Posts Tagged ‘Strain’

The Sideline: Brian Wilson’s Abdominal Muscle Strain

by Steve Hole, MD 2012

Though he’s under a 2-year, $15 million contract with the World Series champion San Francisco Giants, Brian Wilson wears several hats: tattoo canvas, captivating interview star, and closer extraordinaire. The relief pitcher led the majors with 48 saves in 2010 and pitched his best in the biggest moments, striking out Ryan Howard in Game 6 of the NLCS to send the Giants to the World Series, and striking out Nelson Cruz to clinch the team’s first title since leaving New York in 1958.

Despite his obsessive year-round workout program, odds were “less than 50-50” that Mr. Wilson would be ready to play on Opening Day 2011. In a Spring Training game against the LA Angels on March 17, he strained an abdominal muscle during an otherwise routine 7th inning appearance. Pitch counts are an essential part of baseball at all levels, and Mr. Wilson was not beyond his expected workload for this point of the preseason. The injury was undeniably a result of the pitching motion; Mr. Wilson might have felt the strain emerge during one single throw, or emerge gradually over hours or days.

According to Giants manager, Bruce Bochy, an MRI taken after the game showed a “mild strain of the left oblique muscle” but did not show any tears. Fans might remember Mr. Wilson missed time earlier in the spring with a sore back; this injury appears to be unrelated.

Read the rest of this entry →


04 2011

The Achilles’: Your Weakest Link

by G. John Mullen, DPT 2011 |

Achilles’ tendon injuries have been present since the time of the Greek Gods and Goddesses, (remember Achilles from Greek Mythology?).  Achilles’ is the burly, handsome warrior from the Trojan War legends who could only be harmed by a lethal blow to his Achilles tendon…and the name was born.  Contrary to popular belief, this warrior’s surname was not Pitt.  What we really want to know, however, is how does the Achilles tendon affect us today?

We all witnessed the devastating loss Michigan State suffered to underdog, Butler University, in the men’s NCAA basketball tournament. The Spartans put in a valiant effort despite the season-ending loss of Kalin Lucas, a pivotal player averaging 12.3 points per game.  Lucas tore his Achilles’ tendon during the game against Maryland (tragic, we know). Achilles’ tendon tears are not unique to the collegiate super-athlete; weekend warriors are just as susceptible to Achilles’ tendon tears as the pros.  An Achilles’ tear is debilitating, requiring surgery and extensive rehabilitation in most cases.  Successful surgery and rehabilitation of a torn Achilles’ tendon requires a thorough understanding of the anatomy, cause of the injury, patient’s unique health condition & lifestyle and patient’s athletic activities.  These factors are essential to preventing a re-repture of the tendon.

Stat Fact: Most Achilles’ tears occur 2-6 cm above the Achilles’ insertion into the calcaneus, the heel bone in the foot (3).


The Achilles’ is a complex tendon whose rarity is secondary to the fact that the tendon crosses two joints.  Multi-joint crossing places increased stress on the Achilles’, resulting in the tendon’s high injury rate.  Everyday activities like walking place repeated stress on the tendon.  The tendon is the composite of two muscles in the calf: the gastrocnemius (the medial and lateral heads which cross the back of the knee) and the soleus (the bulk of the calf). The tendon is surrounded by two sheaths (which are called “paratendon” and “mesotenon”).  The mesotenon is responsible for the nourishing blood flow to the tendon.  Diminished blood flow is seen at the bottom of the Achilles’ tendon and is responsible for the high rate of tears in this region. The majority of the tendon is made of Type 1 collagen (4).

Stat Fact: The Achilles’ tendon twists in a spiral motion as it wraps around the foot and inserts into the calcaneous.

Types of Achilles’ Tears and Risk Factors

Athletic Achilles’ tears are typically acute injuries caused by a “high rate of loading” associated with specific movements which include landing, pivoting or sweet juke moves on the field…talk about all-time backfires! Acute injuries commonly occur at the distal portion (i.e. the point farthest towards your heel) of the tendon where blood flow is diminished. Out-of-shape athletes returning to high-impact sports make up the largest portion of these injuries.  Trauma from a foreign object is another common cause of an acute Achilles’ tear (i.e. Tonya Harding action to the back of your ankle).  These injuries are not pretty, but if you’ve seen the movie, Saw, you may remember one of the hostages having their Achilles’ sliced to prevent escape.  Uncommon but horrific to say the least.  Tears during motor vehicle crashes are more typical and can be equally debilitating.  Chronic Achilles’ tendon injuries can also eventually lead to tears. Nagging Achilles’ tendonosis (chronic inflammation of the Achilles’ tendon) transforms the molecular properties of the tendinous collagen making the tendon soft and pliable.  Pliability is the Achilles’ kryptonite (not arrows as Hollywood would have you believe)!  As we age, we are more prone to tendon tears.  Two factors lead to increased Achilles’ tears as we age: 1) the transformation that takes place in your tendon’s cartilage and 2) hypovascularity (impaired blood flow) making previously injured, older athletes more prone to Achilles’ tears.

Stat Fact: The Achilles’ tendon is the strongest tendon in the body, absorbing up to 8x our body weight in force during athletic movements (2).

Surgery and Rehabilitation

Surgery is always the last option.  Debate surrounds the efficacy of surgery and rehabilitation in Achilles’ tears.  Studies show conflicting evidence in terms of recovery speed and re-rupture rates for individuals with and without surgery (5). There is further debate on the first phase of rehabilitation for both groups. One theory of rehabilitation promotes 6-8 weeks of immobilization via casting.  Casting is typically done in plantar-flexion (with your foot bent at 90 degrees to your calf) or in the neutral position (imagine your foot’s position as your leg hangs over the edge of the bed).  Immobilization is thought to allow collagen repair following surgery increasing stiffness and strength of the tendon. The other accepted method of rehabilitation is the exact opposite of immobilization: early mobilization. Early mobilization is believed to promote revascularization of the injured tendon. Revascularization is believed to enhance strength (4).  More importantly early mobilization is associated with similar functional gains and a low re-rupture rate (5).  These positive attributes make early mobilization an important variable for surgical and non-surgical treatment of Achilles’ tendon tears.

Rehabilitation regimens vary depending on the surgeon’s approach (early mobility vs. early immobilization).  Early mobilization seems to be gaining momentum with recent publications.  A typical early mobility rehabilitation protocol is listed below:

Postoperative Exercise Program (1)

Group 1 (early mobilization)

Time: 0-3 wk

  1. Flexion and extension of the toes in a supine position; 25 × 3 series

  2. Plantar flexion of the ankle and dorsiflexion to neutral in supine position

  3. Extension of the knee in a sitting position (hold 2 s); 10 × 3 series

  4. Flexion of the knee in a prone position; 10 × 3 series, 3 times daily

  5. Extension of the hip in a prone position (hold 2 s); 10 × 3 series

Time: 3-6 wk

Same as week 0-3

Time: 6-9 wk

1. Ankle flexion and extension exercises with manual help

2. Rotation of the ankles in both directions; 30 × 3 series, 3 times daily

3. Standing on the toes and heels alternately; 30 × 3 series, 3 times daily

4. Ankle extension exercises against a rubber strip; 20 × 3 series, 3 times daily

5. Ankle stretching exercises to flexion with the help of a rubber strip; 30 s × 5 series, 3 times daily

6. Stretching of the calf muscle by standing with the leg to be stretched straight behind and the other leg bent in front and leaning the body forward, with support from a wall or chair; 30 s × 5 series, 3 times daily

7. Stretching exercises for the toes and ankle against the hand in a sitting position; 30 s × 5 series, 3 times daily

Time: 9 wk

1. Raising and lowering of the heel, first with both feet at the same time and later with 1 foot; 20 × 5 series, 3 times daily

Exercises against a rubber strip for

Ankle extension 20 × 5 series, 3 times daily

Ankle flexion 20 × 5 series, 3 times daily

Ankle abduction 20 × 5 series, 3 times daily

Ankle adduction 20 × 5 series, 3 times daily

Stretching of the calf muscle against the wall; 30 × 5 series, 3 times daily

Standing with the knee somewhat flexed; 30 × 5 series, 3 times daily

With any surgery, you must take note of the potential complications. At the same time, the re-rupture rates in Achilles’ tendon tears are significant in the conservative non-surgical group.  A notable complication with Achilles’ Tendon surgical repair is sural nerve dissection.  The sural nerve is damaged in approximately 6% of Achilles’ tendon repairs.  Sural nerve damage can lead to impaired sensation to the dorsal (back) aspect of the heel (2).

Stat Fact: Non-surgical Achilles’ Tendon treatment has a re-rupture rate of 12.6%, nearly 4x the 3.5% re-rupture rate seen in the surgical repair group (2).


While many people believe that stretching is the key to preventing Achilles’ tendon rupture, this may not actually be the case.  Stretching may reduce the number of tendon injuries, but a more thorough approach is needed to further minimize your risk of injury.  Most Achilles’ tendon tears are caused by high force movements.  As your coach always said, “Practice like your play!”  It only makes sense to practice these high force movements via plyometrics to train your body to adapt to these high levels of strain. Therefore a stretching regimen in combination with a light plyometric routine makes perfect sense.  A simple plyometric routine (for example, ankle hops progressing to higher impact squat jumps and then repeated hops) can be utilized before exercise to minimize your risk of injury.  Who doesn’t want strong enough Achilles’ tendons to dunk like Dwight Howard?

Questions? E-mail G. John Mullen:


1. Kangas J, Pajala A, Ohtonen P, Leppilahti J. Achilles tendon elongation after rupture repair: a randomized comparison of 2 postoperative regimens. Am J Sports Med. Jan 2007;35(1):59-64.

2. Molloy A, Wood E. Complications of the treatment of Achilles tendon ruptures. Foot Ankle Clin. Dec 2009;14(4):745-759.

3. Park D, Chou L. Stretching for prevention of Achilles tendon injuries: a review of the literature. Foot Ankle Int. Dec 2006;27(12):1086-1095.

4. Strom A, Casillas M. Achilles tendon rehabilitation. Foot Ankle Clin. Dec 2009;14(4):773-782.

5. Twaddle B, Poon P. Early motion for Achilles tendon ruptures: is surgery important? A randomized, prospective study. Am J Sports Med. Dec 2007;35(12):2033-2038.


04 2010

The Hampering Hamstring

by G. John Mullen, DPT 2011 |

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.


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.


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:


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.


02 2010

Preventing Low Back Pain: $86 Billion Worth of It

by G. John Mullen, DPT 2011

Low Back Pain

Imagine you are working at a desk job for 20 years (or writing an article once a week) and out of left field your low back begins to hurt.  Now imagine you’re trying to impress an individual of the opposite sex by picking up a box of their weights and body building trophies and all of a sudden your low back is killing you.  Next imagine you’re playing a pick up game of basketball, you have your Chris Sabo rec specs on,  and as you’re running down the court you twist to grab a pass and your low back starts to hurt. All of the above are common ways of injuring your low back.

Stat Fact: $86 billion is spent annually on the treatment of low back pain.

There are many structures located in your lower back that can cause low back pain including bony vertebrae, intervertebral discs, ligaments, muscles, nerves, and your spinal cord.  Any one of these could be causing a variety of problems (very scientific, we know).  We will talk about some of the most common problems and a few ways to help strengthen and protect your spine.  The three scenarios described above are the most common back injuries, but there are many more ways to injure your low back (obviously).  It is important to note that if you already have back problems it’s probably a good idea to talk to your doctor or an exercise specialist about it because if the exercises below are done in an improperly things can get worse rather than better.  Now let’s tackle the most common causes of low back pain.

Herniated Disc1. Herniated Nucleus Pulposis (bulging disc) is a disease that occurs when the jelly-like center (the nucleus pulposis) of the shock absorbing disc located in between each vertebrae ruptures through the tough, fibrous outer portion (the annulus fibrosis) of the disk.  One way to think of this is similar to a jelly doughnut: the nucleus pulposis is the jelly, the dough is the annulus fibrosis, and the bulging disc is the delicious, jelly exploding through the wall of the doughnut. This bulging can put extra pressure on the spinal cord and lead to tingling or numbness in your legs.  Some treatment options include: epidural injection, physical therapy or surgery.  Surgery is always a last resort, so we’ll go over a few stabilizing exercises that would be used in the physical therapy clinic to prevent the need for surgery.

2. Degenerative Disc Disease is a decrease in the volume of the intervertebral disc.  The nucleus pulposis and annulus fibrosis break down over time and cause a narrowing of the canal through Spinal Cord Problemswhich your spinal nerves pass and the space between each vertebrae.  This may irritate your joints as the vertebrae sit closer together and possibly rub on one another.  This condition occurs for a variety of reasons:

  • Age-related changes

  • Lifestyle

  • Genetics

  • Smoking

  • Poor Nutrition

As stated, lifestyle is one modifiable variable in the mix.  Poor posture is frequently one of the causes.  It is important to think of your spine as the game Jenga.  All of your muscles and ligaments are your Jenga pieces and as you begin to slouch (the popular choice for poor posture), you are removing key supporting pieces causing your spine to lean and eventually fall.  This is what we call degenerative disc disease.

Stat Fact: There is a high prevalence of dehydrated discs (i.e. breaking down of the intervertebral discs) seen as early as the third decade of life in both men and women.

Back Muscle Strain3. Muscle Strain is another common lower back injury and can be caused by a several of different accidents, the most common being improper lifting.  Proper lifting technique is as follows:

  • Bend with your knees and keep your back straight from your butt to your neck

  • Bring the object close to your body

  • Come straight up while pushing through your legs

Untitled2The most important treatment for an acute muscle injury is rest.  The amount of rest depends on the severity of the injury.  Depending on the severity of the injury, the rest period can be anywhere from 2 weeks to 3 months!  While resting your muscles, it is also vital to improve your flexibility.  When a muscle becomes injured, its natural reaction is to tighten up (which we call “muscle guarding”) ultimately leading to other injuries and impeding the healing process.  Regular, targeted stretching can prevent this further damage during the healing process.

Stat Fact: Roughly 1/3 of all workplace injuries occur while lifting.

Now for the fun part: preventing and treating your back pain with exercises.  Once again, if you currently have back pain it is recommended to see a health professional before completing these exercises.  These exercises are few examples of many options available for back strengthening.


Abdominal Bracing

Abdominal BracingAbdominal Bracing is used to find a safe and supportive position for your lower back.  The exercise involves pulling in your stomach by tightening your abdominal muscles (trust me everyone has them in there…somewhere) but not flattening your back to the floor.  This exercise should be completed in three sets of 10 repetitions, holding for 10 second each repition.

Table Top

Table TopAs you may have guessed, this exercise involves making your legs look like a table top.  Lie on your back and begin by bracing your abdominals as mentioned above.  Next, lift both legs up creating a 90 degree angle at your hips and knees.  Perform this exercise three times for 1 minute each time.  Technique tip: Don’t arch your back!


Dead Bug

Dead BugDead Bug is an uncoordinated individual’s nightmare because it involves alternating arms and legs.  Don’t worry, practice makes perfect.  To start, implement the abdominal bracing from above and bend your knees and hips to 90 degrees.  Now, extend one leg at approximately a 45 degree angle and raise the opposite arm overhead (see the picture to get a better idea of this position).  Hold this position for one minute.  After a minute, return to the starting position, pulling your hip/knee toward your chest and returning your arm back to your side.  Repeat the same leg extension and arm flexion on the other side.  You should feel this exercise in your things and abdominals.  Perform this for 3 sets of 1 minute on each side per set.


QuadripedPosition yourself on your hands and knees and begin with your abdominal bracing.  Your hands should be under your shoulders and your knees under your hips.  Once this position is obtained, use a mirror or a partner to help gauge if your back is straight and flat.  Start by raising one arm at a time and alternate these movements.  When you are comfortable with this movement, advance the exercise by including your legs.  Extend the leg on the opposite side of your body from the arm you are extending.  Once your arm and opposite leg are extended, hold for 5 seconds.  After 5 seconds, return to the resting position.  Do not lift your arms or legs above your trunk during the exercise as this will excessively arch your back.  Perform 3 sets of this exercise with 10 repetitions on each side per set.



The plank is one of our favorite exercises!  Start by lying on your stomach and then lifting your body up, resting on your forearms and knees (beginner) or feet (advanced).   Your body should form a straight line from your ankles to your hips to your ears.  Hold this position for 30 seconds maintaining your abdominal bracing the entire time.  Repeat this 30-second hold 3 times, resting for a minute between each plank.

Beginner                                                           Advanced

Beginner Plank

Advanced Plank

The back is one of the most commonly injured parts of the body, most of which are preventable with proper mechanics and muscle strength.  With the help of your health professional and a little personal motivation and commitment, you can prevent low back injury and help us save some of that $86 billion we’re spending every year!



Mair S, Seaber A, Glisson R, et al. The role of fatigue in susceptibility to acute muscle strain injury. Am J Sports Med 1996,24:137-43.

Martin BL, Deyo, RA, et al. JAMA. 2008; 299;656.


12 2009

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