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!!
Boring!

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 ;-).

Friday, July 22, 2016

A 12 to 18 month process .......

I've been patiently waiting for a follow up appointment with my physio since an ultrasound finally provided an explanation for 5 years of muscle fatigue/cranky muscles/tight upper hamstrings. Despite those ultrasound findings, 'pain' is not the term I would choose to describe my ongoing symptoms. I stick with 'tight and cranky' hammies. It is disappointing that an MRI in 2013 failed to detect the source of muscle fatigue, which I had localised to the hammies/glutes back in 2011. C'est la vie, 3 years later and 4 health professionals later, a diagnosis! It wasn't in my head after all! In the meantime I have totally trashed my proximal (high) hamstring tendons. The question is, what can be done at this point?
Location of proximal or high hamstring tendinopathy
The damage to the tendons cannot be reversed, it is a degenerative tendinopathy. However, the ongoing reactive tendinopathy (occurring in the remaining normal tendon tissue) can be restored back to normal. To manage the degenerative changes, the muscles that support the tendon need to be strengthened. It will be a balancing act of strengthening the hammies and then finding the right exercise program that does not stir up more episodes reactive tendinopathy. Despite the duration of this problem, the ultrasound suggests there is a reasonable amount of normal tendon tissue remaining and the sciatic nerves appear normal (no obvious adhesions or entrapment). So there is something to work with. The physio advises it will be a 12 to 18 month process! Once upon a time that would have sent me into a deep depression. However, this has been ongoing for 5! years, so 1 to 1.5 years doesn't seem that bad. It's all relative.
No more women's100 for a while

As for what that 12 to 18 months will involve, it's early days. The next 4 weeks are the starting point. Phase 1 will be LOTS of isometric exercises (e.g. the isometric bridge). These start the strengthening process and have been shown to reduce the discomfort associated with the condition when performed 3-4 times per day. There are also lots of things one should avoid doing. I really stirred up the reactive component of the tendinopathy recently with 'frustration intervals' (short, sharp speedy interval sessions), so running is something to be avoided. Gentle cycling is okay but no more Rapha Women's 100 for a while!  Other things to avoid include sitting for too long (avoid hard surfaces), too much walking (and walking up hills), hamstring stretches, deep squats, deadlifts, and hip flexion when standing (like when washing dishes and such). After the first 2 weeks of isometric exercises, if the hamstrings are more comfortable, then the next 2 weeks will include a mix of isotonic (e.g. swiss ball hamstring curls) and isometric exercises. Then it will only be 11 to 17 months to go!  

Friday, July 8, 2016

A 'bit of' bilateral proximal hamstring tendinopathy

Finally an explanation for the tight hammies that have been plaguing my running for the last few years! After messing around with various exercises and running form for the last few months, it was time to get some more imaging of the hamstrings. Sadly, back in 2013, an MRI failed to show up anything. Maybe because it is a bilateral problem and back then it was pretty similar on both sides, it wasn't obvious on the MRI (supposedly the gold standard imaging modality). Now days the right  side is always worse than the left and there continues to be a neural component mostly on the right side. An ultrasound today showed bilaterally inflamed proximal hamstring tendons, worse on the right. A shame for it to take this long to find an explanation. Thing is, I have never considered it to be 'painful' just tight and uncomfortable. Further, palpation of the affected region itself never hurt! I only feels tight with activity and gets irritated with prolonged sitting. Other people experience pain with exercise and palpation.
Unhappy inflamed hammies at their origin

Both side appear to be vascularised due to chronic inflammation
It is not a common condition, but there is plenty of information available on the internet. It is much discussed in various running and triathlon forums. Treatment usually involves rest (i.e. no running and limited cycling) and various physical therapy and exercise programs. I'm still to discuss what to do with my physio. But given the prolonged history, it won't be a quick fix if at all. Still nice to know what the problem is even if that means that's it for running. Time will tell.

Saturday, April 2, 2016

Less will have to be more

It's been a few months since the last post. That is because of recurring neural/muscle issues that negatively affect one's running. Efforts to amp up distance or pace consistently trigger the problem. While some people get back pain, I get extreme muscle tightness that is coming from irritated nerves, which get irritated as I try to run faster or if I try to run further. So essentially any of the things one needs to do to be a better runner are the very things that lead to becoming a worse runner! The question remains, how can this be managed so that it will allow some progression? Running form (when fatigued or trying too hard) is one consideration. Lex Anderson is trying to assist by providing some cues that are intended to reduce an exaggerated right to left thoracic twist evident when I run. It's not a dramatic twist, but with a rickety old back, it is probably enough to contribute to the problem. I've also already been through an array of exercise and stretching programmes that have not markedly assisted (focus was building gluteal strength was well as some specific running strength). This is being revisited looking at what can be done to reduce the stress on the nerves. It is a work in progress. That said running may well be THE stress, a reality that may have to be faced sooner rather than later.
What can be done training wise while working on running form and nerve stress? An article about veteran runners racing well with less mileage popped up in my Facebook news feed. It's about getting the right balance in the limited running you do. Don't do long runs every week. Be selective about the type of intervals you do. Don't get caught up in using weekly 5k races as part of your training. My programme has been pretty low mileage for a long time now. But I am guilty of doing intervals and parkruns and long runs all in the same week. I see others thriving on this type of programme. I also see others thriving on lots of long distance, like I once did (for a brief period). Time to play around with things. Slow down the intervals, space the hard sessions well apart and be more patient. There could be the right balance in there somewhere.