The Hampering Hamstring
by G. John Mullen, DPT 2011 | mullen@myhousecallmd.com
Fantasy baseball drafts and spring training are in the air…you can almost smell the finely cut grass, taste the $10 hot dogs and feel the $20 beer in your hand. At the same time, the beginning of the season comes with big question marks hanging over the heads of players with injuries: Tommy John surgery, alcohol related rehabilitation, and hamstring strains (aka “pulling a hammie”) to name a few. Most regular folk have experienced a hamstring strain and know it does not get better without a fight and a bottle of Georgia Moon (maybe not the later for everyone). Before we get into treatment lets hit the basics of the hamstring.
Stat Fact: One-third of hamstring strains will recur with the highest risk of recurrence occurring 2 weeks after the initial injury.
Getting to Know Your Hammies
The hamstring is the predominant muscle in the back of your thigh. The hamstring is composed of three muscles (biceps femoris, semimembranosus, semitendinosis…in case you were wondering) 
and their primary collective action is to flex the knee. The most common cause of a hamstring strain is from the “eccentric use of the hamstring” while running. The eccentric use of the hamstring is highest when your leg is extending, off the ground, and swinging forward prior to hitting the ground for your next step. This stage is termed the “terminal swing” (and yes, we realize this sounds more like a carnival ride than a leg movement). The eccentric load is highest due to the amount of stretch it places on the hamstring muscles (this is similar to the strain you feel in a straight leg raise).
How do you know if you’ve hurt your hamstring?
Hamstring injury usually presents with a pop, pain in the back of the leg and decreased strength and range of motion. The strain can occur in any of the three hamstring muscles at any point in the muscle, but the most common site for a strain is either behind the knee or near the butt. Hamstring strains are classified by the amount of pain, weakness and loss of range of motion associated with the injury. They are commonly graded on a 1-3 scale with I being mild, II is moderate and III is severe. The duration of the injury depends on the site and size of the injury. If you have a large tear near your butt, you’re what we physical therapists call “pretty screwed.”
Stat Fact: The attachment of the biceps femoris is at the outside of the knee (where the complete tear is identified in the picture above). This particular region is the most commonly strained part of the hamstring muscles because it undergoes the highest amount of stretch amongst the hamstring posse.
Hamstring Hangover
The goal of rehabilitation is to return the athlete to their prior level of performance while minimizing the risk of injury recurrence. Multiple factors contribute to a high re-injury risk of the hamstring: (1) persistent weakness in the injured muscle, (2) reduced flexibility due to scar tissue, (3) impaired movement/biomechanics due to injury. Strengthening the hamstring is a fundamental component of rehabilitation and needs to include eccentric (muscle lengthening) and concentric (muscle shortening) exercises. In addition to strengthening your hamstrings, the muscles attached to the pelvis are often weak and require assessment and strengthening. Rehabilitation of grade I and II hamstring strains can be broken into three distinct phases:
Phase I:
The goal of the Phase I is to decrease swelling, pain and scar tissue formation. You should avoid excessive stretching of the hamstring in this phase since over stretching can increase scar tissue formation. To avoid over stretching, limit your knee flexion range of motion by taking shorter strides while walking or using of crutches. 
Ice should be used 2-3 times per day for 15-20 minutes with an ice pack to decrease swelling and pain (no more than 15 minutes at a time as longer amounts of time may increase swelling). Exercises in Phase I should not stress the injury site. The most common exercises prescribed during this phase are single leg balance (seen in the picture to the left), isometric abdominal exercises, and lateral stepping drills (grapevine/karaoke). Advancement from the first stage of rehabilitation includes normal walking and stride length without pain, light jogging without pain, and a lack of pain while resistance is applied with the knee bent to 90 degrees (lay on your stomach with your knees bent to 90 degrees and have someone gently pull your ankle down to the floor…pain = no good). Phase I is typically 5 days long but as doctors love to specify that “it depends.” It always depends.
Phase II:
The goal of Phase II is to increase intensity of exercises, increase range of motion and to begin eccentric exercises. Ice is typically used after training to decrease pain and inflammation associated with exercises. 
In Phase II exercises, we increase speed and intensity of agility drills. Side to side agility drills should be utilized to decrease the risk of overstretching the muscle. At the end of Phase II, you can progress agility and strengthening drills to include forward and backward movements (supine bent knee bridge walk-outs…Google it). Eccentric strengthening is initiated and incorporated as functional movements (light jogging, moderate high knees) instead of isolation exercises. To progress to Phase III, the participant must be able to 1) pull with the full strength of your hamstring against resistance with your knee bent to 90 degrees and 2) forward and backward jogging at 50% of maximum speed without pain. Phase II typically last 1-2 weeks.
Stat Fact: Mobilization (lengthening) of skeletal muscle 5-7 days after injury can enhance fiber regeneration.
Phase III:
Phase III involves sport specific movements with no range of motion restrictions but sprinting and high accelerations should be avoided until return-to sport-criteria are met. Ice should be used as needed after rehabilitation exercises. Exercises in Phase III involve sport-specific exercises emphasizing quick direction changes and proper technique. Trunk stabilization should be improved with movements in multiple planes of motion. Single leg bridges and single limb windmills (see picture) are examples of high intensity exercises. In order to be cleared to return to the sports you need full range of motion, strength and functional abilities (cutting, running, jumping). Phase III usually lasts 1-2 weeks. The total time for hamstring recovery is typically 3-5 weeks.
Prevention:
To prevent hamstring strain, we recommend a combination of stretching and strengthening exercises. Research studies have not shown any significant benefit to stretching your hamstrings 
therefore static hamstring stretching is not the best prevention tip. However, scientists believe that an improper length of the quadriceps and hip flexors are a risk factor for hamstring strains. Therefore, increasing flexibility of these muscles is mandatory to prevent hamstring strains. Additionally, research showed that eccentric hamstring training prevents strains. Eccentric hamstring training should be incorporated into a preseason and in-season training program for all athletes at risk for hamstring injuries. An exercise routine for eccentric hamstring training can include Romanian dead lifts, knee fall downs and single leg Romanian dead lifts (see picture above). Lastly, exercises that incorporate the lower extremities and pelvis are associated with a decreased risk of hamstring strains. Examples of these exercises include high knee marching, forward-falling running drills, and explosive starts.
Reiteration:
Prevention is the key here! Make sure warm-up for 10-15 minutes (and by “warm-up” we mean activity that raises your heart rate and gets you sweating) before any work out. Incorporating a proper warm-up, eccentric hamstring training and proper hip flexor and quadriceps muscle length will decrease your chance of the ending up with a hampering hamstring. Everyone wins!
Questions? E-mail G. John Mullen: mullen@myhousecallmd.com
References:
1. Heiderscheit B, Sherry M, Silder A, Chumanov E, Thelen D. Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther. Feb 2010;40(2):67-81.
incurred during the intense competition in the coming weeks. Shoulder pain, elbow pain, ankle pain? These joints are common sources of pain for professional athletes and law-abiding citizens alike. Whether you have golfer’s elbow, tennis elbow, speed skater’s knee, shoulder impingement, jumper’s knee, Achilles tendon pain, you are suffering from a “tendinopathy.” Tendons, which connect muscles to bones, are composed of collagen. Tendinitis is the most common term associated with tendinopathy. Tendinitis is the acute injury of a tendon and is typically associated with inflammation (note that “-itis” means inflammation). Tendinosis is a term used less commonly but refers to the process in which tendinitis becomes chronic (lasting greater than 3 weeks). To understand the disease of tendinopathy, it is essential to understand the design of a tendon, common causes, treatments for the different types of tendinopathies and what you can do to prevent these disorders.
of the blood supply that muscles have) which means that it takes tendons notably longer than muscles to heal. Following an acute injury, the tendon strained becomes inflamed (filled with cells trying to repair the tissue). After chronic use of the tendon, type III collagen becomes predominant. This change in collagen will make the tendon larger due to increased collagen rather than from inflammation. Along with the increase in collagen comes an increase in water in the tendon as well. These two changes make the tendon thicker which you notice as increased stiffness. At the same time, the tendon becomes more compliant leading to an increased rate of tendon strain after a chronic tendon injury. Cadaveric studies suggest after a chronic tendon injury, the strain increases causing a decrease in stiffness and strength. Strain is “the amount of displacement with an external load placed on the object” or, in the cadaveric study, “the amount of displacement increased after injury.” Essentially, it means the amount of laxity (“looseness”) in the tendon after injury.
(you know doctors don’t like to put timelines on healing!). The majority of treatment for tendinitis consists of anti-inflammatory medication or a cortisone shot (used only in extreme situations) administered by the physician. The list of anti-inflammatory drugs is extensive, including as Ibuprofen, Motrin, Naproxen, Celebrex, and many more. Physical therapists can help reduce inflammation with a number of treatment modalities (electrical stimulation, low level laser therapy, ultrasound, ice) that can decrease pain and inflammation. The last and the most important treatment for tendinitis is a temporary discontinuation of the activity that caused this inflammation. As stated, true tendinitis is from an acute accident therefore discontinuing that activity while the tendon heals makes sense…let’s agree to agree on this one.
if you are performing a squat, lowering your body down is the eccentric phase of the exercise on your thighs and returning to the start position is the concentric phase for your thighs. Overload eccentric exercise training studies suggest eccentric training increases stiffness of the tendon and help change the tendon back to type I collagen. Increasing the tendon stiffness provides the support your muscles need to contract so that it can maintain the muscle in the position where it produces the most force. Let’s look at another example: Achiles tendinitis is common in runners. Mix in a little hard headedness and a desire to keep running despite injury and you have yourself the perfect storm for the development of a tendinosis. To treat this population of patients, a 12-week exercise program consisting of heel drops has shown excellent results. This program uses high repetitions of the exercise: 3 sets of 15 repetitions two times a day with progressively increasing external weight (you can add weight to backpack that you wear during the exercise)1. One key during this exercise is to only perform the eccentric phase of the heel drop with your injured leg. To do this, slowly lower yourself down on the injured leg (the eccentric phase) and then return to your tippy toes by concentrically using the healthy leg. This type of eccentric exercise can be used in any type of tendinosis.
Begin in a sitting position and put loop theraband (an thick elastic band) in which the loop is on the inside of your foot. Move your foot down and in without resistance and then attach the theraband around the foot with high tension. In a controlled manner, allow the foot return to the up and out position.
With the Superbowl only days away, Colts fans across the nation are keeping their fingers crossed for Dwight Freeney’s return. The Colts’ All-Pro defensive end said he’s been walking around barefoot and along the sandy beach outside the team’s hotel to strengthen his sprained right ankle. The question is whether this game-changer, who recently suffered a severe ankle sprain, will be ready for the sharp cuts and quick footwork he will need on Sunday. As simple as this sounds, hard cuts followed by the unfortunate rolling of an ankle cause ankle injuries to numerous players (pro and recreational alike) each year, injuries that may have been prevented with proper footwear, ankle strength and coordination. Before we discuss those topics, let’s go over what an ankle sprain is as well as the main causes of ankle injury.
The most common type of ankle sprain is of the anterior talofibular ligament (which connects the talus to the fibula) and the calcaneal fibular ligament (connecting the calcaneus to the fibula) on the lateral side (aka the outside) of your foot. You can see this ligaments on the image to the right and imagine the type of ankle movement that would strain them. This type of sprain is caused by rolling your ankle downward and inward (exactly what you had imagined). There are many other ligaments in the ankle that can be stretched or torn in the sprain but the overwhelming majority of ankle sprains involve these two ligaments. In addition, there are three different grades of an ankle sprains: Grade I is a stretch of the ligament, Grade II is a partial tear and Grade III is a full tear of the ligament.
Wrap your ankle from your toes upward to your calf, but do not wrap too tightly or more harm than good can be done. Make sure you can still feel a pulse in your foot (blue toes are a bad sign!).
Ankle Braces: External ankle braces such as an Aircast or any semi-rigid external device is recommended during physical activity. This device should be fitted by a trained exercise specialist to make sure the device is working and fits properly. If properly worn the device will provide the support an individual needs to safely perform all of their sports needs (sounds like a good pitch if you ask me).
your ankle simultaneously. As you progress, you can perform these exercises with your eyes closed or on top of a pillow to make them more challenging. A Dyna Disc or Bosu Ball (see pictures) can also be used to improve strength and balance of your ankles. Squat, lunges and various other exercises can be used on these devices to increase the difficulty of the exercise.
Strengthening: Balance and strengthening go hand in hand as it is a critical aspect of rehabilitation for an active individual. Strengthening is usually performed with elastic bands and on a Dyna Disc or Bosu Ball. One exercise that can be used is called the elastic band clock and involves holding the band at 12 o’clock, 3 o’clock, 6 o’clock and 9 o’clock. I know this sounds like nonsense but if you loop the elastic band around your foot and hold the band directly above your foot, you are in 12 o’clock,
and if you hold the band in your hand on the outside of your foot you are in 9 o’clock similar to the picture on your left. Push your foot against the resistance of the elastic band and stretch the band as far as you can without moving your shin or any other aspect of your leg (you are moving your foot at the ankle). Movements in all these planes of direction will greatly strengthen your ankle and improve your balance. These exercises can be done for 3 sets of 15 repetitions and should not be terribly difficult. A little TV time makes them infinitely more enjoyable.
With the New Year comes the annual New Year resolution. At the top of every New Year’s resolution list is a promise to be “healthier”. Everyone has a different opinion regarding what it takes to be “healthier” and it can range from smoking a pack instead of a carton of cigarettes, eat two foot long subs instead of a party sub or increase your running routine from 10 to 100 miles a week. Ok, that may be a bit of a hyperbole but when asked time and time again, the top of the New Year resolution list is related to exercise. The most popular and simplest form of exercise is running. Running is great cardiovascular exercise, however many injuries stem from running and often arise from doing too much too early. One of the most common injuries is iliotibial band friction syndrome (ITBFS). This injury can linger for long periods of time without quick and proper treatment but if assessed and treated soon, the effects can be mitigated.
The iliotibial band is a fibrous band that runs on the outside of your leg from your hip to your knee. It is generally firm, but as it is irritated it may become extremely tough and sensitive. Irritation of the iliotibial band can be due to poor biomechanics, anatomical flaws or muscle weakness. Many of the biomechanical flaws stem from muscle weakness, but the anatomical flaws are a bit trickier. The main anatomical flaw is flat feet, which causes your knee to internally rotate with each step, subsequently stretching your IT band. While stretching is typically good, when done repeatedly it can break down the tissue and inflammation and tightness can occur. The most common biomechanical flaw is too much hip adduction (bringing your thigh bones close to one another) and internal rotation (rotation of the knee inward) of the thigh bone (femur). This motion is controlled by the gluteus maximus (the upper fibers to be exact…also the sexiest muscle in the body) and if this muscle is weak it can cause repeated stretching of the muscle leading to problems similar to those seen with anatomical flaws. These are the main causes of ITBFS, but many other anatomical issues may cause ITBFS (leg length discrepancy, bowed legs, previous injury, improper footwear, etc.). However, simple muscle strengthening is not the solution, especially if you already have ITBFS.
because it is essential to understand the problem before it can be resolved. Some modalities (ice, electrical stimulation, etc.) may be used to decrease pain and inflammation, but these things will only solve the problem temporarily. A proper running analysis, combined with a stretching and strengthening program will be most beneficial in the long run (yes, this is a purposefully placed pun). Every physical therapist will have their own unique treatment style but, as an overview, it should include:
Lie on your side and bend your knees to 90 degrees and your hips at 60 degree with your legs one on top of the other. Now lift your top leg open like a clam, hold for a second and then return your knee to the starting position. Brilliant! Complete 3 sets of 10-20 repetitions on each side.
s exercise is similar to the single leg squat. To begin, stand on one foot and bend your knee slightly (~10 degree). Now bend at your hip bringing your chest towards the floor and touch the ground next to your foot with the opposite hand. Hold for a second and return to the standing position. Repeat 3 sets of 10 repetitions on each side. To advance, you can add dumbbell weights in each hand.
Begin in the tall kneeling position (see picture) and have a partner hold onto the back of your heels to stabilize you. Now lower yourself as slow as possible to the floor maintaining your upper body in a straight line as you lower yourself to the floor from your knees. This can be advanced by holding a weight to your chest during the exercise (2).
Hip thrusts are similar to the glute bridge but with weight involved in the exercise. Begin with your shoulders higher on a couch or bench. Place weights across your hips (preferably a barbell) starting in the seated position (See picture at right). Press your hips towards the ceiling and hold at the top of the movement for 3 seconds then lower your hips to the starting position. Remember to lower yourself slowly on the way down. Perform 3 sets of 15 repetitions (2).
You can picture it now: Your New Year’s resolution to get in shape finally realized. You’re on the beach in your Speedo with your muscles glistening in the sun. Ok, maybe that’s not exactly what you are imagining the finished product to look like. Perhaps your New Year’s resolution was geared more towards building bigger muscles and getting in better shape rather than becoming the next World’s Strongest Man (skin bronzer, shaving, and Speedos may not be your style). Nonetheless, you do want to become more muscular. If so then creatine is the one supplement all your Google searches for “build more muscle” will undoubtedly produce. Creatine is possibly the most widely used and talked about dietary supplement in the world of bodybuilding. It’s definitely something a lot of people come into pharmacies and nutrition stores looking for. The question, of course, is “Does it work?”
In the muscles, creatine acts as a battery charger. In this case the battery is your body’s energy stores called ATP. When muscles use up ATP to perform an action it is converted into ADP. Creatine is able to convert ADP back into ATP, which can once again be used by your muscles to perform actions. This is a quick and easy way for the body to create more energy (twice as fast as the bodies normal way of deriving ATP from glucose). Sounds great, right? The downside is that the creatine is depleted pretty quickly and the body has to go back to breaking down glucose to make more ATP. So when an athlete takes creatine, their hope is that it will help their muscles maintain the ATP levels for a longer period of time subsequently allowing them to train longer before becoming fatigued.
grams of creatine supplements a day for five days (called creatine loading). Then the subjects were asked to consume 5 grams of creatine per day for 21 days. Theoretically, this would increase the stores of creatine in their muscles. The participants were then asked to perform various exercises and their results were compared to their pre-supplementation results. The studies show that creatine does help increase body mass and it does help increase endurance in short-duration, high-intensity exercises (they specifically looked at number of bench press reps, leg press reps, and vertical jump height). However, creatine did not help the men in long endurance exercises such as running a 12 mile race (creatine actually hurt test subjects in long endurance exercises, possibly because they were carrying around excess body mass). Creatine also did not decrease the amount of post-workout soreness reported by the subjects. The amount of soreness felt was the same before using creatine and after the supplementation period.
bound to happen from time to time. To test out these claims more studies were done. The main study on this subject was performed on 14 football players who were told to consume creatine for 8 weeks. They chose football players as the athletes to use as guinea pigs…I mean test subjects…because football is considered a high-intensity, short-duration exercise (which is exactly the kind of activity creatine is supposed to aid in). During the 8-week time period the athletes’ kidney function, liver function, and over health were closely monitored. Their results regarding creatine efficacy paralleled those of other previous studies showing that body mass increased and the athletes’ abilities to perform high-intensity, short-duration exercises did improve. As far as toxicity goes, no signs of kidney or liver damage were seen in any of the patients. In addition, none of the football players became dehydrated or had more cramping than they did at baseline.
under the close supervision of a health professional. Studies have not been done with people who have kidney or liver problems so it is hard to say how it may affect them. Second, all these studies were short term (8 weeks was the longest one performed) so no one really knows the long-term effects of taking creatine. Many of the problems initially reported with creatine supplementation could have been due to impurities in the creatine supplement people were purchasing thus it’s always important to buy supplements made by a well known and trusted company (i.e. don’t order it off the web from some no name company just because shipping is free). In addition, be sure to consume plenty of water when using creatine. Remember that creatine pulls water into your muscles (and out of your body’s circulation). You need to make sure that you are replacing this displaced water while using creatine to prevent dehydration.
