improvements, then, you know, at least we know part of your pain presentation is PHA. Let's continue heading in that direction. But if you decide to get an ultrasound or an MRI and it does link up with your signs and symptoms of a being a burstitis, then prompt intervention. This is where injections probably can be suited. They have what we call an ultrasound guided corticosteroid injection, where they use ultrasound so they're guided by an ultrasound image so they can inject a corticosteroid, which is an anti-inflammatory liquid directly into the burstile. And they know they're directly in the burstile because they can see on the ultrasound screen the injection going into the burstile rather than what some people do is they know some professionals might just willy-nilly take corticosteroid and just inject it in and around the tendon and, you know, kind of blindly just poking around and hoping that is effective. Like I mentioned earlier, we don't want to inject into tendons. But injecting into a burstile is different. That's something that might be clinically warranted and effective. And so they are some treatment paths that we might choose, but thanks for asking your question. Thanks to everyone for submitting their questions. It provides good content for this podcast. No doubt in a couple of months time, I'll be pushing out on my email list again. If you're not on my email list, you automatically go onto my email list when you sign up for the free PhD five day challenge, which everyone's absolutely loving and getting some great feedback on. So if you are interested in five days of free emails to learn all about PhD and how to overcome PhD, you do that absolutely free. Then you get on my email list and then in a few months time, I'll be asking for more questions and you can submit them there. 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. Find out 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. While done, but taking an active role in your rehab, find the seek to content like this, and together, we can start ticking off all of your rehab goals and finally overcome your PhD.