Proximal (High) Hamstring tendinopathy – A Real Pain in the Bum

The hamstring consists of three muscles and it has a very important role in extending the hip from a bent position, e.g. initial phase of a deadlift, and in bending the knee, e.g. at the end of leg swing while running. While this muscle group is a very common source of problems, most commonly tearing when sprinting, this usually occurs in the middle of the muscle belly. In contrast, proximal hamstring tendinopathy refers to a reactive painful hamstring tendon at its attachment point on the base of the sit bone (ischium). This is why it is call a high hamstring tendinopathy.

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Tendinopathy in the hamstrings is common in athletes, particularly in sports that involve large periods of time bent forwards, such as hockey, or involving high driving of the knees, such as sprinting or hurdling. However, it is often seen in other populations also., such as runners and even in the elderly.

How does it happen?

The hamstring tendon runs very close to the sit bone and is protected from compression and friction by the ischial bursa. If you gradually increase your training over time, these protective structures adapt providing greater protection. However, with sudden increases in the volume of compression on the tendon, this protection may not be sufficient, leading the tendon become extremely reactive and irritable. Sudden increases in compression can come from an increase in any of the following:

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Direct compression from an external source, e.g. prolonged periods of sitting, especially on hard surfaces.

·         Extreme positions of hip flexion pull the tendon tight against the sit bones, e.g. pulling knee close to chest, deep squats.

·         Any hamstring stretch will likely compress the hamstring against the sit bone

·         Contraction of the hamstring while already in a position of stretch will pull it tighter against the bone and increase the compressive forces, e.g. hurdling, sprinting (below)

 Figure 1: Examples of positions of stretch with strong hamstring contractions that cause large volumes of compression of the hamstring tendon

Figure 1: Examples of positions of stretch with strong hamstring contractions that cause large volumes of compression of the hamstring tendon

It is important to again note that these compressive forces are normal for the hamstring. It is usually sudden changes in the volume of compression that is the problem, rather than compression itself.

The typical presentation is a deep ache or burning sensation right on their sit bone. It is usually quite focal but can sometimes radiate down the posterior thigh. Symptoms typically develop gradually over time, often without any clear moment of injury. They are usually worsened during activities involving hip flexion, hamstring stretch and hamstring contraction, particularly if all three are combined such as when lunging, squatting, sprinting, hurdling. Running up hills or stairs is usually worse than running down. Early on, the pain is usually worse at the beginning of activity, but warms up and gets better during activity, only to be very sore afterwards and the next morning. As it progresses and becomes more severe, it can worsen into activity and be quite painful even at rest.

What else could it be?

The anatomy in the area is complex and several other diagnoses should be clinically investigated and ruled unlikely before settling on a diagnosis of hamstring tendinopathy. The piriformis (circled in green) and deep gluteal muscles below it run close by and can develop tendon pain. The sciatic nerve (thick yellow band) also runs through this region and can become entrapped and irritated. Further, pain from the lumbar spine (lower back) and sacroiliac joint (where the pelvis meets the spine) commonly radiate into the buttock region and should always be screened for. In rarer cases, the shaft or the outside of the femur can impinge against the ischium causing irritation.

A comprehensive clinical assessment is usually sufficient to evaluate the likelihood of these various diagnoses and develop a comprehensive treatment strategy. In some cases, further imaging or referral to a specialist sports physician may be necessary.

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How do I manage it?

1. Avoid compression – don’t stretch it!!

In the early stages, avoiding compression is the best way of settling symptoms in the early stages. Seating should be improvised or special cushions can be ordered to take pressure off the sit bones. Moreover, having a large glute bulk can provide extra protection. Static glute contractions can ease pain while sitting, and building glute bulk over time can be a useful strategy.

Avoid deep flexion exercises (such as squats or lunges), hamstring stretching and exercises that contract the hamstrings at long lengths such as stiff legged deadlifts or arabesques.

Later in rehab, once the tendon has settled down and is less irritable, then it is important to gradually add compressive activities back in to ensure full restoration of function. Your physio will again guide you through this process as it becomes appropriate.

2. Load management

For athletes, the hardest part is getting the balance right. This condition can be hard to manage if you continue to train at your usual level and you may be required to reduce or at least modify your workload. Typically, we are happy for our athletes to continue some volume of training with the condition so long as the pain is tolerable and doesn’t worsen from week to week. Use a consistent exercise performed at the same time every week to monitor weekly progress. If this is increasing, more modification may be necessary. However, if it is stable or decreasing than the current level is acceptable.

Activities such as sprinting, hockey, rowing, or uphill running are more provocative. We try to limit these activities to 2 times per week to allow sufficient recovery time between sessions. Outside of this, cross training is recommended to improve fitness without further irritating the hamstring tendon. We suggest aqua-jogging, swimming, cross-trainer, upright cycling with a well fitted seat height.

3. Hamstring strength exercises

Lower limb tendinopathies respond very well to exercise and we have found similar results in hamstring tendinopathies by strengthening the hamstring itself. The trick is to get the right exercise for the right person at the right time. The best way is to get a specific rehabilitation program from your physiotherapist. They can guide you on which exercise to do at each stage and how many sets/reps/frequencies to ensure you get the best-fit dosage for your condition at its specific stage.

4. Biomechanics

Certain characteristics may put someone at an increased risk of developing a hamstring tendinopathy. For example, having a very stiff lower back, or tight hip flexors will pull your hips into a forward tilt. This means that while running, your hamstrings will be on a higher stretch throughout. Addressing these biomechanical factors can be very useful in reducing symptoms during activities and preventing reoccurrence.

What else can I do?

·         Dry Needling and Soft Tissue Mobilisation

A tendon that does not like compression is unlikely to respond positively to pressing on it or sticking needles in it. However, soft tissue work can provide effective pain-relief if directly at highly toned muscles surrounding the irritable tendon, such as the hamstring muscle belly, or deep gluteals. Likewise, soft tissue work may be useful to help address some of the biomechanical deficits mentioned above, such as releasing the lower back or hip flexors.

·         Anti-inflammatories

Anti-inflammatories such as ibruprofen can be useful to settle the pain in hamstring tendinopathies, particularly if caught early and applied stringently over a short period. We would suggest visiting your physician before trying this approach. It is important to couple this approach with comprehensive rehabilitation to ensure full restoration of hamstring function and reduce the risk of reoccurrence.

·         Injection

Corticosteroid may provide some short-term relief (approximately 6 weeks). However, symptoms tend to reoccur once the effects of the injection have worn off. Serial injecting is unwise as some evidence suggests it may cause deterioration of the quality of the tendon and worse outcomes. Corticosteroid should be used only with careful consideration after exhausting other management strategies.

PRP injections have been suggested to improve tissue healing. However, the currently available evidence does not support the use of this strategy, as it has a low likelihood of being any more successful than placebo.

·         Shockwave therapy

Shockwave therapy has shown some promise, albeit with mixed results, in the treatment of lower limb tendinopathy. In our experience, it may lead to worsening of symptoms in irritable, acute tendinopathies. However, it can be a useful strategy in some patients, particularly those with more chronic and less irritable tendinopathies.

·         Surgical management

Surgical procedures have been described but should be an absolute last resort for the management of hamstring tendinopathies and only used when all other strategies have failed.

Plantar fasciitis

WHAT IS IT?

Plantar fasciitis Is a very common cause of heel pain. It can be quite debilitating and can last for months if not addressed. Typically, pain will be felt on the inside of the heel and arch. Pain can be sharp or achy. There can be a small amount of swelling over the medial heel as well as tenderness to touch. Mornings are worse, with it usually taking anywhere from 2-3 minutes to an hour for the stiffness and pain to reduce.

POSSIBLE CAUSES

·         Change in load eg Running/jumping

·         Change in footwear

·         Change in activity surface eg. Hard surface

·         Acute trauma eg. Stepping on a rock

 SCANS

Sometimes your GP will refer you for a scan of the affected area. Most likely it will be an x-ray or an ultrasound. This may show that there are heel spurs or “tears” in the plantar fascia. Although it can be good to confirm the diagnosis, scans can sometimes be detrimental as it may cause people to become worried about their condition. Scan results can also correlate poorly with symptoms an example being that people with heel spurs on x-ray don’t necessarily develop Plantar fasciitis.

TREATMENT OPTIONS

·         Soft tissue release

·         Joint mobilisations

·         Taping techniques

·         Orthotics

·         Exercise program (Physiotherapist prescribed)

·         Load management plan (Physiotherapist prescribed)

LOAD MANAGEMENT

Load management is about controlling how much you use the particularly area on a day to day basis. Usually when an area becomes painful, its load capacity (ability to tolerate load) is reduced so it becomes overloaded quicker than normal. This means that even normal tasks or activities like walking or standing can cause it to become more painful and swollen. 

One of the ways to improve the capacity is to progressively build up the amount that you use that area. This can be done with a specific structured exercise program (physiotherapist prescribed) that is made more difficult over a period of time. It is normal for rehabilitation to be painful, you cannot improve load tolerance without causing some discomfort.

The best way to monitor improvement is by recording morning pain (rating it out of 10, 10 is worst, 0 is nothing). It is normal to have ongoing morning stiffness even after pain has completely disappeared.

DIFFERENTIAL DIAGNOSIS

Sometimes Plantar fasciitis might not be the cause of heel or foot pain. It is important to see a physiotherapist to get an accurate diagnosis. Other causes of heel pain are below:

·         Plantar or Calcaneal Nerve pain

·         S1 radiculopathy

·         Stress fracture

·         Tarsal tunnel syndrome

·         Fractures

·         Retrocalcaneal bursitis

·         Spondyloarthropathies

·         Cancer (osteoid osteoma)

TIPS FOR PAIN FLARE UPS

·         Try to avoid walking around in bare feet

·         Using ice over the sore area can give temporary relief

·         Stretching it may be uncomfortable so roll a golf ball/tennis ball under the foot instead to release tight muscles

·         Pain relief or anti-inflammatory medication can be helpful but ask your pharmacist for advice

·         See your physiotherapist!


Groin Pain

As pre-season training gets underway for winter sports codes we generally see an increase in the number of patients with groin pain presenting to our clinic. Discussing groin pain as a whole is a very large topic, so for the purposes of this blog I will discuss non-traumatic groin pain and in particular the most common factors that can lead to injury.

Non-traumatic groin injuries are typically complex and require a thorough assessment to determine the factors that have led to the injury and a comprehensive exercise rehabilitation program to recondition the athlete to be ready to return to their sport.

WHAT IS IT?

Groin pain is an umbrella term for pain felt in the groin area. It is not diagnostic and does not indicate a specific pathology or tissue(s) affected. Groin pain can be sub-grouped into 6 different areas:

·         Adductor related
·         Hip flexor (iliopsoas) related
·         Abdominal (inguinal) related
·         Pubic related
·         Hip joint related
·         Other (neural, referred pain, fractures, abdominal/gynaecological conditions etc)

It is common more than one of these sub-groups to be affected and insufficiencies in one area can lead to an overload in another.
 

WHY DOES IT OCCUR?

Three common reasons for the development of groin pain in sporting people include training errors, poor mechanics and age.

·         Training errors causing injury usually refers to “too much too fast” and is usually seen with athletes rapidly increasing their training amounts without adequate recovery between sessions causing a progressive overload of structures in the groin area. Groin pain will commonly present as preseason training reaches 3-4 weeks in and more commonly as running demands transition into higher amounts of sprinting and agility.
·         Poor mechanics refers to muscle imbalances, poor movement control and patterns, poor posture, inadequate strength, lack of flexibility and sub-optimal technique for sport specific skill. This is where a good sports physiotherapist will be able to conduct a comprehensive assessment to determine which of these factors are contributing to your groin pain.
·         Younger athletes are more susceptible to developing groin pain as their skeletal system is less mature to withstand the stress that training can put on the body compared to older athletes (25+ years).

MANAGEMENT

The pain will generally settle with a combination of rest and anti-inflammatory medication. During this rest period it is important to address the factors that have led to developing groin pain (poor mechanics) to avoid reaggravating the injury when you return to running. It is very important to have a graduated return to running plan in place to allow for optimal recovery between sessions and avoiding too much load too soon.

PREVENTION

The old adage “prevention is the best cure” is applicable for groin pain and there is plenty that can be done to prevent it. If you have had groin pain in the past, having a preseason screen with your physiotherapist is beneficial to assess if any predisposing factors are present. A comprehensive strength and conditioning program to address any factors as well as condition your body to tolerate the training loads can help prevent groin injuries. Also making sure to optimise your recovery between sessions – for helpful tips read our blogs on recovery – will help prevent the development of groin pain.

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Shin Pain and Medial Tibial Stress Syndrome - An Update

Is there an answer or should I toughen up and suffer in silence?

Preseason is a common time for overuse injuries and pain to present due to the sudden increases in training volume and intensity. Shin splints is one such injury, which seems to just get worse and worse. Often this problem plagues the athlete annually at this time of year. Occasionally it persists into the season to the point where the athlete is constantly playing through pain, suffering post-game and performances can begin to be affected. Since they haven’t had an “injury”, the athlete often feels like they just need to toughen up, push on through and it will pass. However, the problems seem to only get worse and worse the harder they push. Other athletes take time off and are increasingly frustrated to find the injury returns as soon as they get back to business.

So what is shin splints and what causes it?

Shin splints is actually a loose term because it encompasses a range of presentations, including stress fractures and compartment syndrome. It is still widely used but an attempt is being made to oust it. You may or may not have heard your physio refer to it as medial tibial stress syndrome. Medial tibial refers to the inside of the lower shin where symptoms are most frequently reported. Stress syndrome simply indicates that relative overuse is most commonly the cause.

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As the narrowest part of the tibia, tiny bending movements occur at this site when running. This causes microscopic breakdown of the bone. There can also be breakdown of the connective tissue that encapsulates the deep muscles of the calf, where it attaches to the bone at this location. However, this is a normal process that occurs in everyone every time they go for a run. The strength of the original tissue and the amount and intensity of the running determines how much breakdown occurs.

Our bodies respond well and adapt to training. Our immune system will usually kick in pretty quickly to clean up the breakdown and lay down new bone and connective tissue in its place.  As seen in the picture below, given proper loading volumes and recovery time, our bones overcompensate each time to get thicker, denser and stronger. This means that we can tolerate increasingly difficult challenges. This is a very similar process to how you can build muscle in the gym. However, bone does take a longer to recover, and longer to grow than muscle, but is just as plastic and adaptable.

 From "How much is too much? (Part 1) International Olympic Council consensus statement on load in sport and injury risk" by Soligard et al. British Journal of Sports Medicine 2016: 50:1030.

From "How much is too much? (Part 1) International Olympic Council consensus statement on load in sport and injury risk" by Soligard et al. British Journal of Sports Medicine 2016: 50:1030.

How do I know how much is too much?

This varies greatly from person to person and is dependent of a number of factors.

Loading spikes:

We know that strong bones better resist breakdown and we know that bones get stronger over time. However, if you suddenly increase your training volume, frequency or intensity, you may not have time to sufficiently develop the bony adaptions necessary. Sometimes even changing mode of training to something very taxing on the calf muscles, such as hill running or skipping, is enough of overload the capacity of the tibia. Consistency and gradual increases in training load are imperative to avoid loading spikes.

Strength

Muscles develop at a different rate to bones. Importantly, muscle size is consistently associated with bone size and strength. This means bigger muscles are usually attached to stronger bones. Resistance exercises had been shown to increase bone density. Therefore, calf strengthening exercises can be useful in increasing the strength and size of the tibia so that less breakdown occurs.

Type of Runner

There are two extremes on a spectrum here. There is the athlete with calf and Achilles tendons like Pogo sticks. They often may be lacking in shock absorption and propulsion elsewhere. Naturally, if this is their primary source of power, it will also be the first area to overload. These athletes can often benefit from addressing the weaknesses elsewhere, reducing the demand on the calf muscles.

The other end of this spectrum is the athlete that has weak calf muscles, and is often knee dominant and heavy footed. A change in loading where calf strength is necessary can expose this weakness and cause overloading. Running retraining, and calf strengthening can work well in this population.

Nutrition and Bone Health:

Some people are genetically more vulnerable to low bone density. A family history of osteoporosis or stress fractures may hint at this as a factor. Another key issue is diet. We all know calcium is good for bones but vitamin D is also essential. Under-eating often occurs unintentionally, but when diet is compared with the massive energy requirements of greater than 5 sessions a week, calorie intake often becomes insufficient to meet energy expenditure. Nutrition is key to good bone health, and you can’t outrun a bad diet.

Pain Threshold

Pain is a protective mechanism, like a car theft alarm. It is designed to go off early and loudly before any substantial damage. This is a warning that there may be something to address. However, this threshold is very adjustable and dependent upon a multitude of factors. For example, the local nerve fibers become increasingly irritated and easier to set off when they are repeatedly overloaded. The red line in the picture above moves upwards and so it takes less to set it off. Like a car alarm that goes off in the middle of the night, it seems to get louder and louder.

We also know that lifestyle factors like getting poor sleep, feeling run down, stress, anxiety etc. can lower your overall pain threshold in the absence of pain or injury. In this instance, it takes much less breakdown to fire a pain response. Here, it is vital to address any of these factors that are modifiable to reconfigure the pain threshold to a more reasonable level.

Can the bone fracture?

The overwhelming majority of cases of medial tibial stress syndrome do not lead to stress fractures. This is because the rate of repair and breakdown usually meet an equilibrium long before the integrity of the bone is compromised. However, in some isolated incidences bone stress fractures can occur but this is rare. The pattern of pain with stress fractures is different from medial tibial stress syndrome. If you are concerned about developing a stress fracture, your physiotherapist can quickly establish the likelihood of it.

How do I know if I have medial tibial stress syndrome?

The common description of pain, is a dull diffuse ache along the inside of the shin. It will usually extend at least 5cm along the middle of bottom third of the shin. This pain comes on the beginning of exercise, but will often “warm up” and be less prominent as the exercise continues. As the local tissue becomes more irritated, it will last longer into exercise and may begin to even cause pain after exercise when walking or going up and down stairs. It is not limited to runners, and is very common in footie, soccer, hockey, netball and other field sports.

How long will it take to get better?

Compression garments, massage, dry needling, taping and shoe inserts may offer some short term relief. However, the results are mixed and often require trial-and-error to determine what works for that individual. They won’t solve the problem but can get you through the pain for long enough to successfully adapt.

There is great potential for long-term success the causing and contributing factors are identified and addressed. It can take time to build up the muscular, tendon and bone capacity. Likewise, the nervous system can take some time to cool down, especially the longer it has been wound up. Until then, a certain amount of patience is required. This carefully measured approach is the best way to ensure the problem doesn’t continue to spiral and progress.

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What can I do for my shin pain?

1.       Catch it as early as possible before it becomes increasingly irritated.

2.       Start a training diary to get an idea of how much you are doing and how consistently you are training.

3.       Address lifestyle factors if they are modifiable, such as diet, sleep and stress – obviously, this is not always possible!!

4.       Visit a physiotherapist to identify your personal contributing factors and develop a management plan – there is no one-size-fits-all approach.

 

Low Back Pain

Approximately 80% of people will experience lower back pain at some stage in their life. It is one of the most common reasons for people missing work and seeing a doctor or physiotherapist. Although it is extremely common it can often a bit of an unknown to the general public as to what is the cause for their pain and disability.

 

There are many different causes of low back pain from strains/sprains, posture related pain and overuse injuries. This blog post will mainly focus on acute strains or sprains of the low back.

 

Similar to other joints around the body, strains or sprains to the low back occur when a stress is placed on a tissue that exceeds what it is capable of handling. An example of this could be someone bending over to lift a heavy object off the floor. However, a heavy force is not always required to strain the back. Repetitive movements of small force can also do this. 

 

Again like other joints around the body, different structures around that area can be irritated or strained. For the low back this can be surrounding muscles, ligaments, facet joints, discs or a combination of a few structures.

 

Timeframes of recovery will vary depending on what structures are involved, the severity of the injury, the demand of the person and lifestyle factors such as sleep, stress levels, diet ect.

 

 

What Can I do?

 

The back responds very well to movement. It is encouraged to continue to keep moving within your pain limitations.  Identify positions and movements your back feels better with adopt these positions rather than the painful ones.  This will differ from person to person so your physiotherapist will go over these particular activities/positions with you.

 

 

What can’t I do?

 

Your pain and symptoms will often be exacerbated immediately during specific activities. However, an increase in symptoms can often be noticed after completing particular tasks or even the following morning/day.

 

It is important to identify these activities or postures and avoid over repetition of them or prolonged time spent in those positions.  These activities are often simple tasks we complete on a regular basis throughout the day so it is often unrealistic to completely avoid them. Instead, modifying how we complete them or limiting how much of them we do of them will be more effective. Eg sitting posture or length of time spent sitting.

 

 

Do I need a scan?

 

The majority of back injuries do not require any scans or imagining and will resolve without the need for a scan. Scans can also be misleading at times as they tend to show everything that is happening in your back even when it’s not the source of your pain. Scan results can make people anxious, worried and stressed which can make their pain significantly worse.

 

 Imaging of the low back is potentially required when treatment/management of the injury could potentially change depending on the diagnosis or extent of the injury.  Your GP or physiotherapist will discuss with you if they think imaging is required in your case.

 

Do I need surgery?

 

Again, like imaging most low back injuries do not require surgery. However, there are circumstances where surgery may be required or beneficial in addressing certain injuries.  Obviously there are risks when any surgery is performed and so they are only recommended when they are truly needed.

 

When can I return to exercise?

 

This is a difficult question to answer as it will depend on a number of factors including the type of exercise you are attempting to return back to, the severity of the injury and previous injury history. However, in general, most soft tissue injuries have a recovery timeline of about 4-6 weeks. There will often still be things you will be able to do during your rehabilitation. This will usually start off with activities that do not exacerbate symptoms followed by modified versions of more complicated tasks with the aim to progress back to your previous level of function.  

 

 

Will this injury reoccur?

 

Like most injuries there is always a risk it re-aggravating Your treating physiotherapist will advise you on ways to best prevent this from happening. This will often involve an exercise program to address any deficiencies and optimising technique and posture with specific tasks/activities.

Wrist and Hand Injuries

Wrist and Hand Injuries

We use our hands repeatedly every day so it’s not surprising that sometimes we develop pain and discomfort in our fingers, wrists and forearms. Injuries in the wrist and hand can be caused due to traumatic events (e.g. a fall on an outstretched hand) or overuse, repetitive activities (e.g. computer use, racquet sports).

Anatomy

THE IMPORTANCE OF MUSCULOSKELETAL SCREENING

THE IMPORTANCE OF MUSCULOSKELETAL SCREENING

Finals time for most winter sports is fast approaching and from a physiotherapy perspective this is the time of year that we see a spike in sporting injuries. A lot of these injuries tend to be to parts of the body that have some sort of deficit, be it strength, length or control. It is quite hard to be able to identify these areas yourself and even physiotherapists would find it hard to accurate identify these deficits purely through observation.