- 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?
- 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?
- 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.
- Minimal amount of loading through a range of exercises e.g. RDL, SLDL, TRx Rollouts etc.
- Minimal number of training sessions completed?
- 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?
- Is the site of palpation smaller?
- Is their pain during rehab? During specific exercises?
- Has their passive knee extension improved?
- 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?
- What sport does that person play?
- What are the positional demands of that sports? Defender vs Midfielder?
- What is the overall running volume of that sport?
- How many max speed runs will that person be potentially exposed to during a game situation?
- Is that person ready for the worst case scenario or minimal demands?
- How can you replicate those demands in rehabilitation?
- Always be on the watch out for the unexpected.
- 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?
- Be aware of pop and loss of function that may suggest an avulsion.
- 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).
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.
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
- 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?
- 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.
- 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!
MSc MISCP CSCS
Here is our latest podcast on the lessons learned from Dr. Eamonn Delahunt’s seminar on lateral ankle sprains and chronic ankle instability.
Plantar Fasciitis: Symptoms and Treatment
Plantar fasciitis is one of the most common types of heel pains, and it occurs when you hurt the plantar fascia, which is a flat ligament connecting your heel bone to your toes. Overexertion, an incorrect posture while running or walking, or a misstep can cause the plantar fascia to stretch too much and become inflamed.
Aggravating Causes and Symptoms
If you continue to strain the already overtaxed ligament, small ruptures can occur and this is, in short, how plantar fasciitis sets in. The most common symptoms of this type of affliction are:
A sudden burst of pain in your foot when you stand up after sitting down for a long time, or early in the morning when you get up from bed;
Jolts of pain while you climb stairs;
Progressively increasing pain when you stand up for a long time;
Pain at the start of your warming-up routine which goes away as you start running, but returns after you stop exercising.
In general, the number one symptom of plantar fasciitis is pain in your heel early in the morning as you take your first steps and at the end of physical exercising, but not during the actual running or cardio routine.
There is no universal cure for plantar fasciitis. Each case is evaluated individually by a doctor and various types of treatments. However, surgery is the last resort, and the doctor will only recommend it if 6 to 12 months of alternative treatments did not solve the problems.
Patients can also help themselves by following these simple routines at home:
1. Rest Your Foot
Allow your plantar fascia to heal by cutting back on the effort and giving it a good rest. Take a break from running or brisk walking for the next few days after you experience the type of pain associated with plantar fasciitis. Just like in the case of other types of muscle injuries, a good rest can do a lot of good.
2. Avoid Walking on Hard Surfaces
The granite or wooden floor in your home looks great, but does not feel so great for your injured foot. Buy some soft carpets and place them on the floors at least for a few weeks until your foot heals (you can keep them indeterminately if you like them, of course!).
3. Ice Your Foot
A pack of ice applied to your foot is both relaxing and healing. It numbs the pain and allows the inflammation to disappear little by little. Leave the ice pack there for 20-40 minutes and repeat every 4 hours.
4. Do Light Exercises
Toe stretches and towel stretches are extremely helpful. For the toe stretch, sit down on the floor, flex your knee and keep your leg up in the air with the back of the heel on the floor. Grab your toe with your hand and stretch it forward, toward the ankle. Hold the position for 15-20 seconds and repeat 4 times throughout the entire day.
For the towel stretch, as you sit down on the floor, with the feet straight in front of you, place your foot in the sling of a rolled towel, and hold the ends in your hands. Pull the ends of the towel, bending your foot forward. Hold the position for 20 seconds and repeat 4 times.
5. Change Your Shoes
Last, but not least, replace your shoes (both for daily walking and your running shoes) with others with a cushioned sole and good arch support. Supplementary, you could wear orthotics in your regular shoes, until your plantar fasciitis heals.
Follow these simple tips, and you will feel a relief from the heel pain. At the same time, do not forget to be evaluated by a doctor and follow their recommendations.
Runner’s knee is also known as Patellofemoral pain syndrome, or runner’s knee, is one of the most common types of injuries occurring in professional or amateur runners, accounting for 20% of all types of injuries.
The symptoms of runner’s knee start with mild pain under your kneecap while you are running. In the early stages, pain stops as soon as you stop running, so many people do not seeking medical help at once. However, if left untreated, the pain will increase in severity and will continue to affect you even after you have stopped running.
The good news is that treatment for runner’s knee is simple, non-invasive and you can do it at home with minimum medical supervision. However, the most severe cases, left untreated for a long time, may require surgery. This should be a powerful enough reason not to ignore pain in your knee while you are running, and seek the doctor’s advice as soon as possible.
This being said, the usual path to recovery from runner’s knee looks like this:
First Stage: 2-3 Days of Complete Rest
You should avoid all types of effort and putting your body weight on the injured leg.
Runner’s knee is not only painful, it also causes swelling and inflammation in your knee,
so you should apply ice packs for 20-30 minutes every four hours.
It is also useful to find a pillow on which you can rest your injured knee in an elevated position. This will improve blood flow through the leg and help reduce swelling. During this period, you should keep your movements to a minimum and use crutches when you have to walk, so that you spare the injured knee all kinds of efforts.
Second Stage: First Light Exercises
There is no specific timeline for the recovery from runner’s knee, except for your doctor’s recommendations. However, as soon as you are cleared to start walking and applying some weight on the knee, you should do so wearing an elastic bandage to offer as much support to your knee as possible.
In parallel, your doctor may prescribe certain anti-inflammatory and pain relief medication of the non-steroidal type. This medication should be taken strictly according to the doctor’s prescription, because its side effects include bleeding and occurrence of ulcers.
Third Stage: Mobility and Strength Exercises
Once you can take off the elastic bandage, you should start a routine of specific exercises to regain mobility and strength. Stretching exercises are extremely effective and recommended by all physical therapists.
In parallel, you may use arch support for your foot, to correct your walking posture. Arch supports, or orthotics, are inserted in your shoes and offer firm support to your soles. They can be bought online or from shops, or they can be made bespoke; before you decide, ask your doctor or Physiotherapist about this.
Just as with every other stage of runner’s knee treatment, you should ask your doctor before returning to your regular running routine. In general, you are completely cured when you feel absolutely no pain in your knee during walking and exercising, when you can fully bend and extend your knee with no pain and you can place as much body weight on it as you can on the healthy knee. It can be tricky and tough to come back from Runner’s Knee patellofemoral pain syndrome, but we are here to help.
In conclusion, the runner’s knee is a frequent occurrence in runners, which can be treated very easily and without complex medical procedures if you seek medical advice as soon as you notice its first symptoms. So if you feel pain in your knee under your kneecap, even at bearable levels, do not ignore it. The sooner you act, the faster your recovery will be.
Achilles Tendon Injury – What Rehab is Forgetting
The Achilles tendon is at risk of injury with high load. Runners have a 15 times greater risk of Achilles rupture and 30 times greater risk of tendinopathy than sedentary individuals.
The Achilles tendon is the thickest and strongest tendon in the body. The three calf muscle attach to the heal via the Achilles tendon.
“Overcoming what was deemed impossible is what I will take with me and cherish the most…That (coming back from injury) will be the number-one thing that stands out because I wasn’t even able to walk.”
– Donovan Bailey (Olympic 100 m sprinter talking about his rehab for his Achilles tendon rupture). After rehab he ran sub-10 seconds for the 100 metres.
Out of the 5 clinicians in Sports Physio Ireland, two of us were unfortunate to have suffered Achilles injuries. Myself a partial tear and Joey Boland a tendinopathy. Depending on the severity of the injury the road to recovery is slightly different. The outcome of rehabilitation is positive, however, with us both returning to our representative sports. The partial tear taking slightly longer to adapt to return to play.
Overuse Achilles tendon injuries (tendonopathies) can arise with increased training volume or intensity. This happens because the load is too much for the tendon to withstand. Decreased recovery time between training sessions may also be a factor. The combination of stiffness (especially in the morning) and pain at the back of the heal is a key sign of Achilles tendinopathy. Pain often reduces during activity and may be pain-free during training only to come back with a vengeance a few hours later. Continuing to train through this causes the structure of the tendon to weaken and puts you at an increased risk of rupture.
As well as looking at injury to the Achilles itself, it is important to determine the causes of the injury in the first place. Injury is often linked to calf tightness or weakness and ankle joint stiffness. Abnormal lower limb biomechanics has been shown to cause torsional stress through the tendon. Weakness around the ankles can cause a whipping like action on the Achilles. A change in playing surface or footwear or poor footwear should also be considered.
Tendons take longer to adapt to training due to their poor blood supply. Rehabilitation takes longer than muscular injuries and is generally in excess of 3 months. Rehabilitation should include loading the tendon appropriately and correcting of predisposing factors that were linked to the injury. Progressing to plyometric and sports-specific activities when the ability to withstand load increases. `
When running approximately 5 times your body weight goes through your foot as you land. The Achilles needs to be strong enough to withstand this force before you go back to running, jumping and landing. Rehabilitation often does not put enough weight through the structure during closed change activities before progressing to running. Heal raises with 15-20 kg, Reverse lunges with greater than 20kg, Squats of greater than 20kg and SLDL of 20 kg should be a realistic expectation for everyone before returning to play or their chosen activity. Distributing the weight through two separate dumbbells makes this achievable for those who struggle with upper body strength. When thinking about the high level of repetitive load that goes through the body when running these weights are not that heavy and are what the body needs to adapt.
Soft tissue therapy including mobilisation and fractioning across the tendon are useful in improving the glide of the tendon in it’s sheath. As stickiness around the tendon is often associated with injury to the tendon.
Return to activity should be gradual.
Activity should be resumed only when local tenderness has settled and weights during rehab exercises achieved.
If long distance running is not the main aim then I would argue that the repetitive loading of that nature should be avoided. If sports are the main aim then interval running should be the focus. This is the nature of the activity they are trying to return to and also allows the tendon brief recovery periods.
MISCP, MSc Sports Medicine
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