House Call, MD: Health Carefully Explained

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.

by G. John Mullen, DPT 2011

With Thanksgiving behind us and winter weather in full effect, snow has already begun to cap the mountains across America.  With a layer of white powder on the ground, everyone is counting the days until they can escape from work, school or writing anonymous cynical comments on message boards and hit the slopes.  Whether you snowboard, sled, cross-country ski or bare foot ski, with the rush of mountain adrenaline comes the risk for injury.  We’re here to help you train those hard-to-reach, unused muscles for the slopes so that you are prepared for anything the mountain can throw at you.

Stat Fact: Lower extremity injuries were the most common injury in the Utah slopes from 2001-2006 for both snowboarding (~27%) and skiing (~50%).

Whether you’ve looking for exercises to prevent future knee injuries, strengthen your legs for the slopes, or help make that knee pain from that 1960 football injury (quit living in the past) go away, you can utilize the exercises below to strengthen weak muscles and lengthen tight muscles. We’ll discuss some plyometrics and exercises you can use to mimic skiing or snowboarding. Even if you’re as big as Richard Sandrack (see Lil Hercules at left) your bulging biceps and six-pack abs won’t prevent lower extremity injuries…training those targeted muscles will.

STRENGTHENING:

There are hundreds of exercises that can be used to train for the slopes.  We are going to talk about the main muscle groups that will prevent injuries and go over our favorite exercises to strengthen these muscle groups.  Unless you’re like hip hop video girl Vida Guerrera, you, like most Americans, may already experience knee or hip pain (or at least feel a little weak when it comes to these joints), due to weak gluteal muscles,.  As stated, there are hundreds of exercises to strengthen these muscles…so we’ve boiled it down to some key moves to get you started:

Overview of Strengthening:

When you first begin these exercises, start with the beginner exercises in your training of  those gluteal muscles.  At the beginning start with 3 sets of 20 repetitions and after two weeks add weight and try 3 sets of 10 repetitions.  After two more weeks add more weight and go 5 sets of 5 repetitions.  After this progressive process, advance to the intermediate exercises and repeat the same amount of repetitions and sets.

Beginner:

1. Clams:

Lie on your side and bend you knees to 90 degrees and your hips at 30 degree with your legs one on top of the other.  Now just lift your top leg open like a clam, brilliant!

Stat Fact: By increasing the amount that your hips are flexed during this exercise (by bringing your knees towards your chest thus changing the angle from 30 degrees to 60 degrees) you change the gluteal muscle you are working, from gluteus medius to gluteus maximus.

2. Bridges:

Lie on your back with your heels on the ground, but your toes in the air (lifting your toes makes sure you don’t use your calves and helps you to better isolate those gluteal muscles!).  Next, lift your lower back and butt off the ground by pushing through your heels.  At this point only your upper back and feet should be on the ground.  Note: a band can be used just above your knees to keep your legs from coming together, but is not necessary.  However, keep your knees apart!

After you’ve mastered double leg bridges, you can advance to single leg bridges or double leg bridges with weights on your hips.

3. Side-lying Leg Raise:

Lie on one side with one leg on top of the other, keep both legs straight and raise your top leg towards the ceiling.  Make sure your leg doesn’t creep forward.  To do so, keep it aligned with your hip or back (you should form a straight line from your shoulder to your hip to your knee to your ankle).

Stat Fact: If done properly, with your leg in correct alignment, this exercise requires the most gluteus medius activation of the exercises without weight.

Intermediate:

Lunges:

We’re not talking about your run-of-the-mill forward lunges.  We need to use exercises that are as close to skiing as possible, thus the use of multi-directional lunges.

1. Transverse Lunge:

Start with your hands on your hips and both feet facing forward like your feet are facing 12 on a clock.  Now, with one leg take a large step towards 2 o’clock.  Make sure your back foot rises on its toes and you don’t allow your front leg’s knee to come in front of your toes!

2. Lateral Lunge:

Once again, start with your hands on your hips and both feet facing forward like your feet are facing 12 on a clock.  With one leg take a large step towards 3 o’clock.  Make sure your back foot rises on its toes and you don’t allow your front leg’s knee to come in front of your toes!

To advance the lunges, you can hold weights (or anything that will add extra weight) in your hands or if you’re at a gym you can put a bar on your back.

Advanced:

1. Single Leg Squat:

Stand on one leg and slowly lower yourself bending at your hip, knee and ankle until you can touch the floor with your middle finger without reaching your shoulder.  Remember to stick your butt out as you come down and try not to let your knee come in front of your toes.  To advance this exercise, you can hold weights in either hand.

2. Single Leg Deadlift:

This exercise is similar to the single leg squat.  To begin bend your knee slightly (~10 degrees).  Now bend at your hip and bring your chest towards the floor, reaching with your hand to touch the ground.  To advance the exercise, you can add dumbbell weights in each hand.

Stat Fact: Single leg squats and single leg deadlifts have been shown to have the highest gluteus maximus activation of any non-weighted exercise…buns of steel, here we come!

STRETCHING:

It is hard to predict what muscles will be tight on each individual, but if we were to grab 10 people off the Red Line subway in Los Angeles and test their muscle flexibility I would bet a liter of cola that 9 of those people have tight hamstrings, piriformis (a muscle in your butt… that’s all you need to know), calves and hip flexors.  What do you say we try and loosen those bad boys up.

Overview of Stretching:

As you move through the stretches outlined below, remember to stretch both legs, completing each stretch twice for 30 seconds or more.  It is hard to overstretch these tight muscles, so the more you do the better.

Hamstring Stretch:

Lie on your back, grab the back of your thigh of one leg and begin to pull that leg towards the ceiling.  If done correctly, you should feel a stretch in the back of your leg and possibly in your calf.

Stat Fact: It is estimated that 80% of persons suffering from low back pain have tight hamstrings.

Piriformis Stretch:

Once again, lie on your back but this time bend one leg over the other.  Now push your bent leg towards the ground, without lifting your back off the ground.  If done properly, you should feel a stretch in your butt.   You have now officially located your piriformis muscle.

Calf Stretch:

Being by standing facing a wall with one leg in front of the other. with the leg to be stretched extended behind you.  With your hands on the wall at the level of your head lean forward.  You should feel a stretch in your calf.  The more you lean forward, the more stretch you will feel.  Repeat these same steps on the other side as well.

Hip Flexor Stretch:

Place one knee on the ground and lunge forward with the other leg, keeping your back straight.  If done correctly, you should feel a stretch in the front of your leg around your hip on the kneeling leg.  As you push forward with your pelvis, you should feel the stretching increase in this area.

Plyometrics:

Plyometrics are activities that enable a muscle to reach maximal force in the shortest possible time.  These exercises are meant to be explosive, but need to done carefully and under proper conditions (outlined below):

• Good landing surface (grass field, suspended floor, rubber mats)

• Plenty of space

• Proper footwear (no flip flops)

• Supervision, it is highly advised to do plyometrics with a training professional (personal trainer, physical therapist)if you are new to the exercises

Since this is a high intensity exercise we will start with one basic exercise as well as some strategies for plyometric training.  First, it is important to complete a proper low intensity warm-up.  Begin with skipping, marching, or jogging. The total amount of time you spend on these activities needs to be strictly monitored.  It is recommended that beginners do a maximum of 80 contacts.  80 contacts simply means each foot should only hit the ground 80 times including the skipping and jogging warm-up.  Anyone doing plyometrics should also include the appropriate amount of rest between exercises (at least a minute per exercise).  Below are a few examples of beginner plyometric exercises that mimic skiing and snowboarding.  We highly recommend doing these beginner exercises with an exercise professional (at least when you’re first starting off…the only thing worse that hurting yourself on the slopes is hurting yourself while training for the slopes).

Forward/Lateral/Diagonal Jumps:

Just as they sound, these jumps are performed with both feet together and you jump either straight forward, to your side or diagonally.  To begin start by jumping, landing and then jumping again.  As you progress you can begin performing multiple jumps in a row.

Now that you know what strengthening, stretching and plyometric exercises to perform, make sure you always warm-up first (at least fifteen minutes of cardiovascular work to get your heart rate elevated and muscles warm).  Perform these stretches exercises every day and the strengthening/plyometrics no more than three times a week.  When you hit the slopes tell Shaun White hello for us.

References:

Distefano, L., Blackburn, J., Marshall, S., Padua, D. Gluteal Muscle Activation During Common Therapeutic Exercises. Journal of Orthopaedic and Sports Physical Therapy.  2009 Jul; 39 (7): 532-540.

Torjussen J, Bahr R. Injuries among competitive snowboarders at the national elite level. Am J Sports Med. 2005 Mar;33(3):370-7.

Wasden CC, McIntosh SE, Keith DS, McCowan C. An analysis of skiing and snowboarding injuries on Utah slopes. J Trauma. 2009 Nov;67(5):1022-6.