We are delighted to welcome back Fearghal Kerin for his second seminar on the Assessment and Management of the Sporting Hamstring. Fearghal works as a Rehabilitation Physiotherapist in Leinster Rugby and the Head Physiotherapist with Dundalk FC. He brings a wealth of experience from the Elite level of sport on the management of hamstring injuries, and he is going to share with us his insights and the latest research around hamstring injuries. Fearghal’s last seminar with us in July was a sell out so we are looking forward to what’s in store for us this time round.

Seminar content:

  • Challenges of the Hamstring Strain
  • Prevention, Prediction and the Nordic Hamstring Exercises
  • Criteria based Assessment and Rehabilitation
  • Exercise Selection
  • Return to Running and Return to Performance

With most of the seminars we will be holding, there will be a large emphasis on practical assessment and interventions, so you can take away some ideas that you may integrate into your own practice. This seminar will be 1 hour of theory and 2 hours of practical assessment and treatment. Plenty of engagement and lots to learn. This seminar is open to physiotherapists, students, physical therapists, S&C coaches and healthcare professionals.

If you have any questions, don’t hestitate to contact us at info@sportsphysioireland.com.

**REFUND POLICY**

No refunds at any time.


Proximal Hamstring Tendinopathy (PHT)

 

What is it?

A tendinopathy is a change in the tendons structure, usually in response to overload. Unlike what was previously thought, there is no real inflammation happening. The pain is due to the changing and swelling of the tendon’s structure.

PHT manifests itself as a deep pain in the glute. (literally a pain in the butt) .Pain is felt on or around the sitting bone(ischial tuberosity). Pain comes on gradually with no acute onset or mechanism of injury.

PHT is common in runners, but also occurs in the non-athletic population. Oftentimes people can have these symptoms for a long time, and they try to ignore it, until the stage where everyday activities are painful- sitting, going from sit to stand, stretching, sitting on hard surfaces.

 

How did I get this?

If you think you may be suffering from PHT you might ask why me? How did this happen?

Oftentimes a PHT develops after a period of increased training load. Have you increased your mileage, starting adding in hill workouts, more speedwork? All of these disrupt the balance in the tendon, not allowing the tendon enough time to respond and adapt, causing the tendon to become irritable and sore.

Similarly movements which put a compressive load on the hamstring tendon can cause symptoms. Excessive Yoga and pilates stretching positions which involve deep lunging can aggravate the tendon.

 

What do I do?

If you think this sounds like you book in with your physiotherapist for a thorough assessment. There are differential diagnoses which need to be out-ruled such a low back pain, stress fracture of the hip or an SIJ problem.

Keep on top of your pain. NSAIDS (anti-inflammatories) have been seen to be effective in reducing tendon pain. Discuss this with your GP or pharmacist. These should not be taken as a means to mask symptoms while running, but rather if pain is limiting your everyday activities. Heat/Ice can also reduce  your pain, see which works for you.

Gentle isometrics- shown in the picture. These exercises stimulate the muscle, maintaining your strength and have been shown to reduce pain symptoms. Aim to do 5 reps of up to 45 second holds, so long as there is no increase in pain. You may feel some tension but not pain, and symptoms should reduce after the exercise.

 

What do I not do?

There are certain positions and activities to avoid, particularly when the tendon is irritable.

Don’t

-Periods of prolonged sitting, get up and move about to avoid compression on tendon.

-Don’t stretch: allow it may feel like this is what your tendon wants, it is not what it needs. Stretching places further compressive load on the tendon

– Deep lunging/ squatting

-up-hill running

– Don’t ignore your symptoms

 

How long will it take?

The sooner you get assessed the sooner you can get on the road to recovery. Tendon healing and restoration of full strength can take between 3-6 months. Within this period you may have resumed your activity fully and may be completely symptom free.

Once the cause of the tendinopathy has been found, you can start working with your physiotherapist to address this, whether that be pre existing weaknesses, training load management or other areas in your day to day which have led to PHT.

 

 

Ellie Harnett, MISCP


First of all, to all the people who attended, I hope you enjoyed the seminar as much as I did. Fearghal gave a great overview of all things related to Hamstring Injuries. It’s a complicated area and while we have made large strides in the past few years, I do think from the research that we are only beginning to really understand the issue.
Normally when we go to these Seminars, we often don’t reflect and learn from them as much as we should (I have been guilty of this). So I would encourage you all to give yourself an hour or two and review the slides over the next few weeks, notebook by your hand and scribble your learning points down. Practice some of the exercises that we did, review the methods of assessment and reflect on how you can upgrade your clinical management of these injuries. The easiest way to re-inforce the information and learn is to chat to people about this and discuss some of the main points.
A few things I took away from the seminar I will outline below.
  • Don’t be afraid to load the hamstrings as soon as the athlete can tolerate the load. This is helpful, not harmful.The traditional conservative approach is not going to help in the long term. The research has shown that having hamstrings long and strong is really important to protect against injury. Fearghal touched on how they use Nordics and other very high load hamstring exercises early in their program, and there will be more research published later this year on this early stage intensive loading. Watch the space!

 

  • Always start from the end. What do you want your athlete to be able to do before returning to play in order for you and the athlete to have full confidence in their hamstring?
  1. Most don’t have access to Nordbord, so maybe a certain number of repetitions of Nordic Hamstring Exercise? Certain amount of strength measured using a Dynamometer.
  2. Minimal amount of loading through a range of exercises e.g. RDL, SLDL, TRx Rollouts etc.
  3. Minimal number of training sessions completed?
  4. Hitting certain speed markers?

 

  • Assess, re-assess, re-assess… As you progress through the rehab programme, are you actually getting better? Fearghal spoke about re-assessing the assessables. Unless the markers you have used during the initial assessment are improving, how do you know that your rehabilitation programme is working?
    1. Is the site of palpation smaller?
    2. Is their pain during rehab? During specific exercises?
    3. Has their passive knee extension improved?
    4. Has their outer range knee flexion strength improved?

 

  • Know the running demands of the sport. This is extremely important. Are you giving out a generic rehab programme or preparing that individual for their sporting demands?
    1. What sport does that person play?
    2. What are the positional demands of that sports? Defender vs Midfielder?
    3. What is the overall running volume of that sport?
    4. How many max speed runs will that person be potentially exposed to during a game situation?
    5. Is that person ready for the worst case scenario or minimal demands?
    6. How can you replicate those demands in rehabilitation?

 

  • Always be on the watch out for the unexpected.
    1. Know your mechanism of injury. This can give you a better idea of the potential area of injury and also give you a better prognosis in the timeline to return to play (Askling, 2013).
      • Sprinting? Probably the Biceps Femoris Long head
      • Stretch? Potential for more proximal tears of the hamstring group. Time to return to play will be longer, median 50 days.
      • Position of knee and hip during injury?
    2. Be aware of pop and loss of function that may suggest an avulsion.

 

Thomas Divilly
Chartered Physiotherapist, MISCP, CSCS

As some of you may be aware we are hosting a Hamstring Seminar at the start of next month, and in preparation we are catching up on some of the latest research surrounding this topic. It can be an extremely confusing area as much has been done in the past 10 years, however people are still unsure of how to properly manage this injury. We are trying to get some of the best clinicians and researchers to give us an insight into their methods of assessment and management of some of the most complex topics. They will try to give us the most up to date research that they are using on their patients, hopefully helping us to stay up to date with best methods and practices.

 

So I would encourage everyone to have a read of the following few articles that have come out recently and consider how they may influence practice

 

 

  1. Hansen et al. Peak medial (but not lateral) hamstring activity is significantly lower during stance phase of running. An EMG investigation using a reduced gravity treadmill. Gait & Posture. (2017). 57 (7-10).

 

  • They discovered that increased hamstring muscle activation occurs with increased speed
  • The pre heel strike (swing phase) muscle activity peaks are higher than the post heel strike (stance phase) peaks for both the medial and lateral hamstrings.
  • The peak activation for both phases was slightly (but not statistically significantly) higher for the lateral hamstrings throughout the gait cycle whereas the medial hamstring peak was approximately 20% lower during stance (large effect size).
  • The reduction in peak activity of the medial hamstrings during swing phase suggests that there could be a relatively higher load being borne during running by the lateral hamstrings as the medial hamstrings are effectively afforded a slight “rest” during the swing phase.

 

We know that Nordics preferentially target the semitendinosus muscle (still has a large effect on muscle activation of the  BFlh). Maybe the role in Nordics is by increasing the load capacity of the semitendinosus?

 

 

  1.   Bourne et al. Impact of the Nordic hamstring and hip extension exercises on hamstring architecture and morphology: implications for injury prevention. BJSM. (2016). 0 (1-9).

 

  • This study compared a 10 week programme between Hip Extension at 45 degrees, Nordic Hamstring Exercise and a control on measures of Bicep Femoris Fascicle length, muscle volume, architectural cross-sectional area (ACSA) and strength.
  • Some of the main findings:
    • BFLH volume increased significantly more in the HE than the NHE, however no significant changes were noted between the NHE and HE on semitendinosus muscle volume
    • The percentage change in BFLH ACSA was greater in the HE training group than in the NHE.
    • Participants increased their fascicle lengths from ∼10.6 cm prior to training, to 12.8 and 12.0 cm in the NHE and HE groups, respectively, which would likely result in large reductions in hamstring injury risk.
    • This study shows, for the first time, that the limited excursion of the hamstrings during the NHE does not prevent the exercise from increasing BFLH fascicle length. Indeed, the exercise resulted in greater fascicle lengthening than the HE, although the current study lacked the statistical power to distinguish between the two.  
    • Both exercises resulted in significant strength increases, which were similarly evident in the NHE and HE strength tests.

 

This study expands our understanding of other exercises often used in the rehabilitation and performance setting. The next step would be to do an RCT looking at the ability of the HE exercises to reduce Hamstring injuries across a season.

 

 

  1. Lovell et al. Hamstring Injury Prevention in Soccer: Before or After Training?. Scand J Med Sci Sports. (2017). Ahead of Print Online.

 

  • This article is an essential read if you are working in team sports whether as a Physiotherapist or Strength & Conditioning professional. It’s always a worry to carry them out before training, however post training fatigue may reduce the quality and compliance rates.
  • Three groups underwent a 12 week program, before training NHE group, after training NHE group and a core stability group.
  • The main findings from the study:
    • Changes in eccentric hamstring peak torque were greater in both NHEBEF (+11.9%; 3.6% to 20.9%) and NHEAFT (+11.6%; 2.6% to 21.5%) versus control (likely moderate effect), with no difference denoted between NHEBEF and NHEAFT .
    • The estimated change in biceps femoris fascicle length (expressed in both absolute, and relative to muscle thickness terms) was higher in NHEBEF versus both NHEAFT and CON.
    • Strength adaptation in the NHEBEF group was characterized only by an increased BF fascicle lengthening, whereas the NHEAFT cohort demonstrated the typical hypertrophic response, identified by an increased muscle thickness and pennation angle.
    • explained by the increased fascicle length that was exclusive to NHEBEF, the magnitude of which (12.9%) exceeded the minimum detectable change thresholds previously reported.
    • This study has demonstrated that scheduling Nordic hamstring exercises before or after football training has similar eccentric strengthening outcomes, but divergent architectural adaptations.

 

We know from some of the work done by David Opar and Dr. Anthony Shield group in Australia that the main protective mechanisms from Hamstring injuries is high eccentric strength and long fascicle length. The architectural adaptations for the NHE before group may be more advantageous however these may need to be explored in more detail over a longer period of time.

 

Let us know your thoughts!

 

Thomas Divilly

MSc MISCP CSCS

 

 


High Hamstring Pain

Runners and sometimes field based athletes can present with lower buttock pain in the clinic. This can reduce performance and be painful carrying out normal daily activities. After assessment, this is usually diagnosed as a proximal hamstring tendinopathy.

A proximal hamstring tendinopathy is when the tendon that inserts into the bony point of the bottom, the ischial tuberosity, gets overused and causes structural changes in the type of collagen present in the tendon. This can cause pain to the bony area, especially with sitting on hard surfaces, in cars, etc.

The main symptoms are:

  • pain on running activities,
  • pain when sitting down, especially on hard surfaces,
  • pain when flexing the hip e.g. putting on a sock.

 

In a clinical setting, the main reasons behind development of the tendon issue is due to overload of the tendon i.e. the tendon has been asked to do too much work for it’s ability to recover. So the typical story of a patient who presents with high hamstring pain is how they felt great during their runs over the preceding weeks and decided to increase the volume or intensity of their runs, or sometimes both! Another factor that may cause the issue to develop is hill running, which causes the hamstring muscles to come under increased eccentric stress, leading to tightened hip flexors, which in turn will contribute to the hamstrings working harder.

It’s important to get the region properly assessed to rule out other pathologies such as: lumbar referral, bursitis of the ischial tuberosity, glute max pain, sciatic nerve irritation, referral from the hip joint.

 

The best solution short term is to reduce and avoid the causing factors until the pain has subsided and get a proper assessment from one of the team to get a good structured rehabilitation programme under way..

 

Thomas Divilly

MISCP CSCS


The Story of the Nordic Curl

Hamstring tears are one of the most common injuries in team sports and track & field events such as sprinting, hurdles and triple jump. Team sports that combine high speed running and kicking are at the greatest risk with gaelic football, soccer and rugby showing the greatest incidence in Ireland. Surprisingly in these sports the majority of the injuries actually occur during running or sprinting activities rather than the kicking activities. Hamstrings have a very high re-injury rate and causes significant loss of training and competition time.

Excessive strain while the hamstring is lengthening (eccentric contraction) is the primary cause of the tear. The time lost from sport will depend on the severity of the tear: classified into grade 1, 2 and 3 tears.

The Nordic curl has received a lot of great publicity recently for the prevention of hamstring injuries. Research has shown a significant reduction (greater than 60%) in the risk of acute injury or re-injury following a Nordic curl training programme. This is good news for those of you who suffer with repeated hamstring tears. There’s only one small problem….Nordic curls are a very hard exercise to do, especially if you are recovering from a recent tear. Very few top notch athletes or clients that come through the door can do them injury free.

The key benefit of Nordic Curls is that they eccentrically load the hamstring i.e. strengthen the hamstring through controlled lengthening. Loading the hamstring in this way improves its neuromuscular control and strength in the at risk ranges of motion. Alternative exercises can be used however that load the muscle in the same pattern and are a more realistic expectation for any athlete wanting to start this type of training. Once these exercises become easy at high load progression to the Nordic curl will be much more achievable.

Catherine Simpson, MISCP MSc. Sports Medicine


Hamstring Pulls are so common

Hamstring rehab step by step at SPI

1) Identification

I find out the main cause of the injury and locate the specific point of injury

2) Strength and regeneration of injured site

I focus in on the injured pattern and pick movements and exercises specific to the individual to both fix and prevent future injuries to the area

3) Return to play

At SPI we understand the demands put on sports people from running to ultimate frisbee. We make sure our clients are fully prepared by simulating game or competition situations in their rehab prior to actual return.

Joey Boland Head Physio at SPI