On this episode of the #AskMikeReinold show we talk about some of the differences between rehabilitating a chronic or acute hamstring strain. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 227: Chronic Versus Acute Hamstring Strains
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Show Notes
Transcript
Mike Reinold:
So let’s see, Trevor from Washington asks, “Hey everyone, what changes in your treatment are you doing between a chronic versus an acute hamstring strain?” I thought this was an interesting question, right? It’s interesting, right? Because sometimes you have acute. Sometimes you have chronic. Sometimes you have acute on chronic, right? And there’s a little bit of a difference between these here. So, man, let’s see.
Mike Reinold:
Acute versus chronic hamstring strain. We know the number one predetermining factor of a hamstring strain is a previous hamstring strain, which by the way, that’s not a fair fight, everybody always says that, we’re looking for more physical type things, but everybody knows that if you get a hamstring strain, something’s going on for some reason, either with your physical capacity or maybe your workload capacity or whatever it may be, the activities that you do that do, that you end up tending to have some chronic hamstring issues. So, I don’t know, why don’t we start with this, right? So, clearly the difference between acute and chronic is probably how fast we go at the beginning, but why don’t we start in reverse, and let’s start talking about chronic hamstring strains and then maybe some things that we can tweak for acute.
Mike Reinold:
So, I know everybody here has dealt with chronic hamstring strains with some of our clients. Maybe we can get maybe Dan or, I don’t know, maybe Dave, or somebody to start off this conversation, but I know you guys have put a lot of thought and research into the literature on what’s best for these chronic tendinopathies. I would love to hear maybe Dan, I don’t know, I don’t want to put a spotlight on you, but maybe hear your thoughts on where we are with chronic hamstring, or really other things, but chronic hamstring strains.
Dan Pope:
Yeah, I guess we have to think about the diagnosis. What is a chronic strain injury? Does that mean that we have a tendinopathy of the hamstring? If we have a chronic person who strains, is that something just strains, strains, strains, strains, repeatedly, and never fully rehabilitates? I guess from the standpoint of chronic, we’re thinking if it’s a true tendon problem. There’s two things to think about. So for one, we’re going to get stressed on that hamstring tendon just from contracting, right? But the other element that I think is a little bit different is if it’s truly on that tendon, you might get some compressive loads as a tendon attaches to ischial tuberosity. So those folks oftentimes won’t handle things like sitting well, I know it sounds silly, but if you sit on that tendon for a long period of time, it bugs you. And if you combine hip flection with the contraction of the hamstring, it also tends to bother these folks as well.
Dan Pope:
And I do think that even in a regular strain injury. So if let’s say, if I injure the muscle belly, if you combine hip flection, so stretching the hamstring with contract at the same time, that’s still something that’s going to aggravate someone with a strain injury, probably above just contracting the muscle, but with a tendinopathy, I think it’s a little bit different mechanism, right? The other piece is that generally speaking with a strain injury, we’re thinking a couple of days for the scar to start, right? So one to two days of really unloading the tendon, maybe some isometrics or very light activity, and we’re starting to ramp things up slowly until about, I don’t know, seven to 10 days when that scar gets stronger. And then we start to progress forward.
Dan Pope:
With a tendinopathy, it’s something different. It’s a chronic injury. We probably have some pathological changes in the tissue and we’re trying to manage that by getting stronger, unload initially, and then just ramping our way back up over the course of time. So they’re really treated a little bit differently from that standpoint, but they’re similar, as well. I find myself rambling at this point. So I’m going to stop and let someone else take a…
Mike Reinold:
Rambling, but because you it’s a big topic, right? It’s a big topic to answer in a little conversation like this, but I think you did a good job outlining here, what is chronic? Is chronic somebody that has acute strain several times or is this a chronic tendinopathy of somebody that’s not healing up and never even returned back to normal? That sort of thing.
Mike Reinold:
My guess is based on the question, it’s more of the recurring hamstring strain and that’s why I wanted to talk about chronic because maybe sometimes we get an acute hamstring strain and then we get them back, but then we don’t address anything to maybe get them over the hump so they don’t have it again, right? So, if we talk about chronic, I think we can really then lead into what we do acute, but Dave, what do you think?
Dave Tilley:
Yeah, I think Dan had a really good example of different types of maybe what looks the same on the surface level. I remember reading a paper and I can’t remember off the top of my head, but they talked a lot about progressions of hamstring strains rehab. They were the first that I saw to really differentiate the capacity-based chronic hamstring injury versus the range of motion or extended, lengthening type injury. And that was really helpful for me because the hamstring strains that I see are very much not straight up force overload, but they’re more about range of motion overload. So I think when you’re thinking about someone who maybe is chronically dealing with an injury, or they continue to have problems, you have to think about what the limiting stress factor is, right?
Dave Tilley:
Is this someone who’s squatting super heavy or sprinting super fast, or is lifting really heavy? That’s definitely a force overload versus in my world, dancers, gymnasts, cheerleaders, I treat a lot of people who have those issues. It’s definitely more of a range of motion issue. They’re so far into their end ranges of motion so consistently that when they contract that end range, that’s when they have issues, like the gymnasts that I work with, they have some discomfort with sprinting, with jumping, but definitely extreme motion is that so the last 20% of our rehab is very high level aggressive on the range of motion e-centric, end range coupling.
Dave Tilley:
Versus if I’m treating someone maybe who’s on a lifting, I’m thinking about more progressive load from more what I take from Dan, which is more of the actual prescription of squatting and sprinting. And I think Tim Gavin’s research has said that more time in high end sprinting is actually protective against hamstring strains, if you train it properly with your workload. So I think it’s really important people to remember that it’s not always about just getting somebody back to sprinting.
Mike Reinold:
That’s a great point too. And again, maybe why we struggle with some things is we’re just blindly calling everything a hamstring strain where the mechanism of injury can be quite different. I know in baseball, believe it or not, hamstrings are one of the top two injuries we see other than pitching injuries because those guys are knuckleheads, but in terms of that it’s hamstrings and obliques, right?
Mike Reinold:
And it’s them sprinting to first. It’s almost every time, them sprinting to first. So , who would think in a sport where you literally just stand around for 45 minutes and then sprint once, that you would be prone to hamstring strains? It’s shocking, right? But it’s a completely different mechanism for them. They probably have poor spring capacity, probably poor e-centric capacity, maybe some muscle imbalances, lumbopelvic, that we see differences, we measure everybody’s hamstring strength profiles left and right using a Norbord from VALD, right? We use their machines so they can tell us those differences, but super interesting.
Mike Reinold:
So, assuming that, we now have some thoughts, right? We have identify what the mechanism is. Dave talked about the elongation type mechanism and making sure that we have strength, stability, and some e-centric control it end range. I think that’s a really good example. I think Dan talked a little bit more about the overload concept a little bit, right? So I think that’s the type of person, if you have chronic tendinopathy, we start switching to different things like more aggressive e-centric training and things like that. So, anybody want to touch on that? I have some of the research on that, e-centric training and stuff like that.
Mike Reinold:
But has anybody done anything fresh? I feel like I was reading something on fitnesspainfree.com recently, but I could be wrong. Dan, do you use the e-centrics? Do you think they’re a big part of your rehab program for chronic tendinopathy? What have you been doing?
Dan Pope:
Yeah, at least from the tendinopathy literature I’ve read over the course of time, I think as a profession, we get really into one research paper that says isometrics and then concentric, e-centrics. I think what we’re finding over the course of time is they all work pretty similarly. And I think the other thing is that we have to prepare athletes for what they’re getting back to. I tend to see, and it sounds silly, but I see a lot of chronic tendinopathy issues from people dead lifting a lot. They do a ton of hinge patterns, just end range, and that’s going to be completely different than a sprinter, right? And I’m not going to treat that person the same way.
Dan Pope:
So, if someone’s having trouble from a loading perspective, from a deadlift perspective, I have to slowly dose that back up. Whereas if someone’s having trouble with sprinting, it’s a completely different movement. The loads are much smaller and they have to be done much more quickly. It’s more plyometric in nature. So, I think that generally speaking, for me, I don’t know if one type of contraction is better than the other, but what it will do is meet the athlete where they are and start to progress them to where they need to be over the course of time. And whether that’s with some e-centric training or that’s with concentric, or if I can get them to do plyometric stuff right off the bat, they’re trying to get back to some sprint training, I’ll try to.
Mike Reinold:
Yeah. And I like, again, I think really, you and Dave so far have said this really well, you have to identify what’s going on with the person in front of you and not treat everybody the same. I like that. So, Len, what do you think?
Lenny Macrina:
Yeah. I want to pose this to the group because I’m trying to think about it in my head. So, does it affect you guys? Seems like we’re talking a lot about tendinopathy. What about proximal versus distal and what about mid muscle? Like muscle belly? How is that affecting you guys in let’s say the chronic, the end-stage rehab. Are we doing things differently or no?
Mike Reinold:
Can I ask a clarification question on that? Can we get chronic mid belly strains?
Lenny Macrina:
I would say yes, right? Why not?
Mike Reinold:
I guess it’s how we define chronic.
Lenny Macrina:
You get scarring in the area maybe. And then you either re-strain it or you perceive that you re-strained it, maybe its scarring that’s trying to elongate. I don’t know, but yeah, I guess how would you… Proximal versus distal especially. Yes, Dave? I feel like this is the Ask Lenny Macrina Show now.
Mike Reinold:
I like it though, because I think, again, I think we’re highlighting right here that the definition of chronic isn’t completely right. Chronic meaning you’ve had the same symptoms, it’s not getting better for six months, or you’ve had four acute strains within a six month period.
Lenny Macrina:
Right.
Mike Reinold:
I think that’s a big, big difference. But I like the question and stuff. So proximal and distal, too. I don’t know, Dave, I think you wanted to jump in. That’s a good point.
Dave Tilley:
And the only two cents I’m going to throw in is because I treated a lot of kids that are under 18. And I think for me, when it’s someone who’s over 18 or over 16 and they’re through puberty, it’s like, “Hmm, can we push the load a little bit, proximally?” If someone’s youth, you should not be pushing the proximal hamstrings, because that’s a boney interface problem. That’s a growth plate injury. And I’ve seen a lot of people come to champion after two, three therapists where they just tried to use e-centric training and use overloads on a kid who has a growth plate injury. And it’s like, “Whoa, that’s a hard six weeks of you need to let that heal.” So that’s just my two cents.
Mike Reinold:
Yeah. Don’t do that. That’s actually way more than two cents. That was way more valuable than that.
Dave Tilley:
Eleven cents.
Mike Reinold:
Because a lot of people will do that, right? Because again, they’re treating all hamstring strains the same, but I think that’s a really good point too. And one of the first things I’m always concerned about with the hamstring strain is do they have some sort of apophysitis? Do they have some sort of [crosstalk 00:12:38]? Yeah, what do you think, Pope?
Dan Pope:
It’s talking too much, but I mentioned this earlier-
Mike Reinold:
I love it.
Dan Pope:
… If someone has a very proximal injury on the tendon, we’re probably going to be thinking more about handling compressive loads, especially early on. So, if someone has, I don’t know, an injury closer to the muscle belly, maybe they just handle stretching a little bit better. So if I’m contracting the muscle in the length and state, they may handle that a bit better. Whereas someone who has a very proximal injury right on the tendon where it’s right on the ischial tuberosity, they may not handle those as well.
Dan Pope:
So we might not be able to throw as much end-range stuff. A good example is those folks may not be able to handle something like a single legged deadlift very well, even though that’s a rehab exercise we’d love to throw at them. Maybe we have to do more, I don’t know, prone hamstring curls, something where the hamstring is not stretched while we’re strengthening it. And then over the course of time, obviously, we got to get back to that compressive load. But early on, you may aggravate that area, especially if you’re dealing with a tendon issue, which may be getting too much stress already.
Mike Reinold:
It makes sense. It makes sense. And I wanted to touch upon a little bit of the literature too, on e-centrics and stuff like that. Cause that’s a hot topic and you can find an article that makes you think like, “Oh, this is what I have to do going forward,” where that’s not always fair for the person in front of you because they’re different people. But if I look at the evolution of treatment for tendinopathies, especially a hamstring type strain, something like that, it went from concentric to e-centric to isometric to now, I think we’re calling it slow load or something like that. If you actually look in the literature. Which is really funny, if you break down this evolution in there. I think the reason why e-centrics were superior to concentrics is because people were literally doing a hamstring curl with a three-pound weight. Right?
Mike Reinold:
So it wasn’t necessarily that the concentric weight itself was inappropriate. It was the exercise selection probably was. All of a sudden now, we jump to e-centrics and it’s putting tremendous stress and force on the muscle in an excellent way, in a way that we want, that’s going to help strengthen it, that’s going to help build some resilience to it. It was amazing. Around the same time we started doing those heavy isometrics, which again, same thing. You’re putting a ton of tension through the tissue, right? I think you can find articles that… The original article always shows, “Isometrics are amazing.” Then the rest of the articles say, “Well, they’re about the same as e-centrics.” Right? And now we’re getting to slow load. Right? So slow load now, which essentially is just a slow e-centric followed by a slow concentric, right?
Mike Reinold:
Finally we’ve putting it all together and just realize that maybe we, again, it’s not about picking, it’s about just doing the exercise as well. Right? So it’s about loading the tissue. So Dan, what do you think?
Dan Pope:
Yeah, sorry, again, talking a lot, but I think-
Mike Reinold:
I love it.
Dan Pope:
… A lot of this research too is just in the patellar tendon, right? Or the Achilles tendon and the studies on the isometrics are beneficial on the patellar tendon, then not in Achilles. So, we’re trying to take this information, apply it to every tendon in the body and not every tendon behaves the same way. So it’s certainly not fair to cherry pick these articles and say, “This is how another tendon behaves,” especially when we have additional research to show that different people respond differently in different areas.
Mike Reinold:
Right. Makes sense. Makes sense. So, just be careful. You can find one article that says, “Hey, Oh man, I got to be doing isometrics. That is now the key to tendinopathy that I never thought of before.” Right? It’s probably not that simple. So just because we’re going over a little bit, I’ll summarize the acute real quickly. The acute’s same concept there. Our whole goal with the acute is to know everything we just talked about the last 15 minutes. Because that’s your end game. That’s your end result. That’s what we’re getting to. So, that’s the goal of your acute. At the beginning, we just got to be really cautious as that tissue is healing. A lot of times people go too fast in the very, very early acute stage and not get a lot of healing going on. And then they struggle when they get subacute or they start running again that they feel like they have recurring hamstrings or it’s just not going away. It’s probably because you didn’t let it heal enough at the beginning.
Mike Reinold:
So we’re pretty cautious with stretching. We’re pretty cautious with elongating the muscle group. We’re pretty cautious with putting too much tension through it at the beginning phases of that. But you can see why this gets tricky now. If the acute phase were super cautious about putting stress on the muscle, but then the reason why they keep getting hurt is because we’re not putting enough stress on the muscle, you see our issue, right? So the key to putting all this together, acute versus chronic, is making sure that we’re doing both ends of that spectrum where not going too fast at the beginning, but we’re not going too slow at the end.
Mike Reinold:
Is that a good summary, I guess? So hopefully that helps. We could talk about this for hours. I know Mike Scaduto is itching to play another prerecorded message, but we’ll get there. But I think that is a good place to start for most people when they’re dealing with these chronic injuries, is some of the big points here. So what I want you to do is next time you get somebody that’s right in front of you, I want you to think about all the great things that Dan, Dave, Lenny, everybody else said is, think about those concepts here and say, “What is this person in front of me? How did they get here? Why did they get here? What is different about this one?” And then pick what you do based on that. Does that make sense?
Mike Reinold:
So, hopefully you enjoyed another good episode. I know this is a good one. The more Dan Pope talks, the more we all learn. So we love it Dan, keep going, but good episode, always. You guys are great. We always learn from each other from these episodes. So, appreciate it. Be sure to head to iTunes, Spotify, rate, review, subscribe. And if you have more questions like this, just head to the website, click on that podcast link and fill out the form and we’ll keep answering away. See you on the next episode.
