Category Archives for "Hamstring Strain Rehabilitation"

Hamstring Pain – Simon Kelly

Mark: Hi, it's Mark from Top Local. I'm here with Simon Kelly of Insync Physio in Vancouver. We're going to talk about something that a lot of people have trouble with, especially as they're trying to do more exercise right now during a pandemic, or just any time. Hamstring pain. What's the story, Simon with hamstring pain.

Simon: Absolutely Mark, thanks for having me. Yeah hamstring pain, I'll just talk a little bit about that. I suppose you can break it down into two different types of hamstring pain, really. One is like hamstring tendinopathy, which is more like gradual in onset. And the other type is more like an acute you know, you might hear somebody kicking a soccer ball and you know, the hamstring is stretched. Or a sprinter, something like that. But you'd know because it would be a very specific event. That would be more the two kind of different areas that I would kind of put them in. 

The one I talk more about today is more the gradual onset, hamstring tendinopathy. I might make another video about the other one at another stage. So I had a client in recently. She was a female. She's a runner. Runs like you just said, during the pandemic. I think she's said she ran six or seven days every week, every day nearly of the week. So, I mean, the history is quite important because a lot of people will come in and say, look, there's pain in my glute region or in my bum region.

Sometimes it refers down the back of the leg. But they won't really say it's like tingling, numbness, burning. That can be more like sciatica type symptom. But in with say that it is aggravated from sitting quite a lot. The pain is quite deep. And sometimes if you can put your finger on your own sit bone or ischial tuberosity we call it, it can be painful right on the insertion point and where the hamstring actually joins. So that's kind of how she presented. And a lot of majority of the gradual onset pain would present. 

Mark: So that's the presenting problem. How do you diagnose it? And then what's the treatment protocol? 

Simon: Yeah. So the diagnosis, Mark, like I kind of said there it's mainly how did it come on? It's usually gradual like I said.And they'll also say it's painful when I go to tie my shoe. In other words, when they bend the body forward. So the main way of diagnosing it is listening to what the client has to say, especially if they're runners. Lots of people who do lots of lunging, deep squats, anything that kind of uses that tendon or pulls the tendon over that bone.

So you break it into two things. It's compression, which can irritate a tendon and it's tensile force. In other words, speed adds a lot of tensile force through the tendon. And the real kicker is when you add the two of those together, the tendon might rear its head and be like listen, you might be doing a little bit too much. 

At that stage, it depends on the client and the individual themselves. What age they are. If they're kind of younger, twenty-five maybe thirty, the tendon is probably and depending on how long the symptoms are, maybe two to three weeks the tendon is probably reactive, we call it. Which means it's just given a signal to the body that something, it might go into tissue disrepair if we keep going at this pace, gradually loading. 

So I kind of describe it at that point as more like a fire alarm going off. Not necessarily a problem at this moment in time, but it may develop into a problem and the tissue may start disrepairing if you continue at that pace. So that would be really how I diagnose and to be honest, the way to deal with it is load management and avoiding compression and avoiding those tensile forces I've just spoke about. 

So, you know, if somebody is doing a lot of dead lifts, a lot of bending with their back, you know, they're going to pull that tendon over the bone. That's going to be very irritating, a lot of very deep squats, deep lunges is also going to be irritating. In that case, it's more compression. But runners will be more the tensile force. So if you have somebody running, it increases the force across where the muscle joins the tendon by four times while you would be if you were walking. So it's a huge increase in the load.

And especially that particular case study. Six days in a row, you know, there's no gyms open. Everybody wants to go out running now because of the pandemic and it's safe and you're on your own. But it can really creep up into somebody like that and present like that. And it's sort of sit down and like I said, it's sort of tie your shoe, which means at that moment in time, it is very, very irritable and something needs to be done.

Mark: So is this mostly a function of increasing your load, running farther and more often than your body's able to adapt, especially since muscles get stronger way faster than tendons do. 

Simon: Yeah, absolutely Mark, exactly. In her particular case, it really was that there was just no respite. Like she was running like quite a lot. I think it was like somewhere between 5 and 10 k's. So it wasn't just like one k every day it was like, At least 5 everyday or 10 K, which is quite a lot of mileage. And she was young and fit and able bodied, but the tendon was just giving her a sign. Listen, we just need to offload this tendon somewhat.

Now, some physios or what I did was because, even for your mental, a lot of people to run just for mental relief. And I know it is COVID. I kind of said, look you can run, but maybe just do it once or twice a week. Maybe do it Monday and Friday and keep it to like five kilo meters and just see how that is.

So it really is a little bit of trial and error. That's kind of how we have to load manage it. Like I was saying. So you are keeping a little bit, or maybe reduce your speed. Don't run maybe just go just above a walk rather than do quick speed that the tensile forces goes through. The other thing about tendons is when prescribing they usually speak to us two days after.  So, if you go running on Monday, you might feel pain Wednesday, because of that run on Monday and be like, well, I didn't do anything on Wednesday. I don't know why this is painful. 

So very important in the rehab to give that two day break after you run, just to see, has it irritated the tendon or not? So that's probably one of the most important points people need to know when rehabbing after not just hamstring tendinopathy but most tendinopathies in general. 

Mark: So other than reducing the load, what else would you recommend? Or what else would you, do you manipulate the body? Do you do IMS?  What other protocols are you going to use to help them reduce the pain?

Simon: Absolutely Mark. Yeah. So sometimes it can be a bit of stiffness and tightness through the hamstring. So you might do a little bit of soft tissue work through through the hamstring. You might do a little bit of IMS, that needling, intramuscular stimulation, and maybe a small bit of stretching. I don't tend to stretch too much, not too aggressively. Just to kind of distend, I don't, I wouldn't friction over where it joins right onto the hamstring either. Like we used to do that back in the olden days, but that can just create a compressive force, which may actually irritate it further. 

So. In clinic, it's important to come in and get that treatment. Usually three or four sessions is usually good enough to just get a little bit of tissue extensibility back into it. But after that it's really all about load management. The other thing I would say about load management is most people, you know, they have pain and they just rest for a couple of weeks and sometimes they take off maybe a bit slower or maybe just as they left off, and that in theory is unloading the tendon. Sometimes too much. So even if they go back sort of slightly decreased or even just where they left off, you've already unloaded the tendon so much at that point. So even then it might get irritated again if you know what I mean. So it's kind of a tricky one and avoid lumbar flexion, or bend forward positions, especially in the very early stages. Hugely important. You got to take out those two things first and then you got to load it. 

So the real part of the treatment then is kind of introducing speed and introducing those, compressed positions, and then eventually introducing both of those components at the same time. The way I do it is, I'd load it up with a single leg bridge, if you even know what bridging is. That's how you load the tendon, it's not compressed and it's an isometric contraction, which means you're not moving at that point. That just breaks down some of the cross links in the tendon and sort of tells it where to the load up properly. 

And then what I do is I would introduce speed, kind of in a bridge position, but I'd be dropping down and catching, dropping down and catching. So you're introducing speed, but not compression. At that stage into rehab, and then I would introduce more compression, like deadlifts, not from the ground, but from knee height. And then you go down to mid shin height and then you go down to like the ground. So that's just speed one side, compression the other side.

And ideally if your clinic has something, it's like, we call it a push sled. Where you start pushing a sled with weight on it across the floor. So at that moment in time, you're introducing compression and you're introducing speed. And obviously you can alter how quick you push the sled. What kind of friction the sled is on, like how much resistance you are pushing through it.

And obviously you progress it by pushing the sled faster and more weight on the sled and so on and so forth. And maybe on a more friction on the surface that the sled is sliding on. If that makes sense. So that would be the idea of rehab for someone with hamstring tendinopathy, but it's so important to know any education of how we do it for people to buy in, to be honest.

Mark: And so typical rehab period might be a little bit longer. 

Simon: Absolutely Mark. Yeah, you're talking like, and this again, very important point. Like it's not, there's no magic pill here. It can sometimes take three months, like, especially with the more irritable tendons, now obviously there's a bit of grace. Some people are better after eight weeks. Some people take a little bit longer than three months or 12 weeks. But like if you don't tell that to someone on day one, like you got to tell them, look, this can take two to three months, especially like some people come in after a year of trying to deal with with the pain, like it's even a number of years.

So they might take a bit longer than the three month period. But the education is quite simple. It's just believing in the process and believing that it will actually work if you do sort of what we say. And it's very important that the people actually do the crossover at home. I think it's more important to actually, the education part and sort of loading the tendon gradually is better than actually to hands-on treatment or some of the passive treatments, after four sessions, if you get my drift. 

Mark: Yeah. So one thing's curing it. The other thing just makes it feel better. So you're dealing with the symptom, not with what's actually the core problem and making it better.

Simon: Mark, absolutely like, you've hit another topic on the head. It's kind of a lot of the passive treatments we do. They're very good, but they're more, they get you better in the shorter. Symptom relief, we call it pain modulation, or I call it pain modulation in the business. So you are. You're modulating somebody's pain, which is obviously very important, you don't want to be in pain, but you need to have the education and you need to have that, know the transference of the education's really get longer results. I don't want anyone relying on me forever. I love to see them obviously, but I want him to get better and not have to come back. 

Mark: So, if you're dealing with hamstring pain, the guys to see, Simon Kelly at Insync Physio. You can book online at insyncphysio.com. Or you can call the office (604)566-9716 to book your appointment. You have to call and book ahead, he's busy. He's well-respected in the physiotherapy community and he will get you feeling better. It might take a little bit longer than you want, but then the problem will be gone for good if you keep working at it. Thanks Simon. 

Simon: Cheers Mark, thank you. 

Simon Kelly Hamstring Tendinopathy

Mark: Hi, it's Mark from Top Local. I'm here with Simon Kelly, Insync Physio in Vancouver. Vancouver's top physiotherapists, multiple times voted by their customers, best physiotherapists in Vancouver. And we're going to talk about hamstring strains. How are you doing today, Simon? 

Simon: How you doing Mark, thanks a million for dialling in. I'm great to talk to you here today. I'm looking forward to chatting to you about hamstring tendinopathy, in particular actually. So,  yeah, we'll get cracking right away, I suppose. 

I had a client who came in a number of weeks ago, she's an avid runner. She's actually run numerous marathons and she was increasing her running up to maybe sometimes even more than that, 35, 40 kilometres. And she was getting really, really bad and pain in her glute, in her bum muscles. So that's generally how she started presented in the clinic. There was no huge swelling or anything like that. At first it was kind of global. It wasn't like she wasn't able to specifically point to a region in her glute muscles.

So again, it was gradual in onset. So you're kind of pretty sure it wasn't like an acute rupture or hamstring tear or strain or anything like that. She couldn't remember a specific event. Again, that crosses off a lot of that diagnosis like I spoke about before. And it just gradually began to get worse and worse where she wasn't able to run it all.

But in particular initially, it was at 35 kilometres and then she couldn't even run 5 to 10 kilometres. So that's kind of when she came into the clinic, so I saw her then. 

Mark: So that's the diagnosis part of it? What was the treatment plan that you put her on and how did it go?

Simon: So I had a treatment plan Mark because initially it was more global. I actually treated her piriformis muscle, which is a tight muscle in the back of her glute. We've all heard about well most of us have heard about that muscle. The sciatica gets compressed down through there so initially, because it was global and she wasn't pointing at a specific spot. I thought it was piriformis syndrome. 

So we settled that muscle first, we desensitize her whole system, but then after two or three sessions, we realized that she was coming in and then she was much more specific. What I mean by specific issue is pointing at her sit bone. So we sit on two bones called ischial tuberosity, is the fancy term we use. That's where all your hamstring muscles attached to. And placing that with her subjective of lots and lots of running, basically lots of hip extension and knee bending. That's what your hamstring does, over many, many kilo meters that the tendon was just breaking down and it wasn't able to keep up with the load that she was pressing on it.

So initial the treatment like you said, is basically what we call an isometric contractions. And isometric contraction is where you contract the muscle without actually moving through to range. You have to load the tendon. But you have to load it in a very specific and sort of measured way.

So new research has told us now that we actually should be loading it pretty heavy. She was in what we call a reactive stage of tendinopathy. So she'd be doing 70% of her own sort of body weight. An isometric max voluntary contraction we call it. What that does is it sort of breaks down the collagen crosslinks, it gets the tendon back to health. 

And then we can do more of what we call isontonic. What do you see people doing in the gym. Lunges, squats lots of heavy weight through weight bearing. One key thing with hamstring tendinopathy is it's good to load it, but not in a compressed position. What I mean is compressed position is where you're leaning over, like bent over like a straight or stiff leg dead lift. That will be put in a lot of compression and tensile force on the issue of tuberosity. So you want to avoid that kind of stuff initially.

But eventually you want to be gone down into that position. So you'd be in a semi bent over position. Then lower and then lower until the tendon is able to withstand it.

And then you do a lot of energy storage and release. Which is like jumping, running eventually. So that was kind of the initial program. We got her isometrics first, then isotonics and then energy storage and then energy storage and release. And we just gradually increased her running back up from 5 to 10 kilometres, right back off to 25, 30 kilometres.

I've seen seeing her at present. So she still has a touch of tendinopathy, but it's much, much better. And we are loading the tendon into compression now so she's almost doing her straight leg deadlifts back to normal. Which is great.

Mark: So there you go. If you've got some problems with hamstring, tendinopathy, it's sore in your hams from running or any kind of exercise where your hamstrings are going to be bothering you. The guy to see is Simon Kelly at Insync Physio, he's in the Cambie Street office. You can reach them at (604) 566-9716, to book an appointment. Or check out the website insyncphysio.com. You can book online on there. And of course,  Insync also has for the folks in Burnaby, they have a North Burnaby office at (604) 298-4878. Again, you can book online at insyncphysio.com. Thanks Simon. 

Simon: Cheers Mark. Thanks very much.

Hamstring Strain Injuries – Big Ball Roll Outs

Kneeling down with a big exercise ball in front. Have either a partner hold down your legs just above your ankles or secure them by hooking them under a bar.

Keeping your back straight and your inner core muscles engaged and slowly roll down your forearms on the pinky finger sides, straightening out your elbows and moving slight past them on the ball. Come back up with control to the start position. Repeat this for 10 repetitions, doing 3 sets per day.

This is another great alternative exercise to further strengthen your hamstring muscles after an injury and retrain your core stability muscles to help them work better together again.

If you’re unsure about the exercise or have uncertainty about where you’re at with your recovery book an appointment and have one of our Physiotherapists at either our North Burnaby or Vancouver locations to check things out. 

Hamstring Strain Injuries – Superman Deadlifts

Begin by bending the knees a little. Keeping your spine in neutral and your inner core engaged, reach both arms forward and extend the left leg back leading with your heel.

Kick your left heel back and keep that pelvis level with the other side and straighten out the right knee with the corresponding foot on the ground. Then return to the start position.

Repeat this for 10 repetitions, doing 3 sets on both sides. This is a closed chain eccentric strengthening exercise for the right hamstring muscle.

If you’re unsure about the exercise or have uncertainty about where you’re at with your recovery book an appointment and have one of our Physiotherapists at either our North Burnaby or Vancouver locations to check things out.

Hamstring Strain Injuries – Heel Sliders

Use a slider or wear a sock so your right heel will slide more easily for this exercise.

Begin by making sure that you’re supported, so you can hold onto the wall or a railing to ensure that you maintain your balance initially.

With your weight on both legs bend both knees into the squat position. As you get close to a 45 degree bend keep the left foot planted on the ground while you push through with force into the right heel to straighten out the right knee, while you move towards a 90 degree bend with the left knee.

Return back up to the start and repeat this for 15 repetitions for 3 sets on each side.

This is a closed chain eccentric strengthening exercise for the right hamstring muscle. It’s important to also do the other side to keep it balanced.​

If you’re unsure about the exercise or have uncertainty about where you’re at with your recovery book an appointment and have one of our Physiotherapists at either our North Burnaby or Vancouver locations to check things out.

Hamstring Strain Injuries – Knee Extenders

This is a good exercise for the initial stages of rehab for your strained or torn hamstring muscle.

Start by lying down on your back on the ground with the knees bent. To keep the spine in neutral, pull the inner core muscles below your belly button in towards your spine and straighten the left knee out on the ground.

Bring the right knee (with the affected hamstring) towards your chest and hold it securely with both hands behind the thigh. Slowly extend the knee to the end of range comfortably and return it back to the bent position. Do this for 15 repetitions 3 sets 2 to 3 times per day.

If you’re unsure about the exercise or have uncertainty about where you are at with your injury book an appointment and have one of our Physiotherapists at either our North Burnaby or Vancouver locations to check things out.

Hamstring Strains – Progressive Strengthening Nordic Hamstring Curl

You can perform this exercise with your ankles secured under a bar, on a squat rack or wall bar or have a partner hold your feet and ankles down. Use a yoga mat to make it more comfortable for your knees.

Start by pulling in your inner core and keep it engaged the entire time. With your hands out in front of you, then slowly lower yourself down to the ground in a controlled manner into a push up position. Once you make contact with the ground, then push yourself back up.

Repeat this for 10 repetitions, doing 3 sets daily. This is an advanced level strengthening exercise for your hamstrings in conjunction with your core stability muscles.

If you have any pain or dysfunction while doing this exercises come into one of our clinics at either the Vancouver or North Burnaby locations to have one of our Physiotherapists check you out.

Hamstring Strains and Tendinopathies: Straight Leg Isometric Bridges

As you move past the initial stages of an acute hamstring muscle strain or acute flare up of your tendinopathy you want to start progressively loading it to rehab it properly.

Start by lying down on the ground with your heels placed on a raised step about half a foot high or so to start. With your core muscles engaged and both knees straight, press your heels onto the step lifting your buttocks off the floor.

Avoid bringing your butt too high up so you can isolate primarily into the hamstrings while also activating your core and gluteus muscles at the same time. Hold this isometric contraction for 45 seconds and repeat 5 reps for one to two times per day.

If you experience any pain or have any problems doing this exercise then consult your local Physiotherapist before continuing. 

Hamstring Strain Injuries: Squat Lunge and Squat Lunge Hops

This exercise is great for the more advanced stages in the rehabilitation of your injured hamstring muscles.

Place the ball of your foot on a chair or bench that is knee height and maintain this pressure throughout. Engage and pull your inner core muscles in below your belly button while you squat straight down keeping your body vertical. Do not extend beyond a ninety degree bend in your knee while your knee stays in line with your hip and second toe and above your foot. Perform 3 sets of 10 for each side.

The Squat Lunge Hops is a variation or progression of this exercise to something more challenging. When you come back up from the squat, push up as high as you can comfortably aiming for a soft & controlled landing. Do not extend beyond a ninety degree bend in your knee while your knee stays in line with your hip and second toe and above your foot. Perform 3 sets of 10 for each side.

If you have any pain during the exercise or are unsure about what you are doing, consult your local Physiotherapist before continuing.

Hamstring Strain: Basic & Progressive Functional Mobility

When you strain and injure any part of your hamstring muscle, an important part of the rehab process is to ensure that the sciatic nerve associated with it is moving properly. Depending on the severity of the injury, you want to start this basic mobilization technique within the first few weeks. With the basic nerve mobility exercise to increase hamstring functional mobility start sitting down with tall posture. Slowly extend your knee and flex your toes towards you to further mobilize the hamstring. Then return the knee and ankle back to the start position. Repeat this for 60 seconds 4 sets 3 times per day. With the Progressive nerve mobility exercise for the functional hamstring retraining start sitting down with your knees bent and feet flat. Begin to slump your spine so you’re slouching forward and then slowly extend your knee and flex your toes towards you. When it reaches full knee extension and toes towards you with a pulling sensation, straighten up you back to tall posture. Then return the knee and ankle back to the start position. Repeat this for 60 seconds 4 sets 3 times per day.