Tag: Training

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

Giving the Boot to Groin Injuries

By playing sports that required me to kick, I guess I should have seen a hip/groin related injury coming from a mile away. However, the way I ended up injuring my groin was squatting in a gym.

I had broken my ankle around 1o-weeks prior to this injury. I was in a cast, initially, for 4 weeks, and a moonboot for the following 6. The day of the injury, I was simply ecstatic to be finally free from the clutches of immobilization. Finally, I was “bulletproof” again.

I was in a squat rack, with the weight the same as it was pre-broken ankle. I remember my knees dipping in, and feeling a slight popping sensation through the front of my pelvis. It didn’t really hurt that much at the time, so I didn’t think I’d done anything serious.

I only realized things weren’t quite normal a few days later, when I was out playing social touch rugby with a few mates. I didn’t really have much pain, but I just couldn’t sprint. It was so strange. I could turn, jog, jump, lunge and dive. As the weeks rolled by, I started to notice that sitting was becoming sore the longer I sat for, and driving was near impossible for more than half an hour. I also had pain on coughing and sneezing, so I started to become quite concerned.

My physio also wasn’t sure what was going on, but had a thought that it could have been coming from my groin, as a GP had ruled out a hernia or anything like that as a diagnosis. The next step was to send me on to a Sports GP due to the length of time that had passed (about 3-4 months since injury at this point), and the with the rugby season approaching
rapidly.

The Sports GP diagnosed an Adductor Longus Tendinopathy. The Adductor Longus is one of the inner thigh muscles that make up the groin, with an origin through the front of the pubis (where the majority of my pain was felt). The most obvious test he used to prove the pain was muscular, was when he got me to lie in a sit-up position, and asked me to squeeze his fist between my knees. The pain was automatically reproduced, and I for the life of me could not generate any power between my knees.

What we did about it:

He started me on what is more commonly known as the Holmich Protocol. Per Holmich is a danish professor and researcher who has contributed a huge body of work to the understanding, treatment and prevention of groin injuries. He mostly works with football players, due to the increased incidence of groin injury in that population. It’s based around a series of exercises that are broken up into two modules, below are 3 of my favourite exercises from each module, but I will attach the full protocol in a link below. The exercises below are slightly modified so that you don’t need a lot of equipment to be able to complete them

Module 1

  • Place a ball between your knees and squeeze as hard as you can for 10 seconds. Move the ball to between your feet and then squeeze for a further 10 seconds. Have 10 seconds rest and repeat 10 times.
  • Place a ball between your knees in a sit-up position. Perform a sit-up bringing your right elbow to your left knee, then a regular sit-up and then bringing your left elbow to your right knee. Repeat this 10 times, for a total of 5 rounds, with 1 minute rest between each round.
  • Place a ball between your knees pre-situp position. Bring your knees up and perform a sit-up at the same time, making a “jack-knife” shape. repeat this for 5 sets of 10 reps, with 1 minute rest between each set.

Module 2

  • Lie on you side and lift your top leg up as high as you can. Repeat this 10 times for a total of 5 sets. (This one is also a good primer exercise before sport/activity.)
  • Using a Theraband tied under a stable table/chair and around one of your ankles, take 5 steps to the side increasing the tension through the band. Take 5 steps back towards the table, controlling the leg with smooth movement. Turn 180′ and repeat the 5 steps out and back. Rest for 1 minute between sets and complete 5 sets in total.
  • Lie on your side with the sore leg up on a bench/chair. Lift your bottom leg up making a side bridge and hold for 10 seconds. Repeat this 5 times, for 3 sets in total. This is the most difficult exercise of the ones mentioned.

I’m not going to profess that at 19 years old I was the perfect patient, I probably got the exercises done two or three times a week rather than every day like the sports doctor recommended. Had I done them more often I probably would have got back to my previous level of sport a bit earlier, but for me the process was around four months to feeling like I could play rugby (sprinting and kicking) freely and without pain.

So if you’ve got a current groin injury, give the Holmich Protocol a go! Even if you got injured a while ago, the exercise programme can still help with your pain and function.

Teej

Effect of Holmich protocol exercise therapy on long-standing adductor-related groin pain in athletes: an objective evaluation https://bmjopensem.bmj.com/content/4/1/e000343?int_source=trendmd&int_medium=trendmd&int_campaign=trendmd

“How Do I Not Over-train?”

This is something I get asked a lot by patients in the physio room, and it seems an appropriate first topic as I get stuck in to power training for a half marathon at the end of Feb.

Training hard and over-training can be a very fine line, with one achieved at optimal loading for the physiology of the body and the other when you strain the body just enough to cause more net tissue damage (and injury) than net growth. It’s important to keep in mind that everyone is different, so there is no formula we can simply plug our height, weight, age, gender or goals into that will tell us exactly how much is too much. We can however, implement some reasonably straightforward principles into training to help us get things right.

  • Avoid Training on Consecutive Days

This one might seem pretty obvious, but its particularly important if you are starting a completely new sort of training or working your way back from injury. Training and recovery are both equally as important as each other, with the latter often not given the respect it’s due. Training is the breaking down of tissue, with recovery being the time you eat the right things and rebuild better, stronger and faster than what was there before. We can easily get sucked in to a boom-bust behaviour. What I mean by this, is you train very hard for a couple of days (the boom) and then find yourself so sore that you can’t walk for the next week (the bust). Training needs to be gradual, and having a day off in-between training days when you get started can be an easy way to make sure your body is given the time it needs to recover, especially as a beginner getting into physical exercise for the first time.

  • Have Variations in your Training

We can still be active while we recover. Keeping with the marathon training rhetoric, my personal goals are to be doing one decent run each week. Other days of the week, I’ll still be getting my Km’s in, but I’ll switch up whether I’ll getting these from the bike, or the rowing machine. Another option would be to get into the pool. All of these are great ways to train without the relentless pounding the body takes from running. It’s also important to respect the benefit that specific strength training can have on the body, and no, this does not mean that we need to go and get ourselves a gym membership to start pushing weights. To typically train for endurance strength, we want to keep the load low and the repetitions high, so body-weight exercises in sets of 12, 15 or 20 are perfect for achieving these parameters. Squats, lunges, step-ups, sit-downs, and floor exercises can all be easily performed in a small space in your own home.

  • Listen To Your Body

This last principle is often easier said than done, and is often accompanied with the question of “how do I know if I’ve done too much”. For this, I like to give my patients a traffic light guide model. A “Green Light” is given to an activity that may/may not be sore at the time, but the pain stops pretty much as soon as they stop doing the activity. They can do as much of that activity as they like, knowing that the pain/discomfort they feel is not physical damage to tissue. An “Orange Light” is given to an activity that again may/may not be sore at the time, but the pain/discomfort stays for a few hours before settling once again by that evening (within 24 hours). The patient can continue with this activity, but must pay attention that the activity does not become a “Red Light”. A “Red Light” activity is one that may/may not be sore at the time, but the pain or discomfort hangs around for a long time afterwards, and is also more sore the next morning (outside of 24 hours). It’s possible that this activity, if continued, could increase the chance of tissue injury and should be adjusted to be less strenuous moving forward, to limit this possibility.

If you’re interested in taking up a new sport or physical hobby, hopefully these three steps can give you the confidence to get stuck into things without the worry or doubt that the pain you feel training is actual damage to your body.

If you’re interested in reading a little bit more, here are some articles to g a little bit deeper into the science of training.

Teej

Over-training and Recovery: A Conceptual Model https://www.researchgate.net/profile/Peter_Hassmen/publication/13545392_Overtraining_and_recovery_A_conceptual_model/links/548199d60cf22525dcb6268c.pdf

Maximal Strength Training Improves Running Economy in Distance Runners http://sport1.uibk.ac.at/lehre/burtscher/efficiency-artikel,2008.pdf

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