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Check out Loopi's Website here: https://www.athletetransitionlab.com/

When proximal hamstring pain just won’t settle, the conversation often turns to surgery — and that’s where confusion, fear, and mixed advice really begin.

In this episode, I’m joined by Dr. Luise Weinrich (known as Loopi), an orthopedic and trauma surgeon with extensive experience in hamstring avulsions, surgical repair, and post-operative rehabilitation. With a background as a former elite breakdancer and years working in top German sports orthopaedic hospitals, Luise brings a rare blend of surgical insight and athlete-centred thinking.

Together, we unpack the “grey zone” — the large group of runners and athletes who don’t clearly fall into “definitely need surgery” or “definitely don’t” — and how to make smarter, more confident decisions when the path forward isn’t obvious.

🎧 In This Episode, You’ll Learn:

• Why most proximal hamstring cases sit in a surgical grey zone
• The key MRI findings that matter — and the ones that don’t tell the full story
• How goals, age, chronicity, and function influence the surgery decision
• When partial tears may (or may not) warrant surgery
• Why surgery for chronic tendinopathy is often not a “winner operation”
• Common mistakes athletes make before and after surgery
• Why pre-op strength, sleep, protein, hydration, and nervous system regulation matter
• How post-op rehab should be phase-based, not timeline-based
• The biggest reasons athletes overdo or underdo rehab after surgery
• What questions you should ask your surgeon before committing
• Why post-operative protocols are essential — and often missing

🧠 Key Takeaways for Runners

• MRI findings alone shouldn’t dictate surgery — context matters
• Chronic tendon pain doesn’t automatically mean “failed rehab”
• Tendons need time, structure, and progressive loading to recover
• Surgery can remove pain drivers, but it doesn’t guarantee a “new” tendon
• Clear rehab phases + 24-hour symptom rules beat rigid timelines
• Being prepared before surgery often improves outcomes after
• If you’re unsure, a structured second opinion can prevent rushed decisions

In other words: the goal isn’t just to fix tissue — it’s to make the smartest long-term decision for your body, your sport, and your identity as a runner.

🎉 Sign up for the FREE PHT 5-Day Course HERE 🎉
🗓️ Book a free 20-minute Injury Chat with Brodie 📞
📄Learn more about Brodie's PHT AI Assistant 🔍

In this episode of the Overcoming Proximal Hamstring Tendinopathy Podcast, Brodie dives into the most commented-on and most challenging questions from the PHT Facebook community over the past 90 days.

Rather than quick comment replies, this episode delivers long-form, evidence-based explanations to help you better understand your symptoms, your scans, and your rehab options—especially when things feel confusing or discouraging.

If you’ve ever been told “it’s severe,” “you’re too old,” or “it’ll never be the same,” this episode is for you.

🔍 What You’ll Learn in This Episode

1. Severe PHT, Tendon Tears & Bursitis — Is Recovery Still Possible?

• Why tendon tears on MRI are often part of the tendinopathy spectrum, not a reason to avoid loading
• How to interpret bursitis findings and when they’re clinically relevant vs incidental
• When ultrasound-guided corticosteroid injections may (or may not) help
• Why age and genetics slow recovery—but don’t prevent it
• Realistic timelines: why “2–3 years and never the same” is poor advice

Key takeaway: Even severe, chronic PHT can improve with the right loading strategy and recovery environment.

2. Load Management: The Missing Piece in Long-Term Recovery

• Why slow, progressive strength training is still the gold standard—even in older athletes
• How to find the “sweet spot” between challenge and flare-ups
• Why setbacks usually come from mismanagement, not irreversible damage
• The role of sleep, protein (especially leucine), collagen, hydration, and overall wellness in tendon healing

3. “Can I Start Walking Again—or Am I Making It Worse?”

• Why waiting for zero pain before returning to activity often delays recovery
• How to reintroduce meaningful activities (like dog walking) safely and progressively
• Why doing something—even 2–5 minutes—can be both physically and mentally therapeutic
• How graded exposure applies to walking, running, and all functional goals

4. Heel Pain & PHT — Are They Related?

• Why plantar fasciitis commonly appears alongside PHT
• How reduced sitting → increased standing can overload the plantar fascia
• Practical strategies for managing both conditions:
  • Footwear and gel insoles
  • Sitting vs standing vs kneeling rotations
  • Step counts, surfaces, and daily load awareness

5. Prone Hamstring Curls Flaring You Up? Here’s How to Modify Them

• How to confirm whether an exercise is actually the irritant
• Why double-leg > single-leg is often the right starting point
• Using reduced range of motion strategically
• How to progress:
  • Double-leg → single-leg
  • Load first vs range first
• Why small, systematic steps matter—especially for sensitive tendons

6. Sciatic-Type Pain With PHT — What’s Really Going On?

• How to tell when symptoms are no longer “pure PHT”
• Red flags for nerve involvement (pain past mid-hamstring or below the knee)
• Possible contributors:
  • Nerve sensitivity in chronic pain
  • Scar tissue or adhesions near the sciatic nerve
  • Compensation patterns (sitting, standing, movement changes)
• Why assessment matters—and what clinicians look for:
  • Piriformis testing
  • Neurodynamic tests
  • Nerve glide exercises and when to use them

🎯 Big Picture Takeaways

• Imaging findings don’t dictate outcomes—management does
• Severe or long-standing PHT does not mean you’re “too far gone”
• Recovery improves when load, recovery, and lifestyle align
• If symptoms spread or change character, don’t guess—get assessed
• Progress comes from doing the right things consistently, not perfectly

🎉 Sign up for the FREE PHT 5-Day Course HERE 🎉
🗓️ Book a free 20-minute Injury Chat with Brodie 📞
📄Learn more about Brodie's PHT AI Assistant 🔍

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.