Saturday, April 22, 2017

The hamstring conundrum

The corticosteroid injection made no difference and another attempt at a walk/jog programme resulted in increased irritation in the hamstrings. The Doctor then sent me off for an MRI to better assess the situation. Alas, as expected the hamstrings looked pretty crappola on the MRI. After that news I was ready to 'accept' my fate. After all, I'm in my 50s and seem to have genetic predisposition to tendon problems (I still have medial epidocondylitis after 6 months and have had other arm tendon niggles in the past). However, my doctor was not going to let me get off that lightly. She was adamant that if I take a rest, it may settle down, but it would flare up as soon as I increased the load on the tendons. Next step, a referral to see Craig Purdam, a physio with much experience with tendinopathies. I have read a number of his publications and he has been at the forefront of tendon research for some time. I was lucky to get an appointment with him as he is reducing his caseload as he heads towards retirement. It's been a bit of a wait and I will be seeing him at the end of April.
In the meantime a few things have seen me re-evaluate the situation. After taking a (complete) rest period, the hammies did seem to settle down, BUT going for some walks set them off again. The rest has resulted in them becoming even less tolerant of load than before! How frustrating! However, I did a bit more research and discovered that this apparently is a common finding. Jill Cook, a research colleague of Craig Purdam, strongly advises that exercise is the best treatment for tendinopathy. That is, the right programme of exercise. Of particular interest to me was Cook's recommendation that there should be at least 2 minutes rest between any tendon exercise repetitions. Well heck, I have not been doing that, it was not pointed out to me that I should be. I have been suspicious that my exercise programme has not been allowing for sufficient recovery, but I did not realise it was at such a microlevel. Oddly this gives me some hope. I know I can settle the hammies down again with isometric exercises, but this time with appropriate rest between repetitions. From there I am hoping Craig Purdam can help me with staging an exercise programme in a way that allows for sufficient recovery and forward progress. Now I'm just waiting for that appointment at the end of April.

Saturday, February 25, 2017

My hammies are trashed

Yep, trashed they are. Despite all the appropriate rehabilitation and taking it easy, they continue to niggle. Because of this and my continuing frustration, I consulted with another specialist sports medicine doctor to see what else, if anything can be done. She did a full assessment and found that strength-wise the hammies are good, the glutes are firing well (they often don't in runners), but the lower back is still far too stiff (admittedly back loosening exercises haven't been a high priority in recent times).

She is a strong advocate of progressive loading of the hamstrings, regardless of my age and other risk factors. I indicated I have had several attempts at doing this only to have the hammies get more niggly. So we then discussed the big 'C' word, yep corticosteroids. CSs are commonly used to control inflammation and the associated pain in joints, ligaments and tendons. The downside is they can mask damage and interfere with healing as inflammation is part of the healing process. Of course, it is also possible that the pathology in my tendons is due to an abnormal inflammatory response and switching it off for a while may be of benefit. So despite my distrust of CS injections I opted to go ahead and get it done. I have two focal areas in my right hammies that continue to niggle and these were the areas to target.

The procedure is done using ultrasound guidance by a specialist medical imaging doctor. The preliminary ultrasound confirmed the presence of ongoing inflammation (not much change from seven months ago 😞). When injecting the solution (in this case Celestone - active ingredient betamethasone) it helps better visualise the tendons and the doctor commented that there are some big holes in my tendons. So yep they are trashed. Prognosis is pretty poor. The imaging doctor commented that he had not treated a lot of people with hamstring tendinopathy as it is not a common problem. He did mention one person with a big defect in a tendon that responded well to CS injection. He said that given the size of the holes, PRP would likely have limited effect given the inability to adequately immobilise the area post-injection. The PRP I had last year certainly hasn't helped.
I hope I enjoy pool walking as much as this woman 😉
So next step is the exercise rehabilitation prescribed by the sports doctor after resting for one week post-CS injection. The CS injection can take anywhere from two days to two weeks or more to have an effect (if it does). At less than 24 hours post-injection, there is no notable improvement, with a bit of 'injection' soreness. Payback karma perhaps from all my days as a horse vet and all the injections I gave my patients in the rump 😉! The exercise rehabilitation will involve some pool walking as this will load the hamstrings more gently and have the added beneficial effect of working the lower back to improve its mobility. Cycling is okay, recommence the walk/jog programme and keep doing all the gym work I've been doing. Then return to the sports doctor in five weeks time for a follow up and progress report.

I'd like to say I'm optimistic, but based on the ultrasound findings I'm not. However, now that I know the opinion of the specialist sports medicine doctor, I'll just figure out a way to manage this so I can stay somewhat active. 

Sunday, December 11, 2016

I've lost that blogging feeling

2016 has been a tough year on the exercise front. No running since early July, limited cycling since August, medial epidondylitis (left arm) brought on by boxing and extra upper body gym work, and those evil #HFH that are taking their sweet time healing. In regards to the #HFH, the platelet rich plasma may have helped a bit. The left #HFH are no longer complaining and the right #HFH discomfort seems to be more focal and sporadic. The medial epidondylitis is actually quite a problem. It limits what exercises can be done in the gym and does affect day to day activities. It also leaves me with a serious meloxicam dependence, as that is the only way to limit the discomfort. It seems this 50+ female has dodgy tendons and has to find a way to manage them. Hence today's title. Blogging about one's ailments is not particularly appealing.

Medial epicondylitis - also known as golfer's or thrower's elbow
I am continuing to follow a prolonged hamstring rehabilitation/strengthening program. The hamstrings are getting stronger and more tolerant of certain activities. The most challenging exercise is the eccentric nordic hamstring curl. It's a popular exercise for a number of sports as a means of preventing hamstring injuries. The main issue for hamstring tendinopathy is avoiding loading the tendon when it is compressed e.g. seated hamstring curls, squats and deadlifts i.e. no bending at the hips with load. So there are only a limited number of strengthening exercises one can do while in the rehabilitation phase. Eventually one can introduce more traditional exercises, which will be crucial for long-term management.

 On the positive, I've been able to do some long walks and hilly walks without too much discomfort/tightness. Cycling if done sensibly is only mildly irritating for the right #HFH. A walk/jog/walk programme may not be too far away. In the meantime, here's hoping the #HFH become super strong and I can build up to the full ROM (range of movement) for nordic curls.

Sunday, October 23, 2016

Platelet rich plasma injections #1

I had my first lot of PRP injections on Thursday. It's a pretty straight forward process. I donated some blood to create the PRP. The affected region was visualised using ultrasound to identify the best position to inject the PRP. Local anaethestic was injected into the skin to reduce the discomfort from the needle used to inject the PRP. Appropriate aseptic technique was used and with ultrasound guidance, the PRP was injected into the hamstring tendons (both legs). The procedure was only mildly uncomfortable and there is a bit of residual soreness in the injection sites. Slow walking at present involves some minor discomfort. The recommendations vary between doctors. At this stage it is best to limit activities for the first week following the injections. Gentle walking is okay, but no more than that. Maybe after that week it will be okay to try a short gentle bike ride. In 3 weeks time I go back for a second round of injections and repeat the process.
It is difficult to know how long the recovery will take. It is important to continue with the exercise programme, which will be with me for the remainder of my active life. The hamstrings will always need to be nursed and kept strong. Similarly core, glutes and hip muscles need to be performing at their best to take the strain off the hamstrings. No opportunity to slack off. In the meantime I'll report back again after the next round of injections.

A nice review about the role of platelets in tissue repair is found HERE.

Tuesday, October 4, 2016

Looking for alternatives #2

Strengthening exercises and appropriate rest are the hallmarks of therapy for high hamstring tendinopathy. For some rest is simply reducing what they are doing to what they can tolerate. For others it means stopping all together as there is no tolerable level. Sadly I fall into the latter category. The question remains, are rest and exercises the best option for healing a chronically degenerative tendon? Is such a tendon capable of healing to a point where it can function normally again? There are other treatment options and one includes injection of platelet rich plasma (PRP) into the damaged tendon. Platelets are full of growth factors and cytokines to promote healing of damaged blood vessels. There is some evidence those growth factors and cytokines help other tissues heal as well. As such doctors have been using PRP to treat tendinopathies. The results are mixed. For some there is an obvious benefit, for others not so obvious.

As it turns out, I have a soft spot for platelets as my PhD focused on horse platelets. Today I spoke with a sports medicine doctor about going down the PRP path to try and boost tendon healing. Despite rest and all the appropriate exercises, the hammies are still pretty niggly. The doctor thinks it is worth trying given the chronicity of my problem. The injections can leave you a bit sore for a few days, so I'm waiting a couple of weeks before starting treatment due to an upcoming work trip. In the meantime it is boxing, swimming and hamstring exercises.

Monday, September 26, 2016

Looking for alternatives

It seems the #HFH will only be happy if allowed to take a proper holiday. Cycling was discontinued on 18 August. The elliptical trainer and gentle walk/jog programme also had to be aborted and the last official leg activity was 8 September. Arghhh - what's a person to do?
This is Donald
It was then that I met 'Donald' in a local Sportsman Warehouse store and I had the answer. What better way to deal with all this pent up energy than a session with 'Donald'? Donald is otherwise known as a reflex bag and allows for a pretty good boxing workout. Obviously with a bit of improvisation to minimise leg use so the #HFH aren't involved. I have been gradually building up the boxing sessions and they do a pretty good job of getting the heart rate elevated. It's just alternate days at this stage to allow the hands and arm muscles time to recover. A bit of variety will probably include a weekly swim session with a pull bouy. I survived my first swim session today, but it's not something I enjoy and I can still smell the chlorine hours later! It's hard to say how long it will be before leg-based exercise can recommence. Maybe sometime in November. Ultimately I need a period of being completely asymptomatic. It's pretty arbitrary, but I'm going to shoot for 4 weeks of no hamstring discomfort including being able to sit down with no niggles! As there are still obvious niggles at the moment, the earliest would probably be November. In the meantime the isometric exercises continue and will eventually progress to more strengthening exercises once the #HFH settle down a bit. It's going to be a while before any running will be blogged. Over and out.

Tuesday, August 23, 2016

Progress is slow

The hamstrings from hell (aka #HFH) are taking their sweet time settling down. It's been a tad over 6 weeks since my last run and symptoms are still hanging on. The good news is the symptoms are reduced, but sitting continues to be a pain in the butt. Thank goodness I have a sit/stand work station at work! Unfortunately, cycling is not agreeing with the #HFH and I've had to abort that form of exercise. My physio wants me to stay active, so it's onto Plan B on the exercise front. Today I tried a short little session on an elliptical trainer. It was a short light session and it looks optimistic that this may be an alternative to cycling. Unfortunately, like wind trainers, time stands still on the elliptical! It is boring as!!

The other option is a bit of the walk/jog combo (mostly walking!). I haven't tried that yet, maybe in a few days time. Otherwise it's a life of gym sessions and daily hamstring work. Yawn! Oh well only another 11 to 17 months to go ;-).