Hamstring injury management – A breakdown of the latest research

Sliding exercise

Athletes rejoice! For decades our understanding of hamstring (HS) injuries has been improving and evolving, yet the frequency of HS injury rates in sport have not declined. Finally, a new paradigm has been developed which consolidates our knowledge of the anatomy and the physiology of this highly prevalent injury, applies effective rehabilitation strategies, accurate return to sport testing and re-injury prevention.

We can broadly define the typical hamstring strain into a sprinting type strain which occurs at high speed running versus a stretch type strain which occurs with high kicking or other stretching movements. Each of these will typically cause an injury to a different muscle in the hamstrings group. They can generally be diagnosed in the clinic without the need for any imaging. The most common type is the sprinting type, frequently seen in football codes, soccer, hockey, athletics and other running sports. The stretch type is more common in dancers, jumpers and hurdlers, although either type can occur in any sport. Knowing the type of injury gives us a chance to apply the right exercise rehab as well as gives a guideline for the return to sport time, which varies enormously between the type, location and grade of strain.

We know that most HS injuries occur when the muscle is working hard in its lengthening phase, therefore it is essential that the rehabilitation program targets this movement at high load. A comprehensive program is undertaken, which incorporates hamstring strength, but also hip, pelvis, trunk and general lower limb strength and stability. This addresses all the factors which will lead to re-injury – that’s not new. What is new is a set of 3 specific exercises, that when applied correctly in soccer players led to a re-injury rate of only 1 in 75 players over 12 months! That’s way down from the average 1 in 4 players with conventional rehab in professional soccer.

The protocol is based on 3 specific lengthening (eccentric) strength exercises and the technique, timing and progressions of these are of critical importance, they need to be integrated and complemented with other exercises and, as a rule, should be pain free. So what can you expect to gain from completing a modern rehab program like the one we provide at NU Moves? A research study by Askling and colleagues found that their protocol of exercises led to an average return to play time of 28 days, compared with 51 days for the conventional group. Combining this with the low reinjury rate means it was proven to be a much better approach to HS rehab. The research also provided an additional return to play testing procedure (H test), which we integrate into our comprehensive existing return to play algorithm in the clinic. It assesses apprehension or feeling of insecurity as well as pain when performing a high load eccentric braking action on the leg, similar to what happens during an injury but in a safe way.

So to put it all together, we have a rehab protocol that fits well with our current understanding of hamstring strains and their risk factors. It is easy and inexpensive to perform once taught. It also reduces the time to return to play and gives better long-term outcomes. If you are ever unlucky enough to be in this position, then things are looking better now than they ever have!

NU Moves physio provides sports physio services to clubs around newcastle. For more information contact us online or give us a call and to view our current sports teams or what services we provide, click here.

Feel better through movement

Manual physio newcastle

The Uni Physio Clinic on Callaghan campus is located within The Forum Sports Centre. NU Moves has been helping staff and students for more than a decade now, specialising in manual therapy, exercise prescription, and rehabilitation. Our goal is to help you feel better in the short term and increase movement / exercise in the long term.

Are you currently:

  • Sitting most of the day?
  • Not exercising daily?
  • Stressed (workload, interactional, emotional)?
  • Have any neck / shoulder or back / hip pain?

If you answer yes to 3 or 4 of these questions then it’s time to reflect and make some changes to your daily habits now.

If you answer yes to the first 2 questions then consider how you can start to fit a walk or another exercise you enjoy into your day. The goal for long term health and feeling better now is 30 mins of activity per day. It can also help prevent muscular pain associated with excess sitting.

If you have neck & shoulder or back / hip pain, that is when we can help you the most. Physiotherapy has a range of treatment options from massage, spinal manual therapy or dry needling to reduce pain. There should always be advice on activity / exercise or we can design a full exercise program suited to your goals. Assessment of your computer ergonomic setup is essential and advice on simple changes often helps. Occasionally we utilise orthotic prescription but only if it helps you get active with less pain.

To book an appointment with NU Moves call 4921 6879 or email admin@numovesphysiotherapy.com.au

Complex ankle injuries

Ankle Injuries

It is commonly thought that ankle sprains are a minor injury, which usually resolve fully and quickly. While this is sometimes the case, research shows that 64% of people who sprain their ankle report ongoing problems 12 months later! The main complaints we see for a “problem” ankle are swelling after activity, loss of normal range of movement, recurrent sprains, tendon pain, inability to participate in high level sport and feelings of instability.

Why? The list of possible injuries that can come from rolling an ankle is rather long, both for acute injuries and persistent ankle pain … tears of the 3 outside ankle ligaments (ATFL, CFL, PTFL) or the inside ankle deltoid ligament; osteochondral lesion (bony / cartilage bruising) of the talus; high ankle sprain (syndesmosis injury); fractures of the ankle malleoli, navicular or base of the 5th metatarsal;  tendon strains or rupture/dislocation of tibialis posterior or peroneal tendons; chronic instability; subtalar joint sprain; joint synovitis; tenosynovitis; sinus tarsi syndrome; anterior/posterior impingement.

Most people don’t get the right diagnosis (or any diagnosis) or just get an incomplete one on the sideline immediately after the injury. Fortunately, with the correct diagnosis and treatment the majority of ankle injuries can be treated non-surgically by physiotherapy. Early intervention is the best management. Unfortunately a lot of poorly managed or misdiagnosed ankle injuries present to our clinic, often months or years after the initial injury. These people have ongoing symptoms and limitations, which leads to frustrated and uncertainty about why it isn’t getting better. The main problem is difficulty competing in sport or doing regular exercise.

There is hope! We can help you accurately diagnose the problem and design a specific intervention. Many of our problem ankle cases have had a full resolution and are now symptom free. So if it’s you, a team mate, friend or family who are struggling with a non-resolving ankle injury get it assessed – get it treated – get back to sport and exercise!

To read more about foot and ankle pain click here.

ACL Reconstruction – When is best?

ACL reconstruction

The NU Moves team recently did a masterclass session into the research associated with ACL tears and reconstructions. The questions we raised were based on a randomised trial published in BMJ in 2013 and several papers this year from Assoc Prof Richard Frobell and collaborates*.

Do you always need to have an ACL reconstruction?

Surgical repair of the ACL depends on the presence of instability and your specific goals. If you want to play sport involving change of direction (football, netball, basketball, etc) then surgery is recommended. However, having surgery in all cases is not as clear as it was 10 years ago. If you only want to walk and cycle then in some cases it’s possible to rehab the knee to an adequate level of stability. Persistent feelings of instability or giving way after rehab would warrant consideration of surgical intervention in any case, even if you don’t want to play sport.

When is the best time to have an ACL reconstruction post injury?

Current evidence clearly shows better outcomes are achieved if the patient undergoes an initial period of rehab prior to surgical intervention, deciding when and whether to have ACL surgery can be made once you have completed your rehab. A 12-week rehab period should be used to reduce swelling and regain strength and stability.

What should you do before ACL reconstructive surgery?

You must have a physiotherapy assessment and intervention. When we refer to rehabilitation following an ACL injury it involves strategies directed at reducing pain and swelling from the initial injury; regaining mobility and muscle length; and mostly importantly strengthening all the muscles of the legs to provide stability at the knee. These factors are the most relevant factors influencing your functional outcome, should you undergo ACL reconstruction.

Do you need to have an MRI?

Yes. If you have a suspected ACL tear then you should have an MRI to investigate, your doctor or physiotherapist can arrange this. The extent of ACL injury and other cartilage damage that can occur with ACL injuries are best identified via MRI. If there is significant meniscal or other cartilage damage then it needs to be considered relative to the rehab management and sometimes earlier surgery.

Do you always need to see an orthopaedic specialist?

Yes. They are the specialists of ACL surgery. Alternatively you could see a sports physician for a non-surgical opinion. There is now debate around the prevention of arthritic changes in the knee by undergoing ACL reconstruction surgery, evidence of its effectiveness is still valid but not as clear cut as it was 10 years ago. Studies over longer periods of time are still required to fully answer the question of whether surgery is better than conservative rehabilitation to delay or avoid arthritic change in the ACL injured knee. Getting a good orthopaedic opinion relative to your injury and goals is advised. For isolated ACL injuries it is now clear that better outcomes are achieved after a 3 month pre operative rehab period. So get the rehab started and then organise an orthopaedic referral at a time that suits you.

If you have any questions or have injured your ACL contact us to organise a time to start your rehab. Read more about knee rehab here.

* Articles reviewed:

  1. Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. Frobell et al. BMJ Jan 2013.
  2. Lower extremity performance following ACL rehabilitation in the KANON trial. Ericsson et al. Br J Sp Med 2013.
  3. Delaying ACL reconstruction and treating with exercise therapy alone may alter prognostic factors for 5 year outcome. Filbay et al. Br J Sp Med 2017.
  4. Surgical reconstruction of ruptured ACL prolongs trauma induced increase of inflammatory cytokines in synovial fluid. Larsson et al. Osteoarthritis and cartilage 2017

Avoiding Pre-season Injury

pre-season injuries

If you want avoid pre-season training injuries – start to plan your pre-season program now! This is good advice if you are between seasons or starting a sport again after a period of not playing. It is also good for trainers / coaches to consider when running a pre-season fitness program for a team.

A few months off regular exercise and training after winter sports is routine and often good for the body. But when pre-season training starts is when our physio clinic starts to fill up with athletes with strains. Here’s a guide to reduce your risk of injury during the next pre-season and regular season.

It starts with understanding injury risk and how we measure it. Why do some people get injured more than others? Can anything be done?

There are a lot of different reasons involved in why an injury may occur and there is no single test that provides an overall level of injury risk. Most professional sporting clubs use a complex battery of preseason testing, but it requires a huge amount of resources, and the chances are your local club doesn’t have that.

Recently a very simple, easy to understand and freely available risk indicator has been researched: The ratio of an athlete’s current exercise load compared to their historical exercise load (current week vs previous four weeks). This has been shown to predict injury risk in Cricket fast bowlers, Australian Rules football players and Rugby League football players. In order to get this ratio, you have to measure exercise load. In professional sport, players will often train with GPS and accelerometers to measure exercise load over the season – large fluctuations in load = higher risk of injury. When those devices aren’t available we have to go back to more simple measures.

Start recording in a diary the type (cardio, speed/sprint, power, strength etc) of exercise you do each day and some indicator of quantity (i.e. distance ran or the total time spent training). Then you need a measure of the intensity of the session which is usually relative to 100% as hard as you could go. If the session varies then record what you think is the average intensity and the amount of time spent at the maximum intensity. The goal of your workload diary is to allow you to plan your workload volume and intensity each week relative to the previous ones to make it a gradual transition during pre-season conditioning. This will avoid large spikes in workload and reduce your injury risk.

So when you get active again make sure you plan what you will do one week to the next and avoid spikes. But if do you get an injury we will be there to get you back on track.

If you want to read more on this see the articles below:

* Hulin BT, Gabbett TJ, Blanch P, et al. Spikes in acute workload are associated with increased injury risk in elite cricket fast bowlers. Br J Sports Med 2014;48: 708–12.

* Hulin BT, Gabbett TJ, Lawson DW, et al. The acute:chronic workload ratio predicts injury: high chronic workload may decrease injury risk in elite rugby league players. Br J Sports Med 2016;50:231–6.

* Murray, N. B., Gabbett, T. J., Townshend, A. D., Hulin, B. T. and McLellan, C. P. (2017), Individual and combined effects of acute and chronic running loads on injury risk in elite Australian footballers. Scand J Med Sci Sports, 27: 990–998. doi:10.1111/sms.12719

Common biomechanical problems with runners – flexibility

Stretching running physiotherapy

Last week’s blog looked at strength in key muscle groups for runners. This blog is highlighting areas of the body where flexibility is useful at preventing pain associated with running. There has been a lot of research on muscle length / flexibility relative to preventing injuries and the summary is commonly that it doesn’t help. However sometimes the research doesn’t give us the full picture on how to help an individual with pain and that is where having an experienced physio counts. Helping runners return to exercise after pain or injury results in a wealth of experience based knowledge. In relation to muscle length it is that if you don’t have the mobility in the correct places it can lead to injury. An obvious example is a hurdler who tightens up in the hamstring and lacks the flexibility to get the front leg over the bar.  The key area for everyday runners to maintain flexibility is in the front of the hip.

The front of the hip / hip flexors includes 3 muscles, one of which is the TFL (tensor fascia lata) that connects to the ITB (iliotibial band). One example of a common runner’s problem is not having enough hip flexor length which can impair the buttock (gluteal) muscle function and lead to the TFL muscle working harder to stabilise the pelvis whilst running. This can then lead to ITB tightness and pain in runners. Another example is tightness in the hip flexors leading to an increased arch in your back. When this combines with the glut’s switching off hip or back pain are common.

hip flexor tightness and low back pain
Tight hip flexors

Correctly stretching your hip flexors should be comfortable. It is possible to make short lasting improvements in muscle length so if you are tight you need to stretch before you run (despite some research assumptions!). Don’t forget to control the pelvis when stretching.

hip flexor stretch
hip flexor stretch – pelvic tilt / roll

The best plan is if you have pain then get one of the experienced NU Moves physio’s to assess and determine if that’s what you need to get you back to running pain free.

Running biomechanics and muscle strength

Running physiotherapy injury

 

Biomechanics refers to how we are built and how we move. Some of us have legs that bow out (varus alignment) and others have knock knees (valgus alignment) which relates to the shape of our bone structure. It is a combination of our bony structure and how well our muscles work that can increase the likelihood of injury with running. This blog is looking at key areas of muscle weakness that alter our biomechanics and lead to injury. Your bony structure can’t be changed but improving your strength in the right areas can be achieved within 6 weeks of an exercise program that is designed for you. Assessing the biomechanics of the body combined with a basic understanding of your running style is important if you are serious about running.

A biomechanical physiotherapy assessment considers whether you have sufficient strength and mobility in the right places for running. The muscles in the back of the leg (calf, hamstring and gluteal) are important to maintain strength for running. Weakness in these muscles often leads to pain and injury in runners.

  • Calf muscle and Achilles tendon strength – it is important to understand that both muscles and tendons can respond to the loads we put on them. A simple test and exercise for the calf and achilles is the calf raise. If you can’t do a repeated full height single leg calf raise of more than 6 reps than you probably don’t have enough strength. I encourage people to get to 15 reps and be able to repeat 3 sets as a baseline but there isn’t a magic number here because it also depends on your running style. If you are about to change your style and get further forwards on the forefoot then check your calf and achilles strength first to minimise the chance of getting achilles tendon problems.

calf raise

  • Hamstring strength is essential for fast running but a base level of strength is also important for your park runners to 10km distances. Clearly the most functional way to strengthen the hamstrings for running is to gradually increase the distance and intensity of your running sessions. If you can’t do a hamstring bridge exercise or it takes considerable effort then you need to get stronger. Caution with doing this exercise – if it causes back pain then stop and discuss with one of our physio’s.

hamstring bridge

  • Gluteal (buttock muscle) strength allows for a stable pelvis during running. If you don’t have adequate gluteal strength it puts extra load on the knees, hips and lower back. Unless you have had a biomechanical physio assessment you probably don’t know if your glut’s are working well enough. A glute bridge is similar to a hamstring bridge but the knees are bent at approximately 90°. By bending the knees it makes it harder to use the hamstrings to lift the bottom and thus challenges the gluteal muscles more. Again if you have back pain stop and get some advice.

glute bridge

  • A squat is another good exercise to get the glute muscles working for runners but it needs to be done correctly. Keeping the back straight and bending at both the knees and hips gets the gluteal muscles working. Once you have been taught to do a squat correctly the challenge is a single leg squat with letting the knee drop in valgus collapse.

Squat exercise

Hope you have enjoyed reading about good strength exercises for runners. Thanks to Pete for his stick figure art which has been enjoyed by his clients for many years.

 

Running injuries – How to avoid them

Running injuries physiotherapy

There is a lot of expert opinion on running technique for performance and injury but its complex and sometimes contradictory. When we look at running without injury what helps one person often doesn’t for the next. Pain is not uncommon with running so for this article lets define an injury as when pain influences your running. This article is running advice that often does help get you running pain free …

Planning your approach to running is important but most of us just run when we get the time.

How often should I run is a great question with many possible answers. Let’s start with why you run? Having a goal is an important part of getting started. What do you want to achieve by running: increase fitness, lose weight, do a 5km park run, improve your time for running a set distance, complete a half or full marathon or simply feel better mentally and physically. Let’s aim to minimise or avoid muscle or joint pain that stops you from continuing to run.

How often (runs per week) and how long (distance)?

This depends on whether you have been running lately or not. If you haven’t run in the past 12 months then you need to start slower and less frequently then increase more gradually. There are apps such as couch to 5kms that can help guide you with graded increases. If you already have a base level of running fitness then you can progress more quickly.

Starting with 2 runs per week and working up to 4 per week is a good guide for frequency but it depends on how far you are running and you base running fitness. Starting with 3km walk / jog progressing to continuous jogging then working towards 5km (park run distance) is a good place for those who haven’t run recently.

One of the most common mistakes leading to joint or tendon pain is just doing too much too soon.

If you have had running injuries such as back or hip pain, shin splints or knee pain previously then a physio assessment is recommended before you start. This will identify stretches and strength exercises that will help and provide a guide to how often and how far you run when getting started.

What surface (grass, beach, cement, road)?

The surface you run on needs to be considered. If you want to do a half marathon on road and cement then we need to prepare your body for these surfaces. But if you are just getting started grass has the least impact and has most give to reduce impact stress through the legs. Road or tar is next then cement is the most stressful. Beach is obviously going to have less impact but be careful on the wet sand near the water if there is a reasonable side slope as this will quickly lead to pain. Soft sand level running is hard work, fantastic fitness and low impact but again don’t go too hard too soon. If you are prone to foot pain, then you should have shoes on even for beach runs.

What type of shoes?

There is a lot of research being done around shoe types and orthotics. You can read more detail in our running shoes blog but the only accurate advice is once you have found a type of shoe that allows you to run without pain then stay with it. Finding that shoe becomes more difficult and it is recommended that a physio assessment look at your foot type, muscle strength and running style to best advise a starting point.

How should I run (technique)?

There is lots of information about the ideal running technique (such as the ‘pose’ method) but what suits one body may not suit the next. To land on your heel first like when we walk is associated with increased pressure on the joints in our legs. Alternately to land on the forefoot increases loads on the achilles, calf and shin. If someone has a natural preference to one style and doesn’t have any complaints then you are best not to change your style. If you are trying to avoid knee pain by running more on your forefoot you might just develop an achilles problem and then not be able to run. If you do have joint pain and have been advised to change your running style then get advice and make the change very slowly.

If you have any questions in relation to preventing or treating running injuries let us know on admin@numovesphysiotherapy.com.au

 

Stand up and feel better

newcastle physio stand up desk

Nothing has changed in the last year. The best advice remains to stand up and feel better whenever you can. If you study or work at a desk consider one of the stand desk options to get you on your feet more often.

Ergonomic setup for stand desk is similar with desk height being at approximately elbow height and the top of the screen should be at eye level. A laptop at a standing up desk offers some benefits of standing but the neck and shoulders are likely to get sore with prolonged use. The screen should be directly in front and keyboard / mouse within forearm arc (i.e. the upper arms should stay beside the body and not reach out). The main point for success of a stand desk is you need to be able to stand comfortably for periods of 20 mins or more. Let us know if you have any questions on stand desks.

Newcastle physiotherapy standing desk

Staying active with some form of exercise and reduce some of the negative effects of sitting. Find the balance between activity and sedentary and you will feel better. Get a reminder on this topic from one of our previous blogs here.

Groin and adductor pain in sport

Newcastle physiotherapy for groin and adductor pain in footballThe NU Moves Physio team has recently completed a masterclass debating the best approach to manage and treat adductor pain and tendon problems with footballers. Journal articles were found and discussed relative to the NU Moves approach to diagnosis and treatment.

The following is a summary of the NU Moves masterclass. The current best approach to assist a footballer with pain in the groin or adductor region:

  • Diagnosis is essential: There are many different possible sources of pain into the groin / hip area. Identifying the likelihood of each of these (e.g. osteitis pubis, stress fractures, avulsion fractures, bursitis, tendon strain, hernia, arthritis, lower back referral) via a thorough assessment is essential. Subsequently investigations (Xray, CT scan, MRI, Ultrasound) to confirm or negate are considered. The timing of investigations depends on the risks of the problems and whether treatment is altered because of the investigation findings.
  • Treatment of adductor tendon pathology:
    • Note that this requires consideration and exclusion of all the other potential causes of hip pain.
    • Don’t stretch the adductor muscle area – the right type of strength and functional return to sport exercises will assist recovery of flexibility and stretching is more likely to irritate the problem.
    • Stability is essential – becoming core stable in the pelvis by focussing on strengthening the gluteal and abdominal muscles in sport specific positions (i.e. one leg stand) is the starting point and can often be done very quickly after injury occurs.
    • Strengthening the adductor tendons – when commenced at the correct time after the injury, adductor strength exercise is useful in improving long term outcomes of full pain free return to sport. This could be a ball squeeze between the ankles / knees in lying or a band or cable resistance exercise in standing (as long as the pelvic stability stage has been achieved).
    • Graded return to running: graded return to jogging then running then change of direction exercises is essential. Once the tendon can cope with it and the pelvic / core stability is adequate then a terrific way to strengthen the area for running is to start jogging. The problem is when you go too hard too soon and create a flare-up of pain that lasts several days. Flare-ups are a set back to the eventual goal of return to playing again.
    • Sport specific exercise: kicking / striking / passing the ball in football can all be done lightly and gradually increased in a comparable way to jogging and running. Similarly, once pelvic / core stability and sufficient local strength of adductors is achieved, these are a great way to strength load the area for sport. Again, be wary of flare-ups by progressing too quickly.

The adductor tendon strain is a frequent problem in sport and particularly in football. The best advice is to get an accurate diagnosis first then an active exercise program including 3 parts: the pelvic / core stability, the adductor tendons themselves, and a sport specific program. Getting the right level of loads on the area during each phase of recovery is essential to the process. That is where we help the best.

If you want the best diagnosis and treatment then call us at NU Moves if you have groin pain or a known adductor problem. If you have a friend or family member needing advice to get back to sport then recommend us.