Proximal Hamstring Tendinopathy is a musculoskeletal problem that usually occurs in athletes who frequently bend their hips with a relatively extended knee. It mainly appears in long and medium distance runners and less often on sprinters. Running uphill is also a predisposing factor.

CLINICAL PRESENTATION

The tendinopathy’s initial presentation mimics a classic case of sciatica. The pain is felt at the buttock, and often radiates at the posterior aspect of the thigh. Initially, it appears only in running, and gradually the condition exacerbates and begins to appear in daily activities, such as walking, climbing stairs, bending and prolonged sitting. Any static posture or activity that compresses or stretches the tendon is capable of causing severe pain. As a result, the athlete is forced to cease the sporting activity.

What is paradoxical about tendinopathy is that the patient often complains of tingling sensation (pins and needles) along the lower limb, a symptom that points to a disc herniation in the lumbar spine. The appearance of neurological symptoms on a purely musculoskeletal condition is presumed to be the proximity of the sciatic nerve with the common origin of the posterior thigh muscles on the posterior/inferior surface of the ischial tuberosity. A misdiagnosis may occur, if it coincides with the appearance of a herniated disc on MRI. It is a clinical sign, which may initially mislead the treating physician.

HISTORY TAKING

Before we initiate treatment, we take a thorough history from the patient, in order to determine the severity of the condition, the sensitivity and irritability of the tendons, so that we can properly plan the exercise program. The latest evidence support that the treatment of tendinopathy is predominantly based on therapeutic exercise (you can read the article “Tendinopathy in Athletes“).

CLINICAL EXAMINATION

The emphasis of the clinical examination should be placed upon the the differential diagnosis of the condition with sciatica due to a disc herniation in the lumbar spine. It is emphasized that the patient has a positive Laseque test and it hurts when he or she bends from standing up with the knees straight, which are clinical signs that are characteristic of sciatica.

The clinical signs which indicate Proximal Hamsting’s Tendinopathy are the following: 1) running as a hobby or sporting activity in the patient’s history, 2) Sudden change in the training load and /or volume, and 3) Painful resistance testing of the hamstrings.

GAIT ANALYSIS

When the patient is a runner, we perform a qualitative assessment of running on the treadmill. The patient runs on the treadmill and we assess the stride length, and check if there is an increased lumbar lordosis and other biomechanical factors related to the disease (you can read the article “Runner Diseases – Gait Analysis“).

The key biomechanical points that we check are the following:

1. We decrease the stride length if the point of heel strike is far away from the body center of gravity (overstriding).
2. We retrain posterior pelvic tilt and instruct the patient to “stand tall” while running, in order to decrease the hip flexion angle and subsequently the compressive loads on the tendon.

ACUTE PHASE – COMMON PITFALLS

Since the main predisposing factors of Proximal Hamstring’s Tendinopathy are the compressive and stretching loads of the tendon, at the acute phase we advise the patients to:

1. Avoid sitting for a prolonged time.
2. Avoid stretching the hamstring muscles.
3. Avoid bending over with the knees extended.
4. Avoid lower extremity exercises, that place intense load on the tendons, such as squatting and forward and side lunges.

TREATMENT – REHABILITATION

The exercise principles during the initial phase of rehabilitation are the gradual application of loads on the tendon and strengthening of the hamstring muscles at positions where the tendon does not receive compressive loads. We begin the exercise program with isometric exercises and assess the pain behavior before proceeding to the next step.

At the next phase, when the symptoms subside, the exercises are more dynamic (Heavy Slow Resistance Training, Plyometrics) and gradually they include compressive loads on the tendon and gradually mimic the patient’s sporting activity.

The last phase is the “Return to Sports” phase, at which point we follow certain guidelines such as leaving 1 day of rest between running sessions and assessing the pain response on the next day after training. The key point is to give clear explanations and educate the athlete how to interpret the relationship of pain and training intensity.

Alex Karagiannidis, MSc., Dip.MDT., BSc(Hons) Physiotherapy

For many years, the prevailing notion has been that the safest way to lift objects off the floor is to bend the knees and keep the back straight, as shown in the icon below.

However, this general guideline, which does not deal with each case separately, does not seem to have reduce the incidence of low back pain. On the contrary, its indiscriminate implementation has created a subgroup of people who have now lost the ability to bend, with harmful consequences.

The prophylactic avoidance of bending at the waist results in stiffness and muscle weakness in the trunk, which are indeed factors predisposing to recurrent episodes of back pain and chronicity of the problem. Imagine that a chalk breaks much easier than bamboo, precisely because it is tough and rigid, with no elasticity.

Finally, the question remains. Is it OK to bend over at the waist or not? The answer is that each case is separate and no general instruction can be given.

Following are some questions and answers to clarify the issue as much as possible. However, because each case is separate, your evaluation by a physiotherapist is essential to have a personalized plan of treatment.

Question 1

Is it OK to bend over at the waist?

Answer

We should be aware that bending at the waist when standing upright is one of the basic and necessary movements of the lumbar spine (i.e. the lower back). The functional anatomy of the vertebrae, intervertebral discs, muscles and ligaments is to serve the function of bending, what we scientifically call lumbar flexion. Therefore, bending is a normal function, such as flexing and straightening our elbow or knee.

Question 2

“Yes, but since I have a problem in my lower back, is it still OK to bend over at the waist?”

Answer

Although, as mentioned above, the normal function of the lumbar spine includes bending, however if there is an acute condition, then we may have to stop bending for a while until the condition stabilizes. The same happens after an ankle sprain. We temporarily immobilize it on the splint until it heals and then we gradually move it to all directions and strengthen it, in order to regain full function.

Question 3

“When the acute episode subsides, can I bend my back immediately?”

Answer

When the acute episode has subsided, then in collaboration with a physiotherapist, you should begin an exercise program aimed at restoring the range of lumbar flexion. This procedure should be gentle and gradual to give your body the necessary time to adapt. In our opinion, it is necessary to restore the range of flexion. We need to emphasize that this adaptive process is neither difficult nor dangerous. Anyway, there is no hurry. A program of gentle exercises that respect the natural rhythm of each body, will provoke the necessary adjustments.

Question 4

When the range of motion in my back is restored, will I be able to lift weight too? “

Answer

When we need to lift a light object from the ground, something we can handle easily, such as a pen, our shoes, a child’s toy, etc. then we can generally bend the back without fear. This will enhance the normal flexibility in our lower back, allowing it to absorb greater load.

When we need to lift a significant amount of weight, which is not in our usual routine, then we should bend our knees and hold a straight back, as weightlifters do, because this way puts less strain on the spine.

However, it should be emphasized that if we need to lift more weight, due to occupational or any other reason, then this is possible with adherence to a strengthening program. However, the effort must be systematic and not occasional.

IN CONCLUSION

1. Bending our back at the waist is a normal and useful movement that in the long run strengthens our back and therefore should not be avoided.
2. When we have an acute episode in the lower back, we should limit our movements temporarily, until the condition has stabilized.
3. The physiotherapist can evaluate our condition and provide the appropriate instructions and the appropriate exercise program to restore normal function to our spine, but also to increase its potential through systematic exercise.
4. Our clinical experience is that people who avoid bending in order to protect their backs, usually end up with more pain. The best way is to strengthen our back through progressive exercise and perform all the movements naturally. 

Alex Karagiannidis, MSc., Dip.MDT., BSc(Hons) Physiotherapy

Active Physiotherapy Solutions

Alex Karagiannidis attended the Isokinetic Medical Conference, in Milan, Italy. The topic of the Conference was “Football Medicine Strategies for Joint and Ligament Injuries” and the emphasis was on the latest evidence regarding the treatment and rehabilitation of the ligamentous injuries in athletes and especially the post-op rehabilitation of the athletes who sustained an ACL injury.

At this article we address 4 key points of the rehabilitation program, regardless of the painful cause (e.g. subacromial impingement, instability etc.), which are important for restoring restoring proper shoulder function and returning to sports performance.

These key points are:

1. The selective activation of the rotator cuff muscles. Regardless of the diagnosis (impingement or instability), the athlete should perform exercises to activate the rotators of the shoulder, which are very important for the stability of the entire shoulder girdle. We must emphasise that these muscles are endurance muscles and therefore to activate them, we use low resistance and many repetitions.
   The resistance must be increased very gradually to avoid the activation of adjacent muscles. When the neighboring muscles activate as well, the exercises do not provide the expected results.

2. Restoration of the full range of motion of the internal rotation of the shoulder. The internal rotation of the shoulder is often restricted in swimmers, and restoring the normal range is essential, especially at the “recovery phase” of the freestyle. When the full range of motion is not available, the movement is compensated by the neighboring scapula, causing further dysfunction and pain in the shoulder region.

3. Proper activation of the scapular muscles. The shoulder blade functions as the base of support for the upper limb, and when the muscles that stabilize and move it are not properly activated, conditions of instability and/or impingement on the shoulder are created.

4. Restoration of the extension and rotation range of motion of the thoracic spine. During swimming in free style, athletes turn their shoulders and hips in order to speed up and breath. Shoulder rotation is greater than that of the hips and therefore the good rotational mobility of the Thoracic Spine is very important. When thoracic mobility is limited, it is compensated by the shoulder girdle, creating strain, and painful symptoms due to impingement and instability.

The above-mentioned key points should be assessed in every athlete, and if deficiencies or dysfunctions are found, appropriate exercises should be provided to restore the normal shoulder function and prepare the athlete for the demanding swimming conditions.

Alex Karagiannidis, MSc., Dip.MDT., BSc(Hons) Physiotherapy

The latest advances at the following clinical entities were emphasised during the 3-day Congress

• «Sports’ Injury Prevention», presented by Dr. K. Thorborg, Dr. J. Harey, Dr. M. Walden and referred to the Hip and the Knee joint, the Groin and the muscle injuries.

• “Latest advances in Muscle Injuries’ Rehabilitation”, presented by Dr. C. Askling

Alex Karagiannidis, MSc., Dip.MDT., BSc(Hons) Physiotherapy

A basic Law that governs our Health is that the root cause of a health problem is largely the result of our way of life, our daily habits, our thoughts and behaviors.

Most of the times, pain is an alarm. It is an alarm that fires, when our Nervous System detects a threatening disruption of our body’s balance. Acute pain is an alarm for an acute physical condition, while chronic pain is usually an alarm that indicates a dysfunction, which has to do with long-held habits, rather than isolated events.

When searching for effective treatment, in the face of a physician or a physiotherapist, let us first consider the following questions:

• Do I want to get rid of the “alarm” or the root-cause that sets off the alarm?
• Am I willing to make positive changes in my life? That is …
• Take an active role in restoring my health
• Reduce sedentary life to the best of my means, and adopt active and healthy habits that will restore balance
• Sleep well enough
• Make a conscious effort to reduce negative thoughts
• Improve my diet
• Reduce and eventually remove the toxic substances I put into my body

Also as therapists, let us consider the following:

• Did I listen carefully to my patient?
• Did I show the necessary attention and empathy to the concerns and fears she expressed in our meeting?
• Did I answer the questions she asked me, in a way to offer her understanding, hope, but also the choice to take an active role in the treatment process?
• Did I offer her the best treatment I could?

When we perceive treatment as a “pain-killer”, then the symptoms will appear again soon. However, when we change the causes that lead to the presentation of a symptom, then the problem ceases to exist.

Alex Karagiannidis, MSc., Dip.MDT., BSc(Hons) Physiotherapy

One of the causes that lead to neck pain is Scapular Dyskinesia.

The term “Scapular Dyskinesia” refers to the abnormal resting position of the scapula or/and its abnormal movement during arm elevation.

When we elevate the arm to perform an overhead activity, e.g. to place an object on a high shelf, the scapula rotates upwards, supporting the arm (pic. 1).

The upward rotation of the scapula is performed by the activation of various muscles such as the serratus anterior, the upper, lower and middle trapezius muscles (pic. 2). Additionally, the activation of the rotator cuff muscles is necessary for the scapula to move properly.

In some cases, the muscles that move the scapula and stabilize the shoulder, are “inhibited or don’t activate early enough”. The Nervous System, in its attempt to maintain the functionality of the arm, “hyper-activates” certain muscles, which produce pain (pic. 3).

There are various “dysfunctional patterns” in the resting position and movement of the scapula. The most common ones are the following:

• The “downwardly rotated” scapula (pic. 4) and is caused by the poor activation of the 3 portions of the trapezius muscle (Upper, Middle and Lower) and “hyper-activation” and “shortening” of the Levator Scapulae muscle (pic. 3).

• The “winging” of the medial border of the scapula, which is caused by weakness of the serratus anterior muscle (pic. 5).

• The prominence of the scapula’s inferior angle, due to increased anterior tilt of the scapula. The increased anterior tilt can be a result of the weakness of the lower trapezius muscle, or the tightening of the pectoralis minor muscle. (pic. 6).

All the “dysfunctional alignment and movement patterns” are non-economical. When the movement is not a result of a balanced contribution of each muscle, some muscles work “overtime” to compensate for the inefficiency of their neighboring muscles. As a result, they develop painful trigger points, they become sore and produce pain in the neck region (pic. 7)

It must be noted that Scapular Dyskinesia is not always related with Neck Pain as a causative factor. Some postural and movement deviations are part of the body’s normal variability, and do not cause painful or other symptoms.

This is easily detected by specific clincal tests performed by the therapist. If, for example, a movement of  the neck that produces pain, stops being painful when the therapist corrects the position and motion of the scapula manually, then we reasonably assume that the treatment of Dyskinesia will have a positive influence on the painful symptoms (pic. 8).

When a causal relationship between Scapular Dyskinesia and neck pain is established, then it is necessary to include a stabilisation program with specific exercises for the scapula (pic. 9).

The various soft tissue techniques (massage, myofascial release, acupuncture etc.) provide only temporary results, because they don’t treat the root cause of the problem, but rather the secondary result.

A comprehensive and successful approach should include the relaxation of the stiff and painful muscles, to provide instant relief, but also the selective activation of the weak scapular muscles, in order to interrupt the vicious cycle.

Alex Karagiannidis, MSc., Dip.MDT., BSc(Hons) Physiotherapy

The topic of his presentation was “The Rehabilitation of the Sports-Related Groin Pain: Key Points, Latest Evidence”

The presentation focused on the following topics:

1. The importance of the assessment of the athletes with groin injury, regarding the anatomical source of the symptoms
2. The presentation of the most common clinical entities
3. The clinical reasoning behind exercise prescription

The oral presentation was followed by a clinical laboratory session, at which he presented the therapeutic exercises  for the treatment of groin injuries. He emphasized how the therapist should gradually increase the intensity of the exercises in relation to symptoms’ response.

The latest advances at the following clinical entities were emphasised during the 3-day Congress

• «Treatment of the Sports-Related Groin Pain», presented by Dr. Christian Thorborg‘s team (Professor in Copenhagen University Hospital Hvidovre)

• «Rahabilitation of Hamsring Muscle Injuries», presented by Jurdan Mendiguchia  (Department of Physical Therapy, Zentrum Rehab and Performance Center)

If your Orthopedist advises you to start exercising, then your rehabilitation program should include the following goals.

1. RESTORE FULL RANGE OF MOTION

Normal function of the knee during the activities of daily living and in sports, requires that the knee can fully straighten and bend as much as possible, without pain.

When you bend and stretch your knee into extension to increase the range of motion, it is normal to feel a slight discomfort at the limit of the available range of motion, provided that it does NOT last. Your body will adapt and gradually the range of motion will come back to normal.

2. QUADRICEPS MUSCLE ACTIVATION AND STRENGTHENING

Our knee can not function properly without an optimal activation of the quadriceps muscle. When our knee hurts, the Central Nervous System decreases the activation of the quadriceps muscle, as a protective reaction. This protective response, in conjunction with the fear-avoidance strategy to put less weight on the painful knee, causes a reduction in the strength of the quadriceps muscle. As a result, the knee loses its ability to absorb the loads of our body.

You should start strengthening the knee with “Open Kinetic Chain” exercises. OPC exercises are performed WITHOUT the use of our body weight. Initiate the exercises in the painless range of motion with minimal resistance and work your way up to a wider range of motion, adding resistance as the muscle’s output increases.

3. GLUTE ACTIVATION

While you are working on the range of motion and quadriceps activation, you can start the glute activation exercises. The glute muscles are important muscles for two reasons.

a) They hold the pelvis level during the single leg stance (ie when we walk, run, go down stairs, etc.),

b) They also keep the knee aligned between the hip and the ankle. When the glutes are inactive and weak, the knees fall inwards and the condition is called “dynamic valgus”. Dynamic valgus is a leading cause of anterior knee pain and knee injuries in sports.

Below are some of the most important exercises for the glutes and can be performed easily on a mat.

4. MOTOR CONTROL EXERCISES USING THE BODY WEIGHT

When you have achieved a satisfactory knee range of motion and have quite strong quadriceps and gluteal muscles, it’s time to begin the “Closed Kinetic Exercises”, with the use of the body weight. Body weight exercises are functional exercises and prepare your knee to meet the demands of daily activities and sporting activities. Your functional goals decide the type and the intensity of the body weight exercises.

As noted above, the proper alignment of the knee joint, between the hip and the ankle joints, is very important. However, keeping the knee properly aligned is not only a matter of strength. It is a motor control task, that needs to be retrained, the same way as a dance move.

These exercises should be performed in front of a mirror, to enable the self-correction of possible errors during execution. Special attention must be paid in the knees staying apart during squatting, side to side movements etc.

5. PROPRIOCEPTION AND BALANCE EXERCISES

When your goals include the participation in sporting activities, you should perform exercises that prepare the knee to adapt in a changing and unpredictable environment. To meet this purpose we use unstable surfaces (balance boards, bosu etc.) and single leg exercises, so you can gradually improve your balance and dynamic stability of the whole lower extremity.

Even if you don’t participate in sporting activities, you should perform balance and weight shifting exercises, so you will adopt a stable and economic gait pattern, with proper activation of all muscle groups.

Alex Karagiannidis, MSc., Dip.MDT., BSc(Hons) Physiotherapy

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