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


Join us here at Sports Physio Ireland on the 1st December 2017 for our 6th educational seminar for health professionals.

The seminar will be hosted by Mr Paul Kirwan who will be discussing the management of the achilles tendinopathy.

Paul Kirwan is a Chartered Physiotherapist and Clinical Research Fellow with over 20 years of clinical experience. Currently, he works as a physiotherapist in Connolly Hospital Dublin in an advanced practice role in Rheumatology/MSK and is completing his PhD through the Royal College of Surgeons in Ireland. His research is investigating the role of Glyceryl Trinitrate and exercise in the treatment of midportion Achilles tendinopathy (the NEAT trial).

Paul also works in private practice and with Bohemians FC. He graduated from Trinity College School of Physiotherapy in 1994. After this he worked in numerous hospitals in lreland, the Middle East and the United States gaining experience in treating a wide variety of MSK conditions and treating recreational to professional athletes as well as non sporting individuals. He became a Certified Strength and Conditioning Specialist (CSCS, NSCA) in 1999.

He returned to Ireland in 2003 and commenced working in Connolly Hospital with the Rheumatology team. While here he commenced working as an advanced practice physiotherapist working alongside the rheumatologists as a first point of contact clinician, and has also completed training in injection techniques.

He completed his MSc in Sports and Exercise Physiotherapy at National University of Ireland, Galway in 2009 graduating with first class honors and was awarded the Mary Sullivan Gold Medal for best student in discipline over the course of his Masters degree. He was awarded a prestigious HRB research fellowship in 2014 to complete his PhD, which he is currently pursuing in RCSI with a special interest in tendinopathy.

Paul has presented research nationally and internationally, and won a research award from EULAR in 2014, this was the first time an Irish physiotherapist has received this prestigious award in recognition for his work in this field.

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

We look forward to welcoming you into the clinic on the 1st December.


Achilles Tendinopathy in Runners

Unfortunately Achilles pain can become the bain of many runner’s careers. Whether you are an elite or a recreational runner it can affect you.

Achilles pain can come on acutely or more gradually with a seemingly insidious onset. Acute pain with a loud audible pop is known as an achilles rupture, and one which is difficult to miss. This article will deal with the less acute, grumbly tendons namely- achilles tendonopathy.

 

What is a tendinopathy?

A tendinopathy is a change is the tendon’s structure. When we overload the tendon, and do not allow it sufficient time to heal the tendon develops a ‘stress shield’.

Unlike what was commonly believed previously, there is not inflammation going on, and so the shift from tendonitis to tendinopathy

 

Tendinopathy can be divided into 3main stages

  1. Reactive- acute,painful, swollen, tender tendon following rapid increase in load(mileage, hills, speed)
  2. Dysrepair-follows on from the acute phase, tendon structure starts to change
  3. Degenerative- chronic, common in the older athlete, thickened with nodules. There is risk of rupture at this stage.

 

What to do?

What to do, will very much depend on stage your tendinopathy is at:

*Reactive stage/early dysrepair*

 

Reduce load

Decrease your running load. This may mean  full rest when the tendon is particulararily angry. You need to be pain free at rest and during walking before you consider running.

When you commence running again bear the following in mind- pain should not go above 3/10 pain. Allow adequate rest between runs (24hrs+). Pain should resume to pre run level by 24hrs post.

Purchase a heel Cushion. These can be bought for approximately 7 euro from Murrays Pharmacy. The small elevation the cushion gives you, ensures you avoid compressive load on the tendon which is provocative for the tendon.

 

Pain Relief

Consult with your GP/Pharmacist regarding pain relief. Anti-inflammatory medications have been shown to be of benefit in managing tendonopathies, despite there being no inflammation.

 

Increase strength

During the reactive stage, exercises such as heel drops are likely to aggravate the tendon. Opt instead for isometrics. Perform these on 2 feet on a step. Go up onto your tip toes, then return to neutral( rather than going into full heel drop) Aim to build toward 10-15reps and 3 sets of these.

 

Avoid the following:

Stretching

Although it may feel like this is what the tendon needs, stretching can compress the tendon and aggravate it more.

 

Very flat shoes/pumps

As with the stretching, flat shoes can aggravate pain with compressive loading

 

**Late dysrepair/degenerative**

 

Increase your strength

Unfortunately you can have a reactive tendonopathy going on alongside a degenerative tendinopathy. In this case management is similar to above.

 

With a more chronic degenerative tendonopathy you can start to increase strength training more without aggravating symptoms. You can progress toward eccentric exercises which ‘strengthen and lengthen’ the tendon such as heel drops

 

Gradually increase your mileage

As a general rule, increase your cumulative mileage by no more than 10% per week.

 

Address weaknesses elsewhere along the kinetic chain

As with many injuries, the area you feel pain may not be the source of your problems. Get assessed by a physiotherapist to address any weaknesses you may have. Runners need to perform strengthening exercises at least once weekly to  prevent and treat injury.

 

Listen to your body

If you have a painful achilles which fails to improve with rest, get it looked at. Don’t ignore your symptoms.

 

Ellie Hartnett, MISCP 


                   

 


Groin injuries in Athletes

Groin injuries are typically associated with athletes involved in multi-directional fast paced sports such as Hurling and Football.

The incidence of groin injuries in elite Gaelic footballers was shown to be as high as 9% (Murphy et al, 2012).

There are many different causes of groin pain in the sporting athlete, the most common diagnoses including acute groin strains, adductor tendinopathy and osteitis pubis. It can be an extremely debilitating injury associated prolonged periods on the sideline. There are many structures around the hip and groin region that must be considered when managing a groin injury, for instance there are 5 different muscles that act as adductors of the hip. When too much pressure is put on a certain part of the pelvis during movement this can lead to failure of other local tissues. This is often seen in sport when players have an unusual way of cutting/turning which can become problematic over time, thus leading to a groin injury as an example.

Red flags for groin injury often seen in GAA are limited hip ROM, reduced groin strength (groin squeeze) and poor lumbopelvic control, characterised by a player leaning excessively over their planting foot during a cutting movement.

Treatment begins with accurate diagnosis of the pathology as without clarifying the exact cause it is hard to implement a fully functional rehab programme due to the complexity of the hip/groin region. Muscle control and de-loading of affected tissues are two components that I like to focus on when approaching these injuries initially. It is important to introduce sports specific drills when suitable especially in multidirectional sports as the groin muscle has a massive role in decelerating the hip movements during quick turns.

 

Paddy Hannon, MISCP


21 Day PT Trial

Want a 21 Day PT Trial?

Right now Sports Physio Ireland is offering you the chance to come in and try out our services for 21 days for only €59!

The 21 Day PT Trial will cover everything from strength and conditioning training to rehabilitation of an injury under the watchful eye of our chartered physiotherapists/trainers who will also be providing dietary advice to help you balance your eating habits.

Space is at a premium and we can only offer this trial to a limited number of people.

This is a HUGE discount and is definitely not to be missed!

We strive to provide the highest quality service in order to help you achieve your goals.

Sign up now by clicking the link below & and an expert trainer will be in touch.

https://functionalt.wufoo.eu/forms/p7b2w0s1qz85lt/

Sports Physio Ireland Team


Acute Groin Injuries in Gaelic Football

We recently had the pleasure of having Mark Roe present on the “Managing Injury Risk when Performance is the Focus” in Sports Physio Ireland as part of our Educational Seminars. A lot of the data presented was related to the GAA, which is highly relevant as they would make up most of the sporting population that Physiotherapist’s and Sport Therapist’s would see in the clinic setting. A few things really stood out in the seminar, mainly the injury burden that some injuries have on Gaelic Football and Hurling.

Mark presented data that showed that Groin injuries accounted for 14% of the total injury incidence in Gaelic Football, with adductor related accounting for 39% of those groin injuries. What was interesting to note was that out of all those groin injuries 72% where acute in on-set. This goes against the popular belief out there that all groin injuries are chronic in nature, with only 28% of groin injuries classified as chronic in this population. Of the groin sub-classification of injuries (based on the Doha Consensus Statement), pubic-related pain accounted for the greatest time-loss of player availability (Mean Time-Loss 49 days). Thus, knowing that adductor related injuries account for a large portion of injuries in Gaelic Football it’s important to consider injury reduction strategies for this group.

This data follows on nicely from some of Andreas Serner work on acute adductor related injuries. His work has looked at the anatomical location of acute adductor related injuries in a sporting population and found that the adductor longus was involved in 87% of all cases. Isolated injuries accounted for 65% of athletes with multiple muscle injuries in 35% of cases, these with a combination of adductor grevis, pectineus etc. The majority of injuries were graded as 1 or 2 (83%) with 17% grade 3 injuries. Of the avulsion injuries, all where proximal adductor longus avulsions, which where combined with at least two other adductor injuries in all cases. Thus a relatively severe injury.

So as a professional working with GAA teams, knowing that groin injuries account for a large portion of lower limb injuries and which the adductor longus will largely make up the majority of those, putting in strategies looking at training load, strength, hip mobility etc to help reduce these injuries is vital.

 

Thomas Divilly


When working with sports teams, you meet a mixture of people working within the management and administration of the club/county. As it is still firmly an amateur organisation, the clubs and counties still rely heavily on the volunteerism that has built the foundation of the GAA, and please God may this never change! These people have a mixture of skills and experiences that make the GAA so unique to our country and culture. Everyone has different backgrounds that make trying to mesh an amateur ethos and drive with the professional demands needed to compete at inter-county and club levels easier. And yes, not only are inter-county setups extremely professional, a lot of clubs are following closely. Managers and coaches are extremely ambitious nowadays and want to create the most professional setups in the country.
And so often Physiotherapists, Strength and Conditioning Coaches and other related professionals are greeted with a mixed reaction within different setups, depending on people’s past experiences. Some are lauded as essential and necessary for continued success on the pitch, while some are greeted with a mixture of suspicion at our role within the team. We have all been in that situation, when you meet a coach or manager who doesn’t understand what your skillset involves, what you can do to help a team succeed. Physiotherapists are seen as giving out “rubs” and S & C professionals are seen as “doing the gym”. And while these may have been our role historically, we have moved on well from this! We have greater skillsets than this and we can heavily influence both the welfare and performance of the athletes we come in contact with.
And so like any profession I believe we should justify our roles within these groups:
  • Are we addressing intrinsic/extrinsic factors that may influence injury risk?
  • Are we putting in injury prevention programmes that have been proven to reduce rate of injuries?
  • Do we use the most up to date methods of preparing our players for their performance demands?
  • Are we continually up-skilling and increasing our knowledge?
  • Are we educating the people who make the important decisions on best practices?
These are all questions that we should be continually asking ourselves when working in these environments. So how do we justify our role first and foremost? What is the one thing every coach and manager puts the most weight on when making decisions? What can they not ignore. They are all striving for the same thing.
Success.
And while talent is important.
We know that team success is heavily influenced by player availability.
In this study by Hagglund et al. (2013) they looked at the injury incidence and injury burden on performance measures in soccer. What made this study unique is that the clubs that participated included the likes of Barcelona, Manchester Utd etc. So massive clubs at the elite level! And over an 11 year period they found that a team that had both decreased injury rates and injury severity compared with the preceding season had a statistically better chance of improved team performance, based on final league standing and league points per match. This is massively important!
The study concluded that the “association between injuries and performance is probably one of the most important messages to convey to management and coaching staff, as well as to other stakeholders in clubs, in order to continue to improve medical services for the players and to increase efforts to prevent injuries”.
Therefore, while we can’t prevent every injury, there is no magic bullet! We can use the best of our knowledge and our understanding of the science out there, how to put in programmes to help reduce the injury risk.
Read the data out there. Collect your own data. React to the data if needed.
Put into place some high quality injury reduction programmes.
Work as a team within the medical and performance department.
Help each other. Don’t let egos clash.
You should have a common goal. Work together to make it happen.
Thomas Divilly
Chartered Physiotherapist, MISCP, CSCS

As we gear up to present our next speaker Mark Roe, who will speak on training loads and injuries, we will begin to explore the role of training load on both athletic performance and injury reduction.

Training load is currently the hot topic within Sports Medicine and Sports Performance. But what is it? Training loads can be broken up into both internal or external variables. Internal training loads are the biological stressors imposed on the athlete during training or competition, these are commonly measured by heart rate, blood lactate, rating of perceived exertion etc. External training loads are objective measures of the amount of work completed during training or competition and common measures include GPS parameters. 

The importance of monitoring training loads has come to prominence over the past few years as its role in enhancing athletic performance and injury reduction has come to light through research. Traditionally the model to stress response imposed on the biological system has been based on the General Adaptation System Model proposed by Hans Selye in 1931. As John Kiely outlined in his article “Periodization Paradigms in the 21st Century: Evidence-Led or Tradition-Driven”, the periodization philosophy of training hinges on the presumption that biological adaptation to future training is largely predictable and follows a determinable pattern. However, we know that individual athletes will respond differently to each other even when doing the same training program/session. Biological stressors are often neglected as just training stress alone, however it comes in many different forms. For example, a wide range of imposed stressors emotional, dietary,social, sleep, academic have been demonstrated to variously down regulate the immune system, dampen adaptive response, and negatively affect motor coordination, cognitive performance, mood, metabolism, and hormonal health, consequently reducing performance and elevating injury risk. These all add up, and both the sports medicine professional or coach needs to be aware of these factors. Therefore, the ability to monitor the training loads of athletes, both internal and external, and their individual response is vitally important to enhance performance and prevent injury.

Thomas Divilly
Chartered Physiotherapist, MISCP, CSCS