Q&A: Bridges, Tears, Flare-Ups, Walking Triggers & Rehab Without Deadlifts

On today's episode I'm 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. Thank you for joining me once again. We are finishing off answering these questions that have been submitted and let's jump right in. The next question comes in from Nell who says "Hi Brody, I loved the interview with Keith Barley released earlier this year. Very interesting. I would like to give his isometric protocol a go and was wondering how you would implement it for proximal hamstring tendonopathy. The idea I got from the podcast is that I should do four sets of 30 second holds with a two-minute rest in between each hold. Keith Bar mentioned a specific bridge for the proximal hamstrings at around the 45-minute mark of the episode but didn't quite understand what he meant. Could you please explain how to do the isometric glute bridge he was talking about? I wasn't too familiar so I went back to that episode and reviewed it. Yes it is around the 47-minute mark so thank you for helping me out with that. For those who aren't familiar or haven't listened to the episode with Keith Barley, I highly recommended you go back and have a listen to that. He said for the first few weeks of a significant PhD so he was talking about maybe an acute onset of a reactive in the phase of an acute reactive tendonopathy. For the first few weeks he would do 30 second hold isometrics keeping the pain level at about a two out of ten pain. He then said to then progress he would go to a single leg bridge and try to bias the high hamstring tendon a little bit with an anterior pelvic tilt. So if you want familiar if you do go into a bridge position so you lie on your back you bend your knees you feed it on the floor and you just practice rotating your pelvis back and forth still keeping everything on the floor but if you roll your pelvis forward in this anterior pelvic tilt you'll notice that the small of your back increases but if you posteriorly pelvic tilt you are almost digging your tailbone under and you're flattening your lower back and your entire spine should go flat against the floor. That's a posterior pelvic tilt. When we anterior pelvic tilt and increase the amount of arch and L lower back we're almost kind of winding up the proximal hamstring tendon as it attaches to the sit bone it kind of wraps and tucks in behind the sit bone to then increase its tension. So Keith I was talking about once we get beyond this sort of acute phase and we want to start loading up the proximal hamstring tendon more we might progress into a single leg bridge hold isometric but with this anterior pelvic tilt with the theory of that being to load up the proximal hamstring tendon while also taking load or tension away from the glutes. So you're saying the glutes kind of I don't want to say switch off but are less prominent in that position with the proximal hamstring tendon to be more prominent and so that might be a method to get better load applied to that area and he said he would do that for two to four weeks and then increase yet again progressing into something that's more dynamic load something like lighter dead lifts or other things like that and then progress then again to something of plyometrics if returning to explosive speed is something that interest you in your rehab journey. So hopefully that helped clear that up for you now I know posterior pelvic tilts and pelvic tilts in general which probably some terminology and slang that just escaped me I tried to make sure that if anyone any guests that I have answer a question with a bit of jargon I like to clarify it as much as I can keeping in mind that the audience listen don't really have a medical background and so I'm sorry that that one slipped by and made it a bit confusing. Okay we have our next question coming in from Kim who says hi Brody what is your advice for building a recovery routine without deadlifts I have a knee issue that is aggravated by even unweighted deadlifts. Thank you for your help. Happy to help Kim I would say okay first and foremost let's rehab the knee let's focus on the knee I don't know exactly what the diagnosis is you'd say that you have a knee issue so we want to try to start doing the right exercise or the right rehab to better improve the knee so that you can start doing your deadlifts because it is one of the most important but also if we're doing bridges or curls or weighted step-ups and the other essential exercises for PhD that's going to load up the knee as well and so it's very hard to rehab a tendon that's around the hamstring area without bending the knee so yes we can then prioritize the knee if we wanted to but you could just try reducing the range of movement for your deadlifts I don't know if a full range of movement deadlifts is what the onset of knee pain is like but what happens if we reduce the amount of range for your deadlift does that trigger the onset of knee pain because if it doesn't I would go just short of what triggers knee pain and then load you up in that position so that the proximal hamstring tendon is still getting the load still getting the benefit of the deadlift yet not aggravating the knee and who knows maybe if you are doing less range of movement that might give you more permission or more success with loading it up heavier that's something we could gradually work on an experiment with to see if that's successful for you but in saying that like again I don't know the diagnosis of the knee but when it comes to a deadlift try to make sure with the deadlift technique that your shins your tibia bone remains vertical because if it does there's not a lot of load that goes through the knee if it is pitalo femoral pain which is the most common pathology of the knee range there will be maybe a certain range that creates that onset of pain but unlike a squat or a step up or a lunge the deadlift doesn't really go through a large range of movement and the knee doesn't pass the toes which steeply builds up the load that goes through the knee joint so if you can just ensure just make sure the tibia remains vertical during your deadlift I would just want to make sure that that's achieved because if you're saying that you've got knee pain with your deadlifts but then you do a deadlift and the knee travels slightly forward beyond the toes and the shins aren't remaining vertical that could just be a simple change that we make that allows you to successfully do the deadlifts without knee pain so we just want to clear that first but and then if it's still painful with the knee play around with the range of the movement and that sort of stuff so I hope that answers your question. Anyone else who says I can't do a deadlift because of they don't have access to the weights typically the replacement that I would do would be a Nordic hip dip tends to mimic the deadlift to the best of its ability that I can think of which is you know you hook your ankles underneath something if people are familiar with the classic Nordic drop and this time with the Nordic hip dip we are keeping our thighs vertical and just dipping at the hips however I can't suggest that for you came because that would aggravate the knee as well because it's pretty aggressive in terms of its kneeling position so unfortunately I couldn't help you out with that but hopefully that answer helps. We have another one coming in from Michelle who says can those with partial tears or very diseased tendons ever be rehabbed or will they always be pain or need surgery? Heated topic where do I start with this? It's very hard to know how significant a tear is if someone has a scan and has identified a tear I would definitely want to know the onset of symptoms of the tear I'm assuming you've had scans and it's shown tears but there's like if you scan the healthy population they'll show tears they'll show fraying of tendons like it depending on your age you know it can be a normal part of a human so we do want to be very careful with interpreting those things also like the orientation of it like you might find that some partial tears are actually like longitudinal like along the tendon itself which in theory will be less problematic because it's in the same direction that load is being applied however if the tear was horizontal and load is being applied perpendicular to the horizontal tear that could obviously be a bit more risky but like I say partial tears are in the healthy population anyway and why are talk about a one-on-oh-no-the onset is that if you were sprinting up a hill and then you felt a ping in your high hamstring and then you had these scans and it shows a significant tear that is very different from someone who has a gradual onset typically with PhD they're training for a marathon or they're just incorporating some speed work and it's a very gradual onset starting with some maybe some tightness some mild soreness that just got worse and worse and then it permeated into sitting and then it permeated into even walking and those sorts of things that gradual onset that then gets a scan and shows a tear would lead me a little bit more skeptical or having less relevance to that finding in which we would just treat it like a tendonopathy. There are significant tears though I don't want to dismiss the significant tears you can have an avulsion fracture which is the tendon pulling away from the bone and with you know very traumatic sudden instances like doing the splits like it can significantly disrupt the function and may require surgery. Typical criteria for it is if a tear impacts all three tendons if there's two or more centimeters of retraction with the tendon pulling away from the bone and if you're encountering very limited function unable to walk and able to straighten the leg or bring the leg behind you definitely you would be a candidate or at least having a review or talk with a surgeon to see if surgery is likely for you but if it's less significant and it is that gradual onset and you have shown some tears partial tears in your scans I would just be considering within your rehab to just focus on strength and function and return to activity. Focus on your symptoms focus on strength focus on function what do I mean by that like throughout your rehab are your symptoms getting better are you getting stronger are you slowly returning back to the tasks that you want to return back to if you are on that trend I would focus more on that rather than focusing on is my tear healing is my tendon improving physically like the physical properties is improving it's less of a priority because we could have you in less pain more function back to pain free running back to cycling symptom free we scan you five years later and there's still some small tears there yet you've been symptom free for years how much do we really worry about it I wouldn't worry about it all if that was the scenario we're presented with 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 linked in the show notes is a 30-second questionnaire 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 Michelle you also asked about like very diseased tendons is that worth you know will they ever be rehabbed yes there is the potential for the most diseased tendons to revert back to healthy tendons if rehabbed the right way like I mentioned there's an earlier episode with Keith bar and I since created a subsequent episode reviewing one of Keith bars publications where he went through a case study he had the one of the most disease tendons he had an MBA player who had 50% of his Patelot tendon in a degenerative state in the central portion of that tendon so we're looking at a very a large portion of the tendon undergoing the most severe stages of tendon opathy in the worst possible position within that tendon so not a lot of things going for this MBA player however with the protocol that Keith bar discusses managed to have this athlete still staying in season still completing an entire season of MBA along with some protocols around vitamin C and some other supplements around collagen some particular specified loading strategies and in 18 months follow up had an MRI the tendon itself was considered completely healed so there's some data to show that it is in fact possible Charlotte says should we do our rehab strength sessions if flare up or do we wait to get back to baseline our flare up questions are always tricky to answer because every flare up is different we do have mild moderate severe flare ups I have done a previous episode on planning a flare up coming up with your flare up plan where I do talk through a potential moderate potential mild potential severe flare up and what kind of what that looks like in terms of decision making but in most cases if you do encounter a flare up and you've progressed something and it's led to an increasing symptoms for a couple of days I would say in most cases one to three days of rest might be appropriate but then thereafter we are then finding your new adaptation zone give it one to three days to settle down not back to baseline doesn't need to get back to baseline but just enough to settle things down somewhat and then we are finding okay what can I tolerate now that might be readjusting your deadlifts that might be changing and reducing the range of movement that might be shortening your runs reducing your speedwork and just seeing how symptoms behave from there and if symptoms behave okay then we're making that gradual build up back to where you were pre flare up that's essentially the principles that are involved like I'm going through this at the moment as I mentioned I think maybe last episode of the episode before I'm managing this knee issue which was brought on by doing a long run and then playing pretty competitively with basketball that night in this combination of those two really flared it up I have since it settled down to when I was symptom-free running I think I ran about 4k or 5k and that didn't increase my symptoms I'm like okay let me try basketball again because I do love it but I returned to basketball playing for about 45 minutes and at about 50% intensity and I told myself these are the restrictions I'm going to follow and if I'm flared up afterwards hey that's the experiment I went with but I didn't want to get too carried away be really flared up and be like damn and sort of beat myself up it was just an experiment that I wanted to try went at 50% intensity flared up slightly it was really sore that night really sore the next morning but actually bounced back a lot quicker than I thought and so I thought oh this isn't as bad I took maybe one or two rest days after that so that follows the one to three rest days that I said before I then went back to strength training did my squats did my lunges that was fine so experimenting again worked out that was okay then I did a three and a half k run I took my daughter in the running pram to a park just trying to squeeze in some exercise when I can with my busy parent schedule so ran to a park for about you know 2k then ran home after the park about a k and a half and that was okay that was I was actually I handed that really well and so I'm like great let me try something else so yesterday I tried two and a half k's on the treadmill and accompanied with some high rocks movements so I did like a sled push and I did 150 wallballs and that slightly flared me up I reduced my range of movement with my wallballs but squats and lunges and everything had been fine up and to that point so I thought I was okay bit sore for the remainder of the day but I would say slightly above baseline the next morning continuously experimenting I feel like I'm in a really good space at the moment because I'm doing it a lot more and it's tolerating a lot more I think basketball needs to take a little bit of a backseat for now I don't really want to take on that risk because I'm really enjoying the workouts I'm doing with my high rocks stuff at home and the amount of running that I'm doing so now with previous experiments with basketball not successful I've decided to maybe give it several weeks off and yeah not risk it but this is what we do we have we constantly experiment how does this sound how does this sound does this sound sensible does this progression sound sensible how do I feel the next day like I'm in the throes of that the moment I encourage you to do the same if you're managing flare ups and just trying to get things under control Charlie has a question who says of the four exercises I do I can still progress them but what happens when I can no longer progress when I get close to my max also as I progress should I do fewer sessions at this point a session once a week rather than three times a week also is there any benefit in switching any of the four of exercises or is it just as good to stick with the four exercises I've been doing for the last six months? Thank you so much for making the podcast and course on PhD. I felt very hopeless before finding your work which has got my leg to 90% in terms of being back to normal which means I can now do what I wish after six years of making no progress and also giving up hope it would ever heal. Congratulations on your success, Charlie. I thought I just um include that bit at the end just to help other people who might be going through similar frustrations. But back to your question. If you feel like you're progressing, progressing, progressing to you can you're reaching your limits, you're reaching your max, you can still progress. However the progressions get smaller and less often I would say. Think of like a bodybuilder or like a Olympic weight lifter. They're constantly like pushing their max but they're going through these periodized training where they're slowly trying to squeeze out five pounds here, five pounds there, one pound, one pound, one pound just to try to you know see gains and you will see those gains but when we do when we do reach close to our max the rate of progression plateaus out. So for example for an exercise let's say we're doing three sets six, one hundred pounds. We'll say one hundred just to keep nice clear um and help follow along with this. So let's say we're doing three sets of six, one hundred pounds. Your next progression could be okay let me do two sets of six at my usual one hundred pounds but then for my third set let me do one set of four at one hundred and two pounds. It's it's reducing the reps a little bit but it's increasing the weight a little bit. I would say it's still a progression and if that's handled maybe we do one set of the last set is now five reps then the last set is now six reps and then maybe we do two sets of that then maybe we do three sets of that and eventually after you know seven progressions we have now progressed from a hundred pounds to a hundred and two pounds sounds like tedious but you know any progress is progress. Some of my exercises I do in the gym um you know approaching my max and my reps are exactly the same I have all my reps written down in my sheet so I'll be like what did I do last time um do I how challenging was it how sore was I after that do I keep it that same weight or have I been doing the same for several weeks and been handling it okay let me try the next smallest progression and that's where I'm at for a lot of my exercises and I might progress once every three weeks but if I'm consistent enough and I continuously progress in six months time I'm significantly stronger than where I was prior so hopefully that makes sense um in terms of the frequency of the exercises if you're doing it three times a week and you're close to your max definitely reduce it because we're now getting to the point where if you're doing it like every second day or close to every second day you're not going to get enough recovery in between those sessions to make the gains and you might find that if you drop from three sessions per week to two sessions per week all of a sudden you're feeling fresher in the gym you feel like you can lift heavier and then you can progress to the next step so I would recommend making that adjustment uh for most muscle groups uh training twice a week is a good one uh if you want to hit like a maintenance phase maybe you're into your marathon training and there's a block of training where it's like high volume running and you just want to maintain the strength you've gained in the gym you can temporarily back it off to once a week um that would be totally fine to do are the other part of the question about do I switch out these exercises um if you like the four exercises I guess you could switch out the exercises if you're bored of the exercises or you just dislike them some people hate a certain exercise and some people are getting really bored of a certain exercise you can switch it out to have it look somewhat different and to sort of keep motivation high but if you're okay with doing the exercises and they're shooting the goals that you're working towards um keep them if they're not shooting your goals or if your goals change and you need to meet different demands then yes we would shift the goals shift the exercises to match your goals but if they're on track to meet your goals and you're not bored of them just keep the four exercises um a lot of people talk about this uh keeping the body guessing and keep it adapting to different things but if you constantly switching it out it's hard to see consistency it's hard to see progress that's being made and I think you better off sticking with consistent consistency and similar exercises if they're meeting your goals last question we have comes in from Alicia who says recently I've begun having a flare up and I'm wondering if walking a mile a day on our treadmill has done it it's similar to walking up a slight hill the treadmill is a true form trainer treadmill I began walking daily in March I didn't ease into it I guess my question is could my daily treadmill walking have caused a flare up and should I introduce walking gradually I've been continuing to do my PhD exercises all this time okay thanks for your question Alicia um I would say walking has particular low load on the hamstring is a low loaded hamstring exercise um if you start walking uphill that's slightly more load I would say or slightly more compression uh if you are walking faster and faster and faster that is more and more and more load on the hamstring because the swing phase becomes a little bit more pace involved and as we know from running talking about previous episodes it's a swing phase or the late swing phase that's the highest demand of the hamstring and so when you start walking faster you start swinging your legs a bit more and so the the load starts to build and so I guess speed would have a component to this as well uh with that said could walking exceed the capacity and cause a flare up yes it could uh it could be a low load high volume situation and maybe on the back of that maybe a lack of recovery I'm not sure because if you're doing a daily maybe your body struggling to catch up with the load placed on the hamstring and the inability to recover in that time before you do another bout of walking um so again speed would be a factor in this but if it's a low load exercise typically it's okay but if you've done too much and your body struggled to accumulate that recovery you might start seeing the load or stress or strain on the hamstring to start to accumulate because the lack of recovery to adapt so if all other variables were consistent around this time of the flare up the treadmill was the only change um and you didn't really necessarily have a gradual introduction I'd say it's a likely cause that the treadmill has caused the flare up but you can test try temporarily backing off do your one mile walk on the treadmill every second day or just have like two or three days off and see if that improves your flare up symptoms and if it does maybe it is the walking and if it isn't then maybe there's something else going on within your day-to-day that is causing the flare up we continue experimenting um but maybe it's worth experimenting with the speed as well maybe with the incline if there isn't incline on the treadmill uh maybe every second day you just walk slower on the treadmill and see if that's enough balance to put recovery back into it but you can continue experimenting hopefully that helped hopefully all these answers has helped your better understanding of rehab and PhD as a whole and as I sign off thanks for listening and we'll catch you in the next episode if you are looking for more PhD resources then check out my website link in the show notes there you will find my free PhD five-day course other online content and ways you can personally connect with me including a free 20-minute injury chat to discuss your current rehab and any tweaks you might need to make well done for taking an active role in your rehab let's need to content like this and together we can start ticking off all of your rehab goals and finally overcome your PhD