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For years, chronic tendinopathy has been treated as a tendon problem — load it, strengthen it, remodel it. But what if, for some runners, the tendon itself isn’t the main driver of pain anymore?

In this episode, Brodie breaks down a new 2026 systematic review that may reshape how we think about stubborn, long-standing tendon pain. The paper explores whether nerve ingrowth and abnormal blood vessels around tendons — not degeneration of the tendon tissue itself — may be the real pain source in chronic cases.

We unpack the emerging research, explain each intervention in plain language, and discuss who this may (and may not) apply to — especially runners stuck in repeated rehab cycles despite “doing everything right.”

This is early, evolving science. But it’s a fascinating glimpse into where chronic tendon treatment may be heading next.

What You’ll Learn in This Episode

• Why some chronic tendon pain may be neuropathic (nerve-driven) rather than structural
• How abnormal blood vessels and nerves grow into painful tendons over time
• Why traditional loading programs sometimes stop working in very chronic cases
• What “neural modification” treatments aim to do — and why they’re gaining interest
• The six intervention categories reviewed in the paper (explained simply)
• How strong (or limited) the current evidence actually is
• Where this research fits alongside exercise-based rehab, not against it

Interventions Reviewed (Plain-English Overview)

1. High-Volume Injections (HVIGI / HVDI)

Large volumes of fluid are injected around the tendon (not into it) under ultrasound guidance to mechanically disrupt abnormal blood vessels and pain-sensitive nerves.

Key takeaway:
Consistent short- to medium-term pain and function improvements, especially in people who had failed exercise-based rehab.

2. Sclerosing Polidocanol Injections

A chemical agent is injected directly into abnormal blood vessels to deliberately close them down, cutting off blood supply to pain-producing nerves.

Key takeaway:
Moderate to strong pain reductions in very chronic cases, with outcomes comparable to surgery in some studies.

3. Radiofrequency Microtenotomy

A minimally invasive procedure using controlled heat to disrupt nerve ingrowth and abnormal vessels at the tendon–paratenon interface.

Key takeaway:
Very strong results in a small cohort, but higher risk and limited evidence so far.

4. Minimally Invasive Paratenon Release

Scar-like adhesions between the tendon and surrounding tissue are mechanically released to restore tendon movement and reduce nerve irritation.

Key takeaway:
Large pain reductions and high rates of pain-free outcomes in non-insertional Achilles tendinopathy.

5. Electrocoagulation Therapy

Electrical energy is used to seal off abnormal blood vessels surrounding the tendon under ultrasound guidance.

Key takeaway:
Promising early results, but evidence limited to one small study.

6. Surgical Interventions (Open & Endoscopic)

Surgery physically separates the tendon from irritated surrounding tissue and removes abnormal vessels and nerves.

Key takeaway:
Effective for some, but invasive, with longer recovery and higher risk.

The Big Picture Takeaway

Across very different procedures, outcomes were surprisingly similar.

That points to a common mechanism:
👉 Modifying the neural (nerve-driven) pain environment around the tendon, rather than “fixing” tendon structure itself.

This doesn’t replace exercise-based rehab — but it may explain why a subset of runners with long-standing, highly sensitive tendinopathy stop responding to load alone.

This research is best viewed as a future direction, not a replacement for good rehab principles.

🎉 Sign up for the FREE PHT 5-Day Course HERE 🎉
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Check out Lasse's website here: https://www.lasselempainen.fi/?lang=en

In this episode, Brodie sits down with world-leading orthopedic surgeon Dr. Lasse Lempainen, a specialist in complex hamstring injuries, to answer one of the most confusing and anxiety-provoking questions runners face:

“How do I know if I actually need surgery — or if rehab is still the right path?”

Drawing on decades of surgical experience and extensive research into hamstring avulsions and proximal hamstring tendinopathy (PHT), Dr. Lempainen walks through how he actually makes decisions in real clinical practice — not just what MRI scans show, but how symptoms, function, timelines, and rehab quality all fit together.

Together, Brodie and Lasse unpack the gray area that most runners live in: partial tears, chronic pain, mixed scan results, failed rehab attempts, and fear-based decision-making. The result is a balanced, evidence-informed discussion that helps runners understand where surgery fits — and where it doesn’t.

What You’ll Learn in This Episode:
How Surgeons Decide Who Actually Needs Surgery

• Why MRI findings alone are never enough
• The importance of correlating scans with clinical function and symptoms
• Why some complete avulsions heal well conservatively — and others don’t

Hamstring Avulsion vs Proximal Hamstring Tendinopathy (PHT)

• Key differences between acute avulsions, chronic avulsions, and tendinopathy
• Why not all “avulsions” are the same (1-tendon vs 3-tendon injuries)
• When retraction distance matters — and when it doesn’t

Critical Timing Windows

• Why acute avulsions should ideally be operated on within 2–3 weeks
• What happens when diagnosis is delayed
• When chronic injuries become harder (or impossible) to fully restore surgically

“Failed Rehab” — What That Really Means

• Why many runners are told they’ve “failed rehab” when they actually haven’t
• Common mistakes in conservative treatment (under-loading, poor progression)
• When even excellent rehab is unlikely to succeed due to tendon biology

What Surgery for PHT Actually Involves

• What surgeons look for during surgery beyond “tendon thickening”
• The role of semi-membranosus release, scar tissue, and sciatic nerve involvement
• Why surgeons often find structural issues not obvious on standard MRI

Common Pre- and Post-Op Mistakes

• Why under-diagnosis is one of the biggest pre-op risks
• Why returning to running too early post-op leads to setbacks
• The importance of fixing why the injury happened — not just repairing tissue

Key Takeaway

This episode helps you understand which group you fall into, without fear-based decisions or false hope.

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In this episode, Brodie breaks down a newly published review paper that takes a deep dive into what’s actually happening inside painful tendons — far beyond the usual “overuse” explanation. You’ll learn how healthy tendons are structured, what changes at a microscopic level when tendinopathy develops, and why pain severity often doesn’t match what shows up on scans. The episode explores how factors like load management, low-grade inflammation, oxidative stress, ageing tendon cells, and overall metabolic health all interact to influence tendon pain and recovery.

Brodie also discusses what this emerging science means for real-world rehab — including why rest alone doesn’t work, why exercises sometimes stall progress, and why a more holistic approach is often needed. The episode finishes by looking ahead at future treatment directions, from improved diagnostics to regenerative and molecular therapies, while grounding everything in practical takeaways runners can apply right now. If you’re dealing with persistent tendon pain — especially proximal hamstring or Achilles tendinopathy — this episode will help you understand why recovery can be slow and what actually gives you the best chance of long-term success.

🎉 Sign up for the FREE PHT 5-Day Course HERE 🎉
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In this episode, we break down a brand-new randomized controlled trial comparing individualized physiotherapy with shockwave therapy for proximal hamstring tendinopathy. I walk through how the study was designed, what each treatment involved, and why the results showed no meaningful difference between the two approaches. We also explore the role of education, load management, and compressive tolerance, and what this means for your rehab decisions moving forward. If you’ve ever wondered whether shockwave is worth trying or how it stacks up against a structured strength program, this episode gives you a clear, evidence-based answer.

Paper 1: Physiotherapy Compared With Shockwave Therapy for the Treatment of Proximal Hamstring Tendinopathy: A Randomized Controlled Trial
Paper 2: Treatment of Proximal Hamstring Tendinopathy with Individualized Physiotherapy: A Clinical Commentary

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🗓️ Book a free 20-minute Injury Chat with Brodie 📞
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For ALL Other Resources, Visit the Website proximalhamstringtendinopathy.info
Run Smarter AI Assistant: Access personalized, research-based answers to your running and rehab questions. This tool integrates Brodie’s database of research papers and podcast episodes for tailored advice.

Research Deep-Dive: Hamstring Strength & Running Biomechanics

This episode reviews the study: “Hamstring Strength and Architectural Properties Are Associated with Running Biomechanics”, including findings from ultrasound imaging, EMG analysis, and 3D running mechanics.

Key Study Questions

• Do stronger hamstrings create better running mechanics?
• Do better mechanics help build stronger, longer hamstrings?
• How do strength, fascicle length, pelvic position, and muscle activation interact?

🔎 Main Findings From the Study

1. Stronger Hamstrings = Better Running Mechanics

Athletes with higher eccentric hamstring strength had:

• Higher stride frequency (cadence)
• Better control of decelerating the swinging leg
• Lower ground contact time (improved efficiency)
• Lower hamstring activation at sub-max speeds → reduced overload

2. Longer Hamstring Fascicles = Safer, More Efficient Loading

Runners with longer fascicle lengths showed:

• Less anterior pelvic tilt
• Lower hamstring activation
• Better ability to tolerate late-swing loading (a high-irritation phase for PHT)

3. A Two-Way Relationship Exists

Strength ↔ mechanics influence each other.

• Stronger hamstrings → better running technique
• Better running technique → better hamstring loading → stronger, longer muscle structure over time
  This creates a positive adaptation loop.

4. Over-Reliance on the Biceps Femoris = Red Flag

Runners with weak or short hamstrings tended to over-activate the biceps femoris long head — the most common site of PHT.
Stronger runners shared load better with the medial hamstrings, reducing tendon stress.

🏃 Practical Rehab Takeaways

1. Build Eccentric Strength

Eccentric strength is one of the strongest predictors of hamstring injury risk.
Examples Brodie recommends:

• Hamstring sliders
• Weighted eccentric sliders
• Single-leg sliders
• Assisted → full Nordic drops
• Deadlifts (when tolerated)

2. Improve Fascicle Length

Eccentric exercises at long muscle lengths help lengthen fascicles naturally — more so than stretching alone.

3. Strengthen the Medial Hamstrings

To prevent overload of the biceps femoris:

• Use toes-in hamstring curls
• Toes-in sliders
• Toes-in deadlift variations
  These help redistribute load more evenly across the tendon.

4. Slightly Increase Cadence (~5%)

A small increase in stride frequency may reduce late-swing strain and improve running economy.

5. Integrate Running Into Rehab

Before adding speed:

• Build to 30 minutes continuous, easy running → symptom-free
  Then introduce:
• Strides (15–20 sec at ~75% speed, 4 reps)
• Gradual progression based on symptoms the next day

Final Thoughts

Hamstring strength, muscle architecture, and running technique are deeply interconnected. Improving one helps improve the others — creating a pathway toward better performance and long-term PHT resilience.

🎉 Sign up for the FREE PHT 5-Day Course HERE 🎉
🗓️ Book a free 20-minute Injury Chat with Brodie 📞

For ALL Other Resources, Visit the Website proximalhamstringtendinopathy.info
Run Smarter AI Assistant: Access personalized, research-based answers to your running and rehab questions. This tool integrates Brodie’s database of research papers and podcast episodes for tailored advice.

Paper Title 1: Porcine Collagen Injection Therapy Affects Proximal Hamstring Tendinopathy in Athletes by Reducing Time to Return to Sport
Paper Title 2: Estrogen and progesterone exhibit distinct yet coordinated roles in the regulation of tendon extracellular matrix remodeling

🎉 Sign up for the FREE PHT 5-Day Course HERE 🎉
🗓️ Book a free 20-minute Injury Chat with Brodie 📞

For ALL Other Resources, Visit the Website proximalhamstringtendinopathy.info
Run Smarter AI Assistant: Access personalized, research-based answers to your running and rehab questions. This tool integrates Brodie’s database of research papers and podcast episodes for tailored advice.

In this episode, Brodie reviews brand new research exploring patients’ real-life experiences receiving physio-led rehab vs shockwave therapy for proximal hamstring tendinopathy (PHT). This qualitative study highlights what people found most helpful, frustrating, and effective during rehab—revealing valuable lessons for anyone currently recovering from PHT. Brodie also provides a personal update on his own hamstring rehab and HYROX training progress.

Check out the paper here: Education, rapport and convenience are key to participants’ perceptions of receiving physiotherapy or shockwave for proximal hamstring tendinopathy: a qualitative study

🎉🎉 Sign up for the FREE PHT 5-Day Course HERE 🎉🎉
For ALL Other Resources, Visit the Website proximalhamstringtendinopathy.info
Run Smarter AI Assistant: Access personalized, research-based answers to your running and rehab questions. This tool integrates Brodie’s database of research papers and podcast episodes for tailored advice.