Hamstring strains continue to rise in sports. As we continue to learn more, the evolution of our rehabilitation programs has also evolved.
Here are our current thoughts on how fast to progress athletes back to sports after a hamstring strain.
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#AskMikeReinold Episode 370: How to Progress Rehabilitation Following Hamstring Strains
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Show Notes
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Transcript
Mike Reinold:
Welcome back, everybody, to the latest episode of the Ask Mike Reinold show. I’m here with the crew from Champion PT and Performance up in Boston. We have Kevin Coughlin, Lisa Lowe, Lenny Macrina, Mike Scaduto, Brendan Gates, Anthony Videtto, and Dave Tilley, all here answering your questions. If you have questions, please submit them. Head to mikereinold.com, click on that podcast link, and you can fill out the form, and we will get to your question.
Let’s see, what do we have for a question today? I’ve got to pull it up on my computer here. All right, Dave from New Zealand. He asked, “I’d love to hear how you manage a hamstring injury for a footballer,” I’m going to assume he means soccer, “And what your benchmarks are for return to sports in terms of strength. Secondly, when do you commence eccentric loading after the initial injury, and how cautious are you with this, given the high recurrence rate of these injuries?”
This is a good question because we actually just started this conversation in our staff meeting on Monday, so it kind of snuck in there perfect, David, so thank you for submitting this question. All right, hamstring injuries. What are our benchmarks of strength? When do we start eccentric loading? When do we start… For this, for the conversation, let’s say, when do we start to return somebody back to sport after a hamstring injury? From exercise to running and probably sprinting is probably, I think, what David is getting to here. What do you guys think? This is a very broad question, but I think the broadness of it is why I liked it. Kev, you want to start?
Kevin Coughlin:
Yeah, I’ll just start with the eccentric portion. That’s something we start generally right away. There’s usually some type of eccentric exercise they could tolerate, and just when we saw this question was coming up, I was just looking back at some of the research I remember coming across, and there was a paper by… It was Jack Hickey, so he’s a big researcher in hamstring, and one of the things that he found with one of his research studies was that you can start eccentric exercises usually within the first week.
The exercise they were using was a Nordic hamstring curl, so that’s definitely intense. What they were doing was… They have the patient come in each session and test their hamstring strength, and they kind of looked at what happens first. Is the hamstring strength testing pain-free, or can we initiate eccentric exercises? I think they started with an eccentric hamstring slider from a bridge position, and then once they could do that pain-free, they went on to progress to Nordics, and they found that even with the dynamometer testing, that was still producing pain in these patients, but they could go ahead and do the eccentric exercises anyway.
I think that’s not something you have to be afraid of, and one of the points that came up in our conversation yesterday, that you were just talking about, Mike, is that these people are going to restrain their hamstring generally when they’re sprinting. It’s not something that’s going to happen with exercises in the gym, so I think you’re safe to start those earlier than you tend to think. Then, I’ll just say that in terms of the return to sport testing, I think what we all tend to do at Champion is we look at range of motion and usually a straight leg raise, but also that max hip flexion, active knee extension test, and then we compare that to the other side, and you want that to be as close to symmetrical as possible. Then we do handheld dynamometer testing, and I think the one we put the most stock in is the outer range strength, which is when the patient’s on their back in supine, hip bent to 90, knee bent to 90, and we usually put a belt across their hips to make sure they’re not cheating. We do a dynamometer test in that position, and an isometric test, and we also want that to be symmetrical to the other side.
I think when you’re hitting those things and you’ve completed a sprinting program, then you’re probably okay to return to sport, but you definitely have to get some sessions in at 100% sprinting in order to feel comfortable getting back, because that’s where the re-injury is going to occur in this patient population.
Mike Reinold:
I think that’s awesome stuff, Kev. I mean, that study from… Hickey has a lot of studies, but Hickey from, I think it’s JSPT in 2018 or 2019, had a really good study that, I don’t want to say changed my mind, that’s probably the wrong word, but it really opened my eyes, we’ll say, to the concept of comparing a group that works out at zero to 10 out of pain versus four out 10 pain, and showing that the four out of 10 pain was actually better, and working within that tolerance with hamstring strains. I’ve actually applied that to a lot of other pathologies too, that whole concept. Sometimes, zero out of 10 just slows down the process. So, with hamstrings, I think that Hickey study you were referring to there, too, has really opened my eyes there, that there is a bit of a pain threshold that you should work in.
I’m pretty sure in the article that they progressed to the next phase when they could perform the exercises of that phase within that pain tolerance, four out of 10, not zero out of 10. Man, that really starts the progression, I think, sooner than you would initially do, normally on paper, if you’re a new grad. But man, I think that once you start to see that and you go through that progression, it’s pretty neat. Who else? Who else wants to jump in here? I know we have some great hamstring stuff. Lisa, why don’t you start up?
Lisa Lowe:
Okay. With our kind of conversation of the week here, I have one rower that keeps popping into my mind as a case example. Okay, so she came to us after having gone to another PT for a chunk of months, kind of all through her spring season, and her hamstrings just were never getting better. She saw this other PT for a few months. She missed out on some of her spring racing. She wasn’t allowed to do stuff because things were painful, and then I asked her what her home exercise program looked like, and not a single one of the exercises targeted her hamstrings. I was like, “Okay, well, how do we get a hamstring strain better if we’re not loading the tissue? That’s not going to happen.”
I think it was a case of… Obviously, loading your hamstring when it is strained to some amount is not comfortable, so I feel like the PT was probably nervous about giving her something that made her not feel comfortable, and it just didn’t help her get better. Legitimately, within her doing eccentric slide-outs, iso-glute bridges, just simple at-home hamstring stuff… I didn’t give her a Nordic because she didn’t have any way to do that by herself at home. But she started doing actual hamstring loading every day within the rule of… I usually tell my rowers, because they’re a little bit ridiculous, three out of 10 or less pain. I feel like some of us say four. I don’t say that to my rowers, and she was back on the water doing things within a couple of weeks, and she was like, “Wow, I can’t believe it took me months to get to this point.” I was like, “Well, you didn’t load your hamstrings at all. They’re not going to get any better.” I feel like, yeah, just kind of with our whole conversation here, I gave her eccentrics the first day I saw her, and it was months into her having hamstring pain, and within a couple of weeks, she was feeling way different.
Mike Reinold:
That’s amazing. Just by loading the tissue. You said that at the very beginning, which I thought was great. It’s like, you have to load the tissue, and I’m going to give every clinician out there listening to this that hasn’t done that credit. I don’t blame you. It’s kind of scary. A hamstring strain is a little scary when you first get them. They’re nasty, they hurt, they’ve got such poor mobility. I get it, you’re kind of nervous to load the tissue, but when you go back to the Hickey study with the pain, and then even, I think if you understand the Hickey study, it’s little things that I think really open my eyes. Nordic hamstrings, we say, is one of the biggest exercises for strain on the hamstring. It’s still nowhere near the hamstring activity of sprinting. I think it’s close to 40% of the hamstring EMG activity during sprinting. It’s not even close, so sprinting is so far up in the spectrum.
You could do, I don’t want to say you could do almost everything, but you can do so much outside of max effort sprinting that people don’t give it enough credit. It’s like, that last phase of sprint is the hard part, but you can do so much stuff before that, and it’s within tolerance of that injured tissue. It’s pretty neat. Dave, what do you want to add?
Dave Tilley:
Yeah, the two things that come to mind with this study and some others, I don’t remember the exact article, I think it was in BGSM… But essentially, they split two rotator cuff tendinopathy patients into two groups and did a very similar thing. Back off as soon as you feel pain, or work through a three to four out of 10. The people who worked through a bit of discomfort and had a good loading got better significantly faster and had better long-term outcomes, and I think really for me, the takeaway of this study, the rotator cuff study, is you have to understand what tissue you’re loading and kind of the tolerance to exercise, and different tissues have different response continuums. Muscle and tendon are very dynamic active tissues that require a bit of load and some of that discomfort, because they need overload more. Versus, you think about a nerve root or a cartilage injury or a bone stress injury. Those tissues are not as dynamic. They’re more passive, and so they don’t really respond to load super well, and in a nerves case, they’re highly irritable.
I think as a clinician, as a new grad, you always have to bucket, “What do I suspect the underlying tissue I’m dealing with is?” Is it tendon or muscle, which probably has a bit more loading tolerance, or is it a cartilage, bone, kind of something more serious like a nerve? Then, on the secondary piece of that, you have to understand the loading timelines of these things and what’s normal and abnormal. How do you know? Just like with strength training, if someone comes in really sore the next day and you worked them pretty hard, that’s a normal response to exercise, versus, if somebody comes in with a bone stress injury and they were walking all day, they did some plyos, and their shins are more sore to point tenderness. That is an abnormal response to loading, and so I think you have to kind of hold those two things when you’re evaluating people with hamstrings or cuff issues. What tissue? And then, what is the normal timeline for this?
Tendons tend to take two days, typically, to resolve, if you load them quite a bit. I think a lot of the net collagen studies showed that you have a 48-hour window of overlap, and then bone and cartilage, you could argue, from Stuart McGill’s work, is up to three days. If you’re somebody with a fracture, you might need to load twice a week, because that’s how long a bone remodeling loop takes. A muscle, maybe a day. Tendon is two days, bone is three days, and you kind of have to hold those things in your mind when you’re making programs.
Mike Reinold:
Dave, that’s awesome stuff. I love it. For me, I’ve been waiting for this, but I want to hear Brendan Gates now, because…
Dave Tilley:
Let’s go.
Mike Reinold:
It’s his first introduction to the podcast, but Gates, you work with a lot of field athletes. And I know that’s your background, stuff like that. I’m sure this is something you deal with all the time. What are your thoughts on this?
Brendan Gates:
Yeah, so I think the conversation we’ve had so far is really helpful. A couple other things to just consider would be location of the strain. Is this a proximal issue or is this more muscle belly? You can kind of use that to help dictate maybe where you enter some of your exercises. If it’s a proximal hamstring issue, we can play around with the degree of hip flexion that we expose this client to, and then I think you can start with something as easy as a manual resisted, concentric-only hamstring curl, prone on the table, and then slowly progress that to an eccentric one. You can kind of feel… You talked about last podcast, about using manual resistance as diagnostic as well as treatment. You can kind of feel the force production, you can gauge their level of tolerance, and you can move to more maybe provocative positions, like a seated, manually resisted hamstring curl.
I think the other interesting thing here too is, as you go through this rehab, velocity I think should be something that we consider. Doing things at a slow, controlled speed is generally pretty well tolerated and easier to do as a person with a new hamstring injury. As we talked about, sometimes the cause is the cure and vice versa, so something like sprinting that’s going to demand a little bit more of a hamstring is typically where a lot of people strain their hamstrings. I think if we kind of leave that off the table and we don’t expose them to that in rehab, sometimes we can be doing them a disservice. I think as you go from the easy stuff on the table, manually resisted, all the way to that continuum of getting back to their sport, as you start to add the velocity piece and monitoring how they do, I think you have to consider… I guess the location and the velocity are two factors that I take into account pretty often.
Mike Reinold:
Awesome. Yeah. Anthony, what have you got?
Anthony Videtto:
I just wanted to add that after maybe we do some stuff on the table or in the gym where we’re loading the hamstring, how do we get them back to sprinting? For me, I like to add maybe some buildups or kind of a progression that way, in order to have the hamstring tolerate some more top-end speed. What I like to do is, if I have someone doing maybe a 10-yard, 20-yard fly to get up to full speed, I might have them do a 10 or 20-yard buildup and then a 10 to 20-yard build-down, so that we’re not stressing the hamstring as much as if we just accelerated as fast as we could and then decelerated as fast as we could.
If they’re tolerating maybe a 20-yard buildup, 20-yard decel, maybe go to a 10-yard the next time and then have them go from a straight stop to then a straight deceleration. That’s another progression that I like to do, if you might have someone who’s a little bit nervous about getting to that top-end speed.
Mike Reinold:
I think going back to what we said earlier with Anthony’s stuff, you can do that, what Anthony just said, as a progression, in the middle phases of rehab, probably more than you think. I hate to label and put a number on this, but running less than, let’s say 90, I mean, excuse me, 80%, that’s what I was thinking, you can perform those progressions that Anthony was saying during their rehab progression. It’s really from that 80 to 100 that you have to have that last bit. You need to have full range. You shouldn’t have pain with any of your testing. You should have symmetry with your outer range strength, that sort of thing, from that last progression, that 80 to 90 to 100% sprint speed, but man, doing those progressions Anthony just laid out in the middle phases, that’s going to make that last phase so much easier and more well tolerated, because to Anthony’s point, there’s some comfort level to that. It’s not the first time they started running.
Lots of good take-homes here for this, David. I mean, I think the number one thing here too is… I don’t have a set number. You ask, “What’s a set number of strength before you do certain things?” I think it’s more of a blend within their capacity, and we measure their capacity through their pain tolerance, and we do measure that every day or almost every day when they come in. We’ll do, to Kevin’s point, we’ll do probably outer range strength and max hip flexion, active knee extension measurements, and kind of just see their progression within their pain tolerance and just slowly load them up. When do we start sprinting? Yeah, you have to have pain-free range of motion and symmetry with their sprint, but everything before that I think can be a nice blend that you can get to.
Hopefully that helped, David. I know it’s daunting at first. The first few people you put through these progressions, you’re like, “Man, I don’t know how that hamstring’s going to handle this,” but it does. I’m the same way with Achilles repairs, by the way. I’m like, “Man, I can’t believe they’re doing plyos right now,” but it’s the same thing. Sometimes the body amazes you. So anyway, David, great question. If you have a question like that, head to mikereinold.com. Click on that podcast link, and you can ask away. And be sure to subscribe, rate, review us on Apple Podcasts and Spotify. We’ll see you on the next episode. Thank you.
