Tag: Physical Therapy

How to “BULLETPROOF” your hamstrings…

I know, slight click bait, but a dodgy hammy can be a real hindrance to you enjoying your sport. I’ve felt the pain, having been on the wrong end of a decent hamstring tear and continuing to push too hard thinking I knew best. Great therapists are typically terrible patients. Or at least that’s what I keep telling myself.

Here’s where I recommend would be a good place to start to get on top of your hamstring niggles. To make things simple, I’ll be talking mostly through my preferred exercises to be included in hamstring rehab through the different stages of injury.

Remember, this blog is general information based on personal experience and my thoughts of where to start. Everyone is different, and every injury is different. It is best practice to seek out a physiotherapist to personally guide your treatment.

Settle Grettle Phase (Day 1-5, or 14 if you’re unlucky)

During the acute phase, there’s a possibility that you will have a small to large tear/multiple tears through the hamstring muscle, musculotendinous junction or tendon to bone insertion or origin. With this in mind, it is imperative you resist the urge to really stretch through the hamstring, and instead, start to get tolerable load through the hamstring early. In my opinion, this helps to promote the “knitting” of the soft tissue for good healing.

Personally, my favourite exercise is the prone self resisted hamstring holds in the mid-range. Hold for 5-10 seconds against as much resistance you can manage without sharp pain or the hamstring “giving out”. Repeat for 10 repetitions twice daily

The other exercise I like to go with is the double leg bridge. The key being that you lift up as high as you can without the sharp or biting pain. Hold for 5-10 seconds and repeat 10 repetitions twice daily.

You can also get yourself on a stationary bike, adjusting the seat height to make sure that the revolutions don’t feel sharp or biting through the injured hamstring. Aim for 10-15 minutes daily.

Steady load phase (Week 1-6)

At this stage, I would expect the hamstring to be tolerable to light stretching and capable of withstanding progressive loading. Cycling should be pain free, with focus shifting to strengthening through full range before engaging in plyometric or running activity. As we load the hamstring up more, the goal is to complete exercises 3-4 times each week rather than daily as the hamstring will need recovery time to cope with the new demands placed on it. My go-to exercises are as follows:

Outer range isometric loading – a simple progression of the exercise in the acute phase, the difference being positioning the injured hamstring in an area of more length to make the muscle contraction more difficult. Same reps, aiming for 5-10 second holds 10 times.

Bridging on swiss ball (double leg to single leg) – again, building on the other exercise from phase one. Bringing in the swiss ball encourages the hamstring and glute to work harder for stability as well as completing the exercise. Start with double leg holds, progressing to double leg holds with rollouts, before moving to single leg. You can also add a hamstring curl to this exercise if you’re feeling pretty good

Nordic pulses – the beginning of a nordic drop. The idea here is to get the hamstring used to eccentric contractions, a vital component for returning to running (and more specifically sprinting). These exercises are best done with quality rather than quantity, so 4-5 repetitions of 5-10 second holds might be all your hamstring manages before it fatigues. I would recommend only doing “nordic” exercises 2-3 times a week initially as they can cause discomfort initially as you build them into your normal routine.

Hamstring flossing – start to get some sliding action along the hamstring by lying on your back with the affected leg up in the air. Gently straighten your leg out as much as you can manage without any severe pulling/biting/sharp sensations. Steadily work through the reps and you should feel the hamstring start to loosen up.

Hamstrings of doom phase (Week 4-6 and beyond)

Progression to this phase will depend completely on the degree of hamstring injury. Typically though, this is where walking, light jogging and all previous exercises have become painfree and equal (to 90+% of the other side) and there is no pain on palpation through the hamstring muscle. It’s time to WORK.

Full Nordics – you’ll need to lock in your feet, either with a heavy piece of furniture/equipment or utilizing a strong friend to hold your feet down. Keep yourself as upright as possible and slowly lower yourself down to the ground. Hold on for as long as you can, the longer the rep the more benefit you will get out of it. You probably want to aim for 6 good reps and 3 sets the first time you give it a go, steadily building up reps to the 10-12 mark. These are non-negotiable and should be done at least 3 times a week. It’s the only exercise that will make your hamstring muscle fibers longer and stronger at the same time. However, not all good things can last forever, and it can take as little as 3 weeks detraining to see a significant drop in fascicle length at the hamstring. I’ll post the study at the bottom for those interested.

Romanian dead lifts – honestly one of the best exercises for glutes and hamstrings, in my opinion. You can also adapt them to a single leg exercise if you don’t have access to a huge amount of weight. The idea here is we keep the distal insertions of the hamstring at the same length, and increase the length at the proximal origin (the opposite of a nordic). You can use barbell, kettlebell, dumbbell, whatever bell you like. I’d emphasize a slow, eccentric down over a couple of counts before coming up at a regular pace. Keep knees straight, or with a very slight bend, and keep lower back/hips in slight anterior pelvic tilt (keep back flat rather than rounded). Complete slow, high reps on this one for endurance, or low heavy reps for maximal strength.

Seated good mornings – the last of my go-to exercises for hamstrings. A lot like the RDL’s we are changing hip position, but I feel as though shifting the point of load allows you get more of a loaded flossing stretch through the hammy. I’d only usually prescribe this in very slow, high rep ranges (15-20 reps)

Again, there are plenty of ways to rehab your hamstring. It may include rehabbing things that are not the hamstring to get to the root cause of your issue. There are also many more exercises I use on a daily basis with patients in the clinic, but, if you’re looking for a place to start, hopefully this gives you that. It is always best seek out a complete assessment and tailored rehab program for you. If that’s with me, well that’s even better.

Thanks for taking the time to read through my blog, if you have any comments or queries feel free to leave a comment below.

Cheers,

Teej

@theinjuredphysio

Extras for overachievers (unfortunately the first of these articles is not free, but the second one can be found through google scholar):

Alonso-Fernandez, D., Docampo-Blanco, P., & Martinez-Fernandez, J. (2017). Changes in muscle architecture of biceps femoris induced by eccentric strength training with nordic hamstring exercise. Scandinavian Journal Of Medicine & Science In Sports, 28(1), 88-94. doi: 10.1111/sms.12877

Tyler, T., Schmitt, B., Nicholas, S., & McHugh, M. (2017). Rehabilitation After Hamstring-Strain Injury Emphasizing Eccentric Strengthening at Long Muscle Lengths: Results of Long-Term Follow-Up. Journal Of Sport Rehabilitation, 26(2), 131-140. doi: 10.1123/jsr.2015-0099

The Crux of Crutches: the 1-2-3 step guide

Crutches… Crutches… Crutches

During my time as a sports enthusiast, I have unfortunately become well acquainted with crutches. They are essential for enabling mobility while keeping weight off injured tissue, allowing natural time to heal as well as possible without overloading it.

But at the time, they can suck.

Crutches are awkward, they make your palms sore, they fall over when you try to lean them against the bench top, they are with us for what feels like an eternity (yes six weeks can feel that long) – and it’s a shame that the safe use of crutches is often left to the user to work out themselves.

Whether young or old, the skill of using crutches efficiently can be learned using these simple concepts. But first, lets make sure they are set up properly.

Small disclaimer: As the axillary (under armpit) crutches are pretty much extinct here in New Zealand, I’ll be focusing on the elbow crutch in this post.

#1 – Setting up the crutches

Crutches must be set up for YOUR body, and typically they are set up too high. It puts unnecessary stress on your arms and shoulders, and when saddled with crutches for 6 weeks or more, this will take it’s toll on your body.

To set up the crutches, stand up straight with your arms relaxed by your sides. If your balance is not good, then do this close to a bench top so you can support yourself, or get a friend to help. Allow your arms to hang so there is a subtle but comfortable bend at the elbows. The handle of the crutch should be set to your palms at this height. Set the forearm cusps to wrap around the upper third of the forearm (closer to the elbow), NEVER above the elbow.

As a quick check, stand in front of a mirror with your crutches. Gently apply force downwards into the handles to take your weight – maintaining that slight bend at the elbows. If you feel/see your shoulders visibly rise, then it is likely the crutches are too high. If you need to lean forwards to apply the pressure through the crutches, then it is likely the crutches are too low.

#2 – Walking for your injury

The pattern of walking could depend a number of factors including type of injury, stage of injury and/or medical teams advice. I will split these into non-weight bearing, partial weight bearing and near-full weight bearing (NFWB).

Non-weight bearing (NWB):

This is usually in the early stage of recovery, following some surgeries or if you have been put into a non-weight bearing cast.

This is the hardest stage of using crutches both physically and mentally. Every effort to stand up, get out of bed, go to the toilet will test you. Factor in the pain you’re likely experiencing and some days might not feel worth it.

But,

There is a reason for this, and it is to give your body the best chance it has at healing. So turn those mini-challenges into mini-victories! Apply the following patterns to make things as easy as possible.

The concept is simple. And its based on simple geometry.

You are going to use a triangle as your guide. The two crutches in tandem will make up two points, and your good (uninjured) leg will be the third.

Place the two crutches one regular step ahead of yourself, and step through one step ahead of the crutches with the other foot, and repeat. Take your time, be methodical initially until it becomes natural

Easy – but be wary.

It’s possible to get caught out by putting the crutches too far ahead of yourself. This will mean that rather than stepping through with your good foot, you end up swinging your body through. Although quicker, more momentum simply increases the chance of you or the crutches slipping, or having to hop to regain control. Be smart and stay safe.

Partial weight bearing (PWB):

Perhaps the injury is on the low end of the severity spectrum, or you’ve gone an extended period of NWB and the doctor/physio/specialist has given you the green light to start loading gradually.

Awesome job! Celebrate this mini-victory!

The pattern here doesn’t change. Put your crutches out first as before, next step with your injured foot to the middle of the crutches and “weight-bear” within pain-free limits, step through with your good foot and repeat.

Near full weight bearing (NFWB):

You are nearly there! Graduation and the point of throwing those blasted crutches out the door is almost upon you. Once again, well done on getting this far!

The likely change here is that you will be wanting to only use one crutch. As easy as that sounds, it is super common for people to make this harder than it needs to be.

Make sure the crutch is on the OPPOSITE side to your injured leg. This is crucial. Having it the same side will cause a walking pattern similar to a pirate with a wooden peg leg. It results in overuse of the upper body on that side an “hitching” of the hip on the affected side. It also abolishes the triangle rule that has served you so well to this point. Why change something that isn’t broken?

Instead have the crutch on the opposite side to promote even weight distribution and a far more regular walking pattern. The crutch and the affected leg come forwards at the same time, followed by a step through with the good foot. If you don’t believe me, try both ways! One will feel far more comfortable than the other

#3 – Conquering steps

Steps and stairs are another challenge for someone fresh to using crutches. It can be scary, and fear of falling can be debilitating enough to keep people at home or even worse confined to the ground floor of their homes.

Steps are managed by remembering this: GAS goes UP, and SAG comes down.

G.A.S means Good, Affected and Sticks, and applies to scaling UP stairs.

  • First, place your GOOD leg up one step,
  • Next, bring your AFFECTED (injured) leg up to the same step,
  • Last, bring your STICKS (crutches) to the same step as well, and repeat.

S.A.G is the opposite, for when going DOWN stairs.

  • First, place your STICKS on the step below,
  • Next, bring your AFFECTED leg to the same step below,
  • Last, bring your GOOD leg to the same step below, and repeat.

It’s now up to you to put this into practice!

If you’ve made it this far, thank you for reading my blog. All the information covered is intended to help you through your injury, as it has helped me through mine.

If you did find this helpful, don’t hesitate to mention it to a friend who might benefit from it as well.

Take care out there, and lets continue to rehab and train together!

Teej

A LisFranc Fracture: The next rare injury to add to the collection

I am convinced I must have done some terrible things in a previous life.

I’m writing this from my hospital bed following surgery for a Lisfranc foot injury I sustained 5 days ago playing a club rugby. For the record, a Lisfranc fracture is one of the most commonly missed injuries in primary care, and mine would have fallen into this category had I ignored my gut instinct and followed the advice of the urgent doctors.

But this post is not a gripe about the sometimes sub-par treatment delivered for musculoskeletal injuries in after-hours care, they have a really difficult job with patients that are often in immense levels of pain and discomfort. In this post I’m going to take you through how to not miss a lisfranc fracture, with a first-hand account of what it felt like to sustain it, and what my next steps are on the road to recovery.

Lisfranc Fracture

The Lisfranc joint involves the tarsometatarsal (TMT) joint complex. The injury is usually sustained with the foot in full weight bearing and plantarflexion, with a translational or torsional external force applied to the foot. This causes the small ligaments between these bones to tear and sometimes avulse, resulting in displacement and therefore unstable joints under weight bearing.

Previously, I have seen one case which presented to me after 4 weeks of being in a moonboot and foot pain that was not improving. The mechanism was simple, the patient had stepped down from a curb and stumbled forwards while crossing a road. She felt/heard a popping/crunching sensation at the time and her main complaint was that her foot felt like it was separating under her own weight, pretty much a 1, 2 and 3 of key things to look for should someone present to you with mid-foot pain.

One thing I’ve learned with Lisfranc injuries, is that appropriate radiographs need to be taken as soon as possible. To pick this injury up, it is almost empirical that weight bearing x-rays are obtained as well as non-weight bearing views. This is because the radiologist looks for widening of the Lisfranc joint, which will not be shown in non-weight bearing views.

So it seems pretty simple doesn’t it: A plantarflexed foot under translational/torsional load, popping and cracking sensation through the midfoot (NOT THE ANKLE) and a sensation of separation or the foot being unstable after the injury will make you suspicious of a Lisfranc fracture, with the logical next step being to obtain weight bearing comparison radiographs to rule in/out a Lisfranc fracture.

How I knew I’d broken my foot

It all happened very quickly, but I feel like I had a good handle on the sequence of events. I was stepping a player pushing of my right foot, the tackler made contact so I looked to offload to my left. As I came down in the tackle, I felt the toes of my right foot stick into the ground, and the middle part of my foot roll inwards, with multiple clicks and crunches as I came down. It hurt immediately, and as I went to stand and run to the next phase of play, I felt my foot give way and the bones in the middle of the foot did not feel like they were sitting in the right place. It was a deeply sickening sensation. Even before getting my rugby boot off the swelling had already started, and within 15-20 minutes my foot had ballooned completely with swelling. Putting two and two together, it was obvious that I’d seriously damaged my foot.

I went to urgent doctors as that was the best care available where I was, and they took non-weight bearing x-rays. The initial impression was that there were no obvious misalignment or fractures of my foot, but the radiologist report recommended the weight bearing views be obtained as there was evidence of subluxation of the second metatarsal on the lateral view. Two days later after waiting 5 or so hours in accident and emergency I got the weight bearing views which confirmed a lisfranc fracture. A CT scan shortly followed and 3 days later here I am with two plates and a screw holding the middle part of my foot together. Overall, this is a really good outcome compared to my previous patient that had been walking around for four weeks with a broken foot that was not going to heal by itself.

What comes next?

I’m currently waiting on final x-rays, after which I’m hoping to be discharged to go home. I’ve been told that I will be 6 weeks in cast, and then a further 4 weeks in a moonboot before progression to full weight bearing. Thankfully, a progression of rehabilitation following a lisfranc surgery has already been published by Porter et al. 2019. I’ll leave the link at the bottom of the page but unfortunately the paper is not free to view. I’ll briefly explain the four phases of rehabilitation: (these have been taken from table 4 of the paper by Porter et al. 2019)

Phase 1: 1-6 weeks post-op

Clinical goals:

  • Full ROM ankle – dorsi, plantar, inversion and eversion
  • Full ROM MTP joints (toes)
  • Control swelling
  • Desensitize foot

Exercise

  • NWB for full 6 weeks
  • Toe curls – active and passive
  • Achilles tendon stretching with towel
  • Strengthening with theraband at 2 weeks all directions of the ankle
  • All upper extremity lifting
  • Body weight leg extension and curls, seated calf raises in non-weightbearing

Phase 2: 6-12 weeks post-op

Goals:

  • Strength comparable to opposite side
  • Bilateral double to single toe raise
  • Wean out-of-boot into carbon fiber plate and orthotic/athletic shoe
  • Proprioception retraining activity in shoe
  • Wean off crutches over 10-14 days

Exercise

  • Stationary bike in boot until 8-10 weeks post-op
  • Proprioception retraining in boot 6-10 weeks post-op and in shoe 8-12 weeks post-op
  • Bilateral standing toe raise work to single toe raise

Phase 3: 12-16 weeks post-op

Goals:

  • Full ROM, strength and flexibility
  • Restore normal proprioceptive retraining at rest/standing
  • Begin running, and sports-specific training

Exercise:

  • Advanced proprioceptive retraining
  • Increase from biking to stair-stepper/elliptical/AlterG to running
  • Can begin leg press when able to do stair-stepper/elliptical
  • Can do squats/clings/lunges after can run

Phase 4 – 3.5-9 months post-op

Goals:

  • Removal of hardware typically at 3.5-5 months post-op
  • Return to sport is 4-6 months for high school, 5-8 months for college and 6-10 months for professional athletes

Exercise:

  • Sports specific performance exercises and conditioning for full play

https://scholar.google.co.nz/scholar?hl=en&as_sdt=0%2C5&q=Injury+Pattern+in+Ligamentous+Lisfranc+Injuries+in+Competitive+Athletes&btnG=

If you have made it this far, thank you and stay tuned for updates on my progress via my instagram @theinjuredphysio. Let’s get back to rehabbing together!

References:

Mora, A., Lunz, D., & Kao, M. (2018). Return to sports and physical activities after open reduction and internal fixation for Lisfranc injuries in recreational athletes. Foot & Ankle Orthopaedics, 3(3), 2473011418S0036. doi: 10.1177/2473011418s00361

Porter, D., Barnes, A., Rund, A., & Walrod, M. (2018). Injury pattern in ligamentous Lisfranc injuries in competitive athletes. Foot & Ankle International, 40(2), 185-194. doi: 10.1177/1071100718802264

Singh, S., George, A., Kadakia, A., & Hsu, W. (2018). Performance-based outcomes following Lisfranc injury among professional american football and rugby athletes. Orthopedics, 41(4), e479-e482. doi: 10.3928/01477447-20180424-03

Time to Push the Boat Out

So the time has come, I’m writing my first blog. I’m not exactly sure where this will go, so I’m going to start writing, stop when I’ve had enough, and hopefully what I’ve produced at the end of it all isn’t a huge pile of verbal diarrhea.

So, where do I start. I guess a bit of background about myself wouldn’t go amiss. I’m 23 years old, and am working in a sports-focused private practice on the Kapiti Coast in New Zealand. It’s been a bit of a windy road getting here, but if you’re still sitting at your computer reading this, I guess we’ll have a look at the shortened version.

I was born in Reading, England. My parents are both teachers and I have one brother who is two years younger than I am. On my 5th birthday, we moved to a small town called Attleborough in Norfolk and it was here that I first discovered I was pretty competitive when it came to sports. I played football then, as pretty much every kid does in the UK.

In 2004, my dad had a midlife crisis, and instead of buying a motorbike or getting some tattoos like most middle-aged men do, he decided to move our tight knit little family to New Zealand. On the other side of the bloody world.

It was here that I would grow up, throwing in the spherical ball for one a little more oval and not looking back. Through high school, I played almost every sport I could, but rugby was the big one. At the time of finishing high school, I had only had a couple of injuries; a broken hand and sprained calf. I played through a lot of minutes with niggles. Going to the physio back then wasn’t overly common practice, and in a small town the good old Kiwi “she’ll be right” attitude meant you just got on with things unless you were seriously hurt. The small town life wasn’t for me, so off to the university of Otago I went, full of hope and expectation.

It was during my time here that I really learned first hand what it means and feels like to be properly injured.

Things started off not too bad. I played colts for a club and had a pretty good first season; minor rolled ankle here, sore shoulder there, nothing that kept me off the footy paddock for more than 5 days. That is, until I played a game of “social” rugby just after the start of my second semester against a rival hall and rolled my ankle so that I couldn’t walk on it afterwards. X-rays showed that I had broken it, but everything pretty much lined up and I was in a cast for 4 weeks and a moonboot for another 4 after that.

This was the start of a cascade of injuries that would plague my sporting life at uni; multiple rolled ankles, a groin tendinopathy, a torn quad muscle, a broken jaw, a subluxed shoulder and a torn MCL. I spent that much time on a physio bed (we luckily had free sessions through our rugby club) that I think that’s what made me decide to become a physio myself. Through all these injuries, I would keep coming back. I was young. I was determined. And I still somehow thought my body was indestructible. 

Fast forward to 2 weeks in to my last placement, at the end of my fourth year of university, 4 weeks away from handing in my last portfolio and expecting to graduate in December of that year. I was playing in the semi-final of an invitational sevens tournament, and I attempted a last ditch tackle to stop a player from scoring. I came down in a heap, landing directly on top of the opposing players heels, and just felt deep, deep extreme pain. I had, without knowing exactly what I’d done, ruptured my pancreas, requiring emergency surgery that night, waking up in hospital with over 30 staples holding my abdomen together, a couple of drains and a catheter. What the hell just happened.

I did as was told, spent a few weeks at home, and with a lot of support, managed to complete my studies by the end of 2016. I passed with distinction, and now I’m here.

As you can see, I do know what it feels like to be injured. I know how difficult it is to mentally keep pushing yourself back. It’s why I wanted to start this, as I know I can’t be the only person like me.

Through this blog, I hope to cover a range of topics:

  • Published research
  • Go-to exercises
  • Personal experiences I have while working as a physio
  • Updates on how my training is going
  • What I’m working on to get back to my own sport.

Peace out,

Teej