Hamstring health, performance and injury prevention

With new COVID lockdowns in place for Greater Sydney and community sport taking a 2 week break, we often see these types of unscheduled breaks lead to injuries when sport resumes.

Planning ahead and implementing some strategies for injury prevention will help you navigate the lockdown break and keep you on the pitch for longer.

Hamstring injuries are common amongst professional footballers and Sunday afternoon superstars alike.

Some research into hamstring injuries has demonstrated that if the hamstring musculature is strong and flexible as opposed to weak and short then it significantly decreases the risk of hamstring injury throughout the course of a season (Timmins et al. 2016 and Bourne et al. 2018). 

The Quadrant of Doom

Below is an infographic from YLM Sports Science that clearly demonstrates the relationship between strength, flexibility and injury risk. The other way to frame this is in terms of capacity. The greater the strength and movement capacity then the less likely things are to go wrong. 

The other benefit from all of the below is that by incorporating this it will not decrease injury risk but also improve performance!

Knowing this is all well and good but we also want to practically act on this. How do we build things up from a loading, flexibility and strength point of view. Below is another great infographic from YLM Sports Science that shows specific ways to address all these areas.

In summary to build strong, functional and flexible hamstrings then it is worth looking at an exercise program that includes hip and knee dominant exercises that is gradually overloaded to create adaptation. It is also worth adding some running and sprint work into the program as this is shown to have a protective effect and also some loaded flexibility work to strengthen the hamstrings in lengthened positions (Oakley et al.2018).

Take Home points for hamstring performance and health:

• Strong and long hamstrings are the goal

• Use knee and hip dominant strengthening exercises

• Incorporate sprint work

• Work on flexibility

• Progressively overload

• Stay consistent

References:

1. Timmins RG, Bourne MN, Shield AJ, et al. Short biceps femoris fascicles and eccentric knee flexor weakness increase the risk of hamstring injury in elite football (soccer): a prospective cohort study. Br J Sports Med 2016;50:1524-1535. https://bjsm.bmj.com/content/50/24/1524

2. Bourne, Matthew N., Timmins, Ryan, Opar, David A., Pizzari, Tania, Ruddy, Joshua, Sims, Casey, WIlliams, Morgan, & Shield, Anthony (2018) An evidence-based framework for strengthening exercises to prevent hamstring injury. Sports Medicine, 48(2), pp. 251-267. https://link.springer.com/article/10.1007/s40279-017-0796-xhttps://ylmsportscience.com/

3. 2017/11/26/hamstring-strain-injury-escape-the-quadrant-of-doom/

4. https://ylmsportscience.com/2017/05/06/holistic-hamstring-health-not-just-the-nordic-hamstring-exercise/

5. Oakley AJ, Jennings J, Bishop CJ. Holistic hamstring health: not just the Nordic hamstring exercise. Br J Sports Med 2018;52:816-817. https://bjsm.bmj.com/content/52/13/816

Office worker neck pain - strengthening exercises - Sutherland Shire Physio

Zac Fowler is a physiotherapist from Flow Physio Co Sutherland who talks to us about how to treat neck pain in office workers

Neck pain is one of the most common medical conditions that presents at Flow, with most presentations of neck pain coming from populations of office workers. It is not uncommon for these office workers to present very similarly, a forward head position, pain around the trapezius muscles and upper neck that gets worse when sitting and a slouched thoracic spine position when sitting.

It is estimated that between 42%-63% of office workers will experience some form of neck pain within any given year.

Office workers often get neck pain

It is estimated that between 42%-63% of office workers will experience some form of neck pain within any given year. Office workers also have the highest incidence rate of neck pain at around 17%-21% when compared to other occupations.

Interventions for neck pain usually focus around some form of ergonomic adjustment of the workplace setting, soft tissue relief and some postural exercises. 

What is effective in treating neck pain in office workers

A recent study looked at the effect of intervention and prevention programs on neck pain in office workers when compared to no interventions over the course of 27 randomised controlled trials. These trials looked at the effect of strengthening programs, ergonomic adjustments and frequent rest breaks. 

A key finding of the review was that shoulder and neck strengthening exercises can be effective in reducing pain intensity in the population of office workers with neck pain.

In terms of neck pain prevention, the same review found evidence that a regular strength routine can help to reduce the incidence of pain in an identified “at risk” population of office workers.

The reviews went on to discuss the positive impact on multiple ergonomic adjustments in the symptomatic population but could not find a link to this assisting in the prevention of pain. 

The review then goes on to report that of the population that saw improvement in their neck pain, interventions focused on specifically strengthening the neck were superior to general fitness training. 

Take Home Messages

Due to the high incident rate of neck pain in office workers, we believe that all office workers should complete a weekly strengthening prevention program and that office workers who experience neck pain should benefit from a strengthening program targeted to the muscles of the shoulders and upper back.

 

Source:

Xiaoqi Chen, Brooke K Coombes, Gisela Sjøgaard, Deokhoon Jun, Shaun O’Leary, Venerina Johnston, Workplace-Based Interventions for Neck Pain in Office Workers: Systematic Review and Meta-Analysis, Physical Therapy, Volume 98, Issue 1, January 2018, Pages 40–62

ITB band pain, lateral knee pain, ITB friction syndrome - what is it, what it isn't, what to do about it.

Joel Potter from Flow Physio Co Sutherland talks to us about a common presentation of ITB pain/lateral knee pain/ITB friction syndrome.



What is the ITB?

The ITB, or iliotibial band is a thick band of fascia that runs along the whole length of the outside of your thigh, it attaches to the outside of your knee and to the outside of your hip.

The ITB is designed to absorb and produce a lot of force when you're doing things such as running, especially as your leg stretches back behind you - kind of like an elastic band.

ITB pain - how does it come about?

ITB pain is pain on the outside of your knee. It's something that tends to come on gradually, generally with no clear reason - there often isn't one sudden moment where you notice it start.

It can also be quite a strong and sharp pain, which is pretty scary given you haven't done anything specific to injure it.

Some people talk about this being a friction issue, but that's not quite right. It's more an issue about compression of a small fat pad on the outside of your knee.

More than anything else, this is an issue of capacity and tolerance within your leg, leading to an irritation of this fat pad, rather than tightness or any particular damage that is occurring.

What movements aggravate it?

You'll notice it first when moving your knee from straight to bent when you're running, particularly if you're going downhill, downstairs or running with your feet in a narrow stance.

With most people, we find a change in training load tends to be what leads to this issue, especially if you're a runner.

A few key things to look out for are an increase in trail running, downhill running, or total amount of time spent training.

Technique, motor control and strength

Other things we will look out for are technique issues when running - particularly how much control your hip has over your knee, alongside the strength of the key running muscles in your leg - your calf, hamstrings, quadriceps, hip flexors and glutes.

Sometimes there might be a related mobility/range of motion restriction, particularly if you lack range of motion in your ankle or hip.

Occasionally, we will see this kind of ITB pain popping up if you are having issues on the other leg, such as an old injury flaring up which might slightly change your technique.

Foam rolling won’t loosen your ITB, you don’t want it to!

A pretty common thing people try to do is to stretch or foam roll the ITB. Good luck with that!

The ITB is too strong for us to truly make any difference to it's length, plus it's designed to be tight so that it can support everything else in the leg, so we don't really want to mess with that.

Be careful foam rolling, some people find it helpful, but a lot of people find it really painful without much benefit - which makes sense if we are using the foam roller to compress the ITB, when compression of the fat pad underneath the ITB is the cause of all this pain to begin with.

You may get more benefit from using a foam roller or spikey ball around the back and side of your hip; or stretching your glutes and hip flexors, as long as getting your leg into those positions isn't painful.

Things you can do with ITB pain

As you recover from this injury, we hope to keep you moving and training as much as you can.

For runners, the best thing is to jump on the treadmill at a pretty steep incline, often this doesn't cause any issues for the knee. Otherwise there are other options for cross training like swimming, cycling, the rower or the elliptical depending on what works for you. If all else fails, a short period away from repetitive exercise will allow the tissues to settle down.

Rehab

For rehab, we divide it into two major phases.

1. Pain dominant phase

   1. Here we respect the pain and inflammation around the knee and allow it space to settle, rather than pushing on with things that are making it feel worse

   2. We will assess you, looking at strength, mobility and movement control so we know what things we need to work on to get you back to running

   3. There will be some exercises to work on that involve your ankle, knee, hip and core all working together, but we will make sure they're happening in more comfortable positions.

2. Load dominant phase

   1. This is where we begin to start loading up your hip and knee and ITB with heavier, more challenging exercises

   2. Our goal here is to improve on what we found in our earlier assessment - likely a combination of strength, mobility and movement control

      1. Our focus will particularly be strength, as we know that as muscles get stronger, they're able to tolerate more work, meaning running becomes a lot easier for the ITB and everything around it

3. What we will also do now that pain is settled is start working on a return to running program

   1. We will play around with the distances, speeds, surfaces you are running on, plus looking at hills and stairs

   2. It must be a gradual program that is lined up with your strengthening work, so that your knee has more capacity to handle the repetitive motion of running.

   3. The last things we will return to in this program are downhill running and trail running as these place the most demand on the ITB

Timeline

• The timeline of getting back to 100% can be quite variable. It is often dependent on how long this issue has been hanging around for, and what things we need to improve to allow the ITB to be comfortable absorbing lots of force again

• Some people are back to 100% and doing everything they want after 4-6 weeks

• Some people find this can hang around for a few months and that they need to be much more careful in how they progress back to what they were doing before

Joel Potter from Flow Physio Co Sutherland talks to us about a common presentation of ITB pain/lateral knee pain/ITB friction syndrome.

 



Returning to sport after ACL surgery - When are you ready?

What is guiding your return to sport after your Anterior Cruciate Ligament (ACL) surgery?

What makes you confident in your decision to return to sport?

We too often see clients who have no clear pathway to return to sport. Here is a brief snapshot of what we assess to make sure we are helping our clients decrease their risk of re-injury when returning to sport:

1. >90% on lower limb strength testing comparative to uninjured side

2. >90% on hop testing comparative to uninjured side (single leg hop, single leg triple hop, single leg crossover hop, timed 6m hop, lateral hop)

3. >9 months post surgery

4. Implementation of an ongoing prevention program

5. Confidence to return to sport as assessed through questionnaires

We know that returning to cutting sports like AFL, soccer, rugby, netball after an ACL surgery means around a 4 times greater risk of re-injury. Making sure you meet these criteria before return to sport has been shown to reduce injury rates by up to 84%.

What guiding your decision to return to sport after ACL reconstruction? We’d love to know!

Exercise for Low Back and Neck Pain

Exercise is Medicine - Low Back and Neck Pain

Exercise is not only the key to a healthy life but also leads to a comfortable life. The old saying “move it or lose it” was correct! We have previously discussed the importance of movement for general health and well being purposes HERE.

Move it, or lose it

Today we will talk about the benefits of movement for reducing the incidence of neck and back pain, which, unfortunately is becoming far too common in society today.

In 2014-15, 1 in 6 Australians reported back and neck problems which equates to approximately 3.7 million people.

1 in 6 Australians Reported back and neck problems in 2014-15.

The AIHW reports that neck and back troubles were the 3rd leading cause of disease burden in Australia in 2011 (1).

What does the research say?

As these levels are very high, there is a growing field of research to identify what we can do to prevent these issues. The recurrent stand out is exercise! Exercise has time and time again shown to be medicine for a variety of conditions (2-3).

Exercise programs have been shown to substantially reduce the risk of a new episode of neck pain (4) and the same just happens to be true for low back pain. Evidence suggests that exercise as a stand alone intervention or in combination with education is effective in the prevention of low back pain (5).

The Cherry on top

To really add the cherry on top, if this is combined with some strengthening exercise, then the risk of not only neck and back issues but all sports injuries is reduced to less than one third and the rate of overuse injuries is halved (6).

What does this mean?

Exercise is one of the best things that can be done to not only live a healthy life but also to feel good whilst doing so. All of the research suggests that it doesn’t necessarily matter what you are doing as long as you are moving. So don’t over analyse things just do what you enjoy!

In case you’re wondering how much?

• It is advised that for adults aged 18-64 years, 150-300 minutes of moderate intensity physical activity or 75-150 minutes of vigorous physical activity, or an equivalent combination of both, per week is recommended.

• Strengthening activities should be performed at least twice per week.

• For adults 65+ at least 30 mins of moderate intensity exercise is advised daily(3).

Take Home Message

• Exercise is meant to be a long term drug, consistently taking it over time leads to the greatest benefits.

• Do what you enjoy and do it often.

• Add some variety and gradually progress.

• If you fall off the bandwagon don’t stress, life happens, just get back on.

References:

1. https://www.aihw.gov.au/reports/chronic-musculoskeletal-conditions/back-problems/contents/what-are-back-problems

2. https://www.primalplay.com/research/

3. http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/4364.0.55.001~2014-15~Main%20Features~Exercise~29

4. de Campos, T. F., Maher, C., Steffens, D., Fuller, J., & Hancock, M. (2018). Exercise programs may be effective in preventing a new episode of neck pain: a systematic review. Journal of Physiotherapy, 64(3), 159-165. DOI: 10.1016/j.jphys.2018.05.003- https://research-management.mq.edu.au/ws/portalfiles/portal/89732879/Publisher_version_open_access_.pdf

5. Steffens D, Maher CG, Pereira LSM, et al. Prevention of Low Back PainA Systematic Review and Meta-analysis. JAMA Intern Med. 2016;176(2):199–208. doi:10.1001/jamainternmed.2015.7431- https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2481158

6. Lauersen JB, Bertelsen DM, Andersen LB. The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials Br J Sports Med Published Online First: 07 October 2013. doi: 10.1136/bjsports-2013-092538- https://bjsm.bmj.com/content/early/2013/10/07/bjsports-2013-092538