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


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 


                   

 


Acute low back injuries can be caused by a disruption to the muscles/ligaments supporting the lower back.

The area around the compromised structures can become sensitised due to spasm or strain in the affected tissues.

It can be a very debilitating injury but early activation and relaxation techniques are important in the early stages of treatment to promote mobility and desensitisation of the muscles involved.

Check out these simple exercises we like to use here at SPI for early rehab of acute low back injury.

SPI Team


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


Groin Injury Screening In Gaelic Football

 
The role of musculoskeletal screening has been a hot topic in recent time, see here, with the debate on the validity and efficacy of some tools. It can cause serious confusion for some clinicians on whats the most effective strategies to put into place, what is worth measuring etc.
The past 10 years clinicians have been sold false promises on the role of the FMS and other such tools in predicting and preventing injuries.
And while we shouldn’t abandon the screening process to reduce injuries, we need to be a bit more aware on what they actually measure and does it even help the clinician? 
 
A recent paper by the group led by Dr. Eamonn Delahunt has looked at the adductor squeeze test and the Copenhagen Hip and Groin Outcome Score (HAGOS) questionnaire to assess its ability to identify Gaelic Football players at risk of developing groin injury. There was 55 players within the cohort and they where followed over a 9 month period. The chartered Physiotherapist during pre-season as part of an injury screening evaluation included both the adductor squeeze test and HAGOS. No groin injuries or other injuries where found during the pre-season testing. 
 
Results revealed a significant difference in pre-season adductor squeeze test scores between those players who did (median = 210 mmHg, n = 10) and did not (median = 260 mmHg, n = 45) sustain a groin injury, U= 107.5, z =  2.58, p = 0.01, r = 0.35.
The optimal cut point for the squeeze test to discriminate between players who did and did not sustain a groin injury, to be 225 mmHg. 
 
Results of the Mann-Whitney Test revealed a significant difference in pre-season HAGOS function,sport and recreation subscale scores between those players who did (median=76.56, n=10) and did not (median=96.87, n=45) sustain a groin injury, U=114.5, z=2.48, p=0.01, r=0.33. With regard to the HAGOS function,sport and recreation subscale score, the cut point with maximal sensitivity (0.70) and specificity (0.73) to discriminate between players who did and did not sustain a groin injury was 87.50.
 
What should be of great interest to clinicians when reading this study is both the ease to administer of both tests and the cost-effectiveness. Unlike many studies which look at expensive and time-heavy methods, these are available to all clinicians with no heavy burden also. While the relative sample size was small, it does give clinicians both some normative data and cut off points to make some meaningful decisions within the team setting. It may also allow the clinicians to individualise both Strength and Conditioning programs and injury prevention methods within a group setting. 
Thomas Divilly

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


Skin Care for Gym-Goers

We live in times where a healthy lifestyle is not only recommended but also popular and fashionable. Today we are more aware of how we live, work and rest, what we eat and how the environment affects us. Introducing exercises to our activities can reduce the risk of many disorders. Taking care of ourselves by going to the gym and keeping fit is a great habit for the body and the soul. However it might not be as beneficial for our skin if we are forgetting few important rules:

  1. Wash off your makeup before every workout.

Makeup combined with sweat increases the risk of clogged pores and acne. During physical exercise pores open up naturally so makeup can affect the skin’s capacity to breath. Choose a cleanser that is suitable for your skin type and it will help to maintain the effects of the natural waterproofing barrier of the skin.

Recommendations

Environ Dual Action Pre-Cleansing Oil (all skin types), Environ Mild Cleansing Lotion (all skin types) or Environ Sebuwash (perfect for oily, blemish-prone and congested skin)

  1. Don’t forget the sunscreen.

UV protection is crucial even if you are exercising indoors. After removing your makeup apply light moisturiser that provides sun protection factors, along with antioxidants, vitamin C and E which help to fight free radicals. Use a product that will help to retain moisture in the skin. When exercising our skin loses water due to perspiration, leaving it dehydrated. To make sure your skin is protected use proper/adequate cream.

Recommendations:

Environ RAD SPF15 (all skin types), Environ Alpha Day Lotion SPF15 (problematic skin)

  1. Tie your hair back

Always try to keep your hair away from your face. Continuous contact with the skin can transfer oil, dirt and grease causing spots. Headbands across the forehead are responsible for a backup of oil and perspiration in the pores. Try to refrain from using them but if you can’t imagine workout without the headband push it further back in your hairline.

  1. Avoid touching your face and body while exercising.

Gym equipment is a perfect breeding ground for germs. During a workout you should always keep your hands off your face and body. Open pores and sweaty skin make for a welcoming environment for bacteria to grow. Transferring impurities onto your skin can lead to spots and breakouts. Remember to wash your hands before and after working out.

  1. Always use a clean towel to wipe your face.

Don’t wipe your face aggressively as it can irritate your skin. Use a small, clean face towel to pat your skin dry. Avoid face wipes as they are harsh on the skin affecting its pH, striping natural oils out of the skin, leaving it vulnerable and more prone to dehydration.

  1. Stay hydrated.

The average human being is made up of 60% water and it is a major and vital body component. Excessive sweating leads to dehydration and can affect your skin. Make sure you are drinking plenty of water before, during and after workout to restore the balance.

  1. Shower straight after the workout.

Wash your whole body straight after the workout and make sure you are gently cleansing your face afterwards as well. The mixture of body fluids and dirt can be responsible for the skin problems and imperfections. Avoid hot water as it can strip the skin of its vital, natural oils. Instead take a short lukewarm shower to rinse off all impurities.

  1. Moisturise your skin.

After the shower use a body oil or cream. Make sure you are using products that replenish water your skin lost during your workout. Protect your skin using products that contain vitamin A and antioxidants including vitamins E and C. After cleansing and toning your face be sure to apply suitable moisturiser and sunscreen. Never leave your skin “naked” as it exposes you to pollution and bacteria.

Recommendations

FACE – Environ’s B-Active Sebutone (toner – oily, problematic skin), Environ Vita-Antioxidant AVST Moisturiser (all skin types), Environ Vita-Peptide C-Quence Serum (all skin types), Environ Super Moisturiser+ (dry, dehydrated skin, pregnancy)

BODY – Environ A,C&E Oil (all skin types), Environ Derma-Lac Lotion (great for stretch marks, scars, Keratosis Pilaris, ingrown hair).

Proper skin care routine is key to ensure healthy and good looking skin. Never neglect your complexion as caring for your skin and body is an investment that will last a lifetime.

Joanna Koniorczyk-Sobanski

L’ACE Beauty Studio

111 Baggot Street Lower

Dublin 2

087 390 4788

 


Fatigue Markers in Sport

Following on with some of our most recent posts on training load and injury/illness as we prepare to welcome Mark Roe for our August Seminar “Minimising Injury Risk and Maximising Performance in the GAA”, we will look at fatigue as a useful marker to monitor the athletes that we work in day to day, especially within the team setting.

Management of fatigue is important in mediating adaption to training and ensuring the athlete is prepared for competition. These training responses can be both positive and negative, and helps both the Strength and Conditioning and Medical staff see how the athlete is responding to the training load prescribed.

Different times of the year, different objectives will always make these slightly open to interpretation of the support staff e.g. during a period of planned overreaching,

the support staff will expect to have changes in fatigue markers that may be negative. Fatigue can also give us a better ability to reduce the athletes’ susceptibility to nonfunctional over-reaching, injury, and illness, by picking up signs and symptoms of difficulties to the training load early.

An excellent recent systematic review in Sports Medicine highlighted the role of fatigue on injury rates and illness in athletes. Below I have outlined some of the main findings from the review on fatigue markers and injury within that paper.

Fatigue Markers and Injury

The review showed that only 9 studies investigated fatigue–injury relationships, seven of which used perceptual wellness scales.

  • In soccer players 3 studies showed greater daily hassles to be associated with increased injury, using the Hassles and Uplifts Scale (HUS) (Ivarsson et al., 2010; Ivarsson et al., 2013; Ivarsson et al., 2015)
  • Laux et al. (2015) further support the positive perceptual fatigue– injury relationship in their findings, which reported that increased fatigue and disturbed breaks, as well as decreased sleep-quality ratings, were related to increased injury.

However, In contrast rating of perceptual fatigue showed slightly different findings in other studies:

  • Killen et al. (2010) found increased perceptual fatigue (measured via worse ratings of perceptual sleep, food, energy, mood, and stress) was associated with decreased training injury during an elite rugby league preseason.
  • Similarly, King et al. (2010) showed increased perceptual fatigue (measured via various REST-Q factors) was associated with decreased sports performance training injuries and time-loss match injuries.

The authors theorise that these unexpected findings may be due to the fact that when players perceive themselves to be less fatigued they may train/play at higher intensities, increasing injury likelihood.

Most of the studies used wellness scales that take approximately 1–4 min to complete. These are extremely practical to administer to athletes and are quick and not too time consuming. The Rest-Q has been also well-validated within the literature.

The review also showed that current self-report measures fare better than their commonly used objective counterparts. In particular, subjective well-being typically worsened with an acute increase in training load and chronic training load, whereas subjective well-being demonstrated improvement when acute training load decreased. Using quick subjective questionnaires and “knowing” the athletes is vitally important. Earning the trust of the athlete and building a strong relationship over a period of time, is just as useful as any expensive monitoring system.

The authors also noted the poor investigation within the literature of the relationship between sleep and injury.

Sleep is a vital part of the body’s recovery process and has been well highlighted in recent times on it’s relationship to productivity, chronic pain and depression (Rosekind, (2010); Smith (2004); Tsuno (2005). The review showed that three studies assessed sleep–injury relationships via sleep quality ratings, with only Dennis et al. (2015) investigating objective measures of sleep quality and quantity in relation to injury. No significant differences in sleep duration and efficiency were reported between the week of injury and 2 weeks prior to injury.

fatigue

While the number of studies is quiet limited in the review, evidence of the use in the team setting to monitor the role of fatigue on injuries is supported. However, anecdotally and from experience within the field the importance of speaking to people, building strong relationships and creating a supportive environment cannot be underestimated. An athlete who trusts your role and job in helping their performance and having their wellness as a priority will often speak to you sooner than any subjective or objective marker can pick up.

So while using these tools is of great importance, don’t forget the strength of building personal relationships with your athletes.

Thomas Divilly

  • Ivarsson A, Johnson U. Psychological factors as predictors of injuries among senior soccer players: a prospective study. J Sports Sci Med. 2010;9(2):347.
  • Ivarsson A, Johnson U, Podlog L. Psychological predictors of injury occurrence: a prospective investigation of professional Swedish soccer players. J Sport Rehabil. 2013;22(1):19–26. 93.
  • Ivarsson A, Johnson U, Lindwall M, et al. Psychosocial stress as a predictor of injury in elite junior soccer: a latent growth curve analysis. J Sci Med Sport. 2014;17(4):366–70
  • King D, Clark T, Kellmann M. Changes in stress and recovery as a result of participating in a premier rugby league representative competition. Int J Sports Sci Coach. 2010;5(2):223–37.
  • Kinchington M, Ball K, Naughton G. Reliability of an instrument to determine lower limb comfort in professional football. Open Access J Sports Med. 2010;1:77–85.
  • Kinchington M, Ball K, Naughton G. Monitoring of lower limb comfort and injury in elite football. J Sports Sci Med. 2010;9(4):652.
  • Killen NM, Gabbett TJ, Jenkins DG. Training loads and incidence of injury during the preseason in professional rugby league players. J Strength Cond Res. 2010;24(8):2079–84.
  • Laux P, Krumm B, Diers M, et al. Recovery-stress balance and injury risk in professional football players: a prospective study. J Sports Sci. 2015;33(20):2140–8.
  • Rosekind, Mark R., et al. “The cost of poor sleep: workplace productivity loss and associated costs.” Journal of Occupational and Environmental Medicine52.1 (2010): 91-98.
  • Smith, Michael T., and Jennifer A. Haythornthwaite. “How do sleep disturbance and chronic pain inter-relate? Insights from the longitudinal and cognitive-behavioral clinical trials literature.” Sleep medicine reviews 8.2 (2004): 119-132.
  • Tsuno, Norifumi, Alain Besset, and Karen Ritchie. “Sleep and depression.” The Journal of clinical psychiatry (2005).
  • Dennis J, Dawson B, Heasman J, et al. Sleep patterns and injury occurrence in elite Australian footballers. J Sci Med Sport. 2015;19(2):113–6.

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

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

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