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.