From Fear to Safety: A Roadmap to Recovery

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Proximal Hamstring Tendinopathy: A Roadmap to Recovery


Welcome to this podcast episode where we’ll be delving into the world of proximal hamstring tendinopathy (PHT), also known as high hamstring tendinopathy. We aim to help you understand this condition better, learn about evidence-based treatments, and dispel common misconceptions. I’m Brodie Sharp, your host, an online physiotherapist, recreational athlete, creator of the Run Smarter series, and someone who has battled chronic proximal hamstring tendinopathy.

Discovering Valuable Insights

In this episode, we’ll be discussing a 2022 paper titled “From Fear to Safety: A Roadmap to Recovery from Musculoskeletal Pain.” I stumbled upon this paper on Twitter, where I often keep up with the latest scientific literature. The paper explores pain science, chronic pain, and the journey to recovery—topics I’m deeply passionate about.

The Complex Nature of Pain

Pain is not just a physical ailment; it’s a complex interplay of various factors. Beyond the injury itself, it involves psychological, social, cultural, sensory, and many other dimensions. These elements interact and fluctuate over time, making chronic pain a unique experience for each individual.

The Influence of Language and Communication

The way healthcare professionals communicate information can significantly impact a patient’s pain experience. For example, a study mentioned in the paper found that patients who received threatening language in their MRI reports were more likely to perceive a need for high-risk interventions like opioids, injections, and surgery. This highlights the importance of delivering information in a way that doesn’t escalate fear and anxiety.

Understanding Pain-Related Fear

“Pain-related fear” refers to the cognitive and emotional response when the body is perceived as being in danger and needing protection. It’s important to recognize how pain-related fear can influence a person’s perception of their pain experience and their behavior.

The Role of Psychological Factors

Psychological factors, including pain-related fear, psychological distress, and self-efficacy, play a significant role in the relationship between pain and disability. High levels of pain-related fear can predict increased disability and poor outcomes in individuals with chronic musculoskeletal pain.

The Need for a Holistic Approach

The management of chronic musculoskeletal pain should encompass biological, psychological, and social perspectives. However, clinicians, especially physical therapists, often lack clear guidance on implementing psychologically-informed approaches in practice. Addressing the psychological and social aspects of pain is essential for comprehensive care.

Overcoming Fear Learning

Fear learning can be a significant obstacle to recovery. It occurs when individuals associate specific activities or movements with pain and subsequently avoid or modify them to reduce fear and pain in the short term. However, this avoidance prevents positive learning experiences that challenge their expectations and beliefs.

Factors That Reinforce Fear Learning

Several factors can reinforce fear learning and avoidance behaviors, including:

  1. Diagnostic Uncertainty: When individuals are unsure about the cause of their pain, it can lead to anxiety and fear.
  2. Threatening Scan Reports: Negative language in medical reports can increase fear and anxiety.
  3. Conflicting Advice: Receiving conflicting advice from different healthcare providers can create uncertainty.
  4. Societal Beliefs: Widespread beliefs about the vulnerability of certain body parts can contribute to fear and avoidance behaviors.

Generalization of Fear and Avoidance

Fear can generalize to other activities and movements, both similar and dissimilar to the original painful trigger. For example, someone with PHT might initially avoid sitting but may eventually avoid bending, lunging, or even walking. This generalization reduces opportunities to disconfirm fear expectations, reinforcing unhelpful behaviors and perpetuating disability.


Proximal hamstring tendinopathy is a multifaceted condition influenced by various factors, including pain-related fear and psychological distress. Understanding these factors is crucial for developing effective treatments and promoting recovery. In the next part of this series, we’ll delve deeper into cognitive functional therapy and its role in helping people overcome musculoskeletal pain and fear. Stay tuned for more insights and strategies to overcome proximal hamstring tendinopathy and similar conditions.