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HAMSTRING STRAIN

Hamstring Strain

Hamstrings strains are a common injury is most running, or field based sports. A strain is when a muscle is stretched past is normal length. There are different degrees of strain (grades), most common are grades 1 & 2. Grade 1 is generally cause in high speed running which is common in field sports, generally seeing a stretch in the long head of the bicep femoris near the musculo-tendinous junction. Grade 2 is an increased stretched of the muscle generally around the ischial tuberosity (tail bone) of the semimembranosus.
Grade 1 is generally a shorter recovery process 2-4 weeks, with Grade 2 taking longer. Grade 3 is a tear of the muscle which can between a partial tear right up to a full rupture.
Brukner, P. (2012). Brukner & Khan’s clinical sports medicine. North Ryde: McGraw-Hill.

Key:

ASO = Affected side only

USO = Unaffected side only

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Training Considerations

Phase 1 - Sub Acute
PHASE 1 Sub -Acute
1. Physio – Assessment to determine muscle, location and grade of strain
2. Exercise Physiologist– Set plausible return date, outline plan and modify the training program
0 to 3-5 days: PRICE
Protect the injured site
Ice to prevent secondary damage to surrounding tissues
Compression to reduce and remove swelling*most important
Elevation to assist lymphatic drainage of swelling
Training Modifications
Rest & protect injury site
Continue gym program where possible e.g. single leg and upper body
Continue conditioning work where possible e.g. single leg rower or seated boxing
Checklist to progress to Phase 2
1. Pain-free daily activities
2. Reduced inflammation
3. Able to tense/recruit muscle without pain

Phase 2 - Acute
 PHASE 2 - Acute
1. Exercise Physiologist – Review progress, modify program where necessary & begin the return to running program
3-5 to 9-11 days
• Low load eccentric contractions inner to mid-range of motion e.g. double leg hamstring curl concentric to single leg eccentric lower to 45 degrees *two days rest post eccentrics
• Combine with isometrics & isotonic work on other days e.g. single leg supine heel digs & double leg hamstring bridges
Training Modifications
Begin % fly’s/stride throughs to build sub-max speed tolerance e.g. 1st session: 55-60-65%x3 & 3 days later 55-60-65-70%x3
Gradually progress walk: run ratio from 4mins:1min to 2mins:3mins
Checklist to progress to Phase 3
1. Pain-free to touch site of strain
2. Run >70% max speed
3. Straight Leg Raise within 75% of other leg

Phase 3: Functional
PHASE 3 - Functional
1. Exercise Physiologist – Review progress, modify program where necessary & begin return to running program
9-11 to 13-15 days
• High load eccentric contractions e.g. band assisted/swiss ball assisted Nordics progressing to Nordics *two days rest post eccentrics
• Progress isometric & isotonic work on other days e.g. GHR isometric holds, romanian deadlifts & concentric only sliders
• Add low volume power exercises e.g. max single leg bridge isohold/broad jump/kettlebell swings
Training Modifications
Progressively increase % of fly’s/stride throughs towards max speed 2-3 days rest b/w sprint sessions
Add change of direction mod-high intensity running e.g progress from S-shape to Z-shape agility drill
Checklist to progress to Phase 4
1. No pain or discomfort during training
2. No major strength & power deficits e.g. <10% difference b/w max weight lifted on both legs e.g. SL Hamstring Curl & <10% difference b/w legs with horizontal hop distance
3. 100% running + pain free change of direction

Phase 4: Return To Ninja
PHASE 4 - Return to Ninja
1. Exercise Physiologist – Review progress, modify program where necessary & begin return to running program
Training Modifications
Continue progressing with Strength & Conditioning program (see attached), progressing towards max strength & power training, along with maintaining consistent running routine, as large fluctuations in high speed running are a risk factor for re-injury
Training Program

Warm Up
Exercises Sets x Reps
Foam Roll Calves & Quads 2-5 mins
Banded Hip Flexor + Adductor Stretch 1 min each side
Spiderman w/ Rotation 2x10
Miniband Crab Walk 2x10
Glute Bridge 2x15
Phase 1: Sub-Acute

Phase 1: Sub-Acute Week 1 Session 1
Exercises Sets x Reps Weight Rest | Tempo
1. SL Hamstring Bridge IsoHold (USO) 3x6s BW 2mins | MAX
2. SL Romanian Deadlift (USO) 3x12 Light-Moderate 2mins | Slow
3a. Heel Digs (ASO) 10x3-5s BW 2mins | Static
3b. SL DB Hip Thrusts (USO) 2x12 BW 2mins | Slow
4. Hollow Hold (arms down) 4x20s BW 90secs
5. Arch Hold 3x15s BW 90secs
6. Kettlebell Farmers Carry 2x20m Light-Moderate 90secs
7. Hamstring Stretch Accumulate 2mins ES BW 2mins | MAX

ACHILLES TENDINOPATHY

Achilles Tendinopathy

Your Achilles is the thickest and strongest tendon in the body. The Achilles tendon shares with your gastrocnemius and soleus (calf) muscles and attaches to the calcaneus (heel). The Achilles is prone to injury with repeated high loads, with runners showing a 15 x greater risk of a rupture and 30 x risk of tendinopathy compared to sedentary control groups. Tendinopathy is a degeneration of a tendon from overuse, resulting in local pain in the area. Tendinopathy goes through 3 stages: reactive, dysrepair & degenerative.
With the Achilles, there are two reported sites of potential tendinopathy. Midportion and Insertional Achilles tendinopathy. Midportion refers to the centre of the Achilles and Insertional refers to the where it attaches to the heel. It’s important to make sure you know which one you have, as rehab is altered slightly for both.
Brukner, P. (2012). Brukner & Khan’s clinical sports medicine. North Ryde: McGraw-Hill.

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TRAINING CONSIDERATIONS

Phase 1 - Isometrics
PHASE 1 - Isometrics
1. Physio – Assessment to see whether mid portion (middle) or insertional (base) & which stage of tendinopathy
2. Exercise Physiologist – Set plausible return date, outline plan and modify training program
Depending on ability to hold without shaking, choose from:
Seated single leg calf raise
Standing double leg calf raise
Standing single leg calf raise
Standing smith machine double leg calf raise
Standing smith machine single leg calf raise *this is the aim*
Calf Raise range for type of Achilles Tendinopathy
Mid Portion AT – hold in middle of raise
Insertional AT – hold in top half of raise
• Build from 3 x 20secs to 5 x 45secs @heavy weight w/ 2mins rest between sets, see attached program for example
Training Modifications
Reduce weekly running volume by ~40-50%. Minimise jumping and hopping for the week
Checklist to progress to Phase 2
1. Once pain has settled from peak
2. Pain stable in morning

Phase 2 – Heavy Slow Resistance Training
Phase 2 – Heavy Slow Resistance Training
1. Exercise Physiologist – Review progress, modify program where necessary & begin return to running program.
Continue with Isometric 5 x 45sec protocol each day & more if necessary. Add heavy slow resistance training, same exercises as Phase 1
Calf Raise range for type of Achilles Tendinopathy
Mid Portion AT – bottom to middle of raise
Insertional AT – middle to top of raise
• Build from 4 x 8 to 4 x 6 @heavy weight, see attached program for example
Training Modifications
Progressively add ~10% to weekly running volume. See attached program for example of adding jumping and hopping into program
Checklist to progress to Phase 3
1. Pain stable in morning
2. Good strength i.e. 25 single leg calf raises & 0.5-0.8x BW smith machine single leg calf raise

Phase 3 – Stretch Shortening Cycle
Phase 3 – Stretch Shortening Cycle
1. Exercise Physiologist – Review progress, modify program where necessary & begin return to running program.

Continue with Isometric 5 x 45sec protocol each day & more if necessary and heavy slow resistance training. Add stretch-shortening cycle training.

Single Leg Hop to opposite leg landing - 2 x 6 each side building to 3 x 15 each side w/ 2mins rest b/w sets & 3 days rest b/w this type of training, see attached program for example.

Training Modifications
Progressively add ~10% to weekly running volume, ensure you add a de-load week every 4th week (~50% reduced volume).
See attached program for example of adding jumping and hopping into program.
Checklist to progress to Phase 4
1. Pain stable in morning.
2. Good strength i.e. 25 single leg calf raises & 1.5x BW single leg leg press.
3. Tendon is tolerating phase 3 training.

Phase 4 – Return to Ninja
Phase 4 – Return to Ninja
1. Exercise Physiologist – Review progress, modify program where necessary & begin return to running program.

Continue progressing with Isometric 5 x 45sec protocol each day & more if necessary, heavy slow resistance training and stretch shortening cycle exercises.

Gradually Add Sport Specific Training Including:
40-60 jump/lands a week e.g. 4-5x quad step attempts
~10% running volume a week

TRAINING PROGRAM

Week 1
Phase 1: Isometrics Every-day
Exercises Sets x Reps Weight Rest
1. Isometric Smith Machine DL Calf Raise 3x35s Mod-Heavy 2mins
2. 1/2 Back Squat 3x8 60-80% 2mins
3. Barbell Hip Thrust 2x12 50-70% 2mins
4. Hollow Hold 4x20s BW 90secs
5. Arch Hold 3x15s BW 90secs
6. Kettlebell Farmers Carry 2x20m Mod-Heavy 90secs

QUAD STRAIN

Quad Strain

A quadricep strain usually occurs due to a powerful movement such as acceleration, jumping and changing directions. It is a separate injury to a contusion (known as a corky) which is a direct blow to the muscle as well as cramp, which is spasming of the muscle. Pain is usually felt at the front of the thigh following a forceful movement.

The quadriceps are a group of 4 muscles comprising the rectus femoris, vastus medialis, vastus intermedius and vastus lateralis muscles. The rectus femoris is the only quadriceps muscle that results in hip and knee movements. It is also the most common muscle injured when a quadriceps injury is sustained.

The other 3 muscles are only involved in straightening the knee. There are generally three grades of quadricep strain injury. Grade 1 injuries are classified as mild strains that only affect a small number of muscle fibres. There is generally no decrease in strength or range of motion in the knee joint, and pain with touch is usually felt the next day. Grade 2 injuries are classified as moderate strains with approximately half the muscle fibres affected.

There is a minor decrease in strength, however pain and swelling is present with this grade. Grade 3 injuries are classified as severe strains and occur when there is a complete rupture of the muscle. This is accompanied by a complete loss of function of the muscle in regards to strength and range, as well as severe pain and swelling.

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STRENGTH

Training Considerations
Initial management – straight after obtaining injury
• RICE immediately following injury to decrease swelling
•Rest – avoid powerful/strenuous activity, preventing worsening the severity of the injury. • Ice - 20 minutes every hour
• Compression - as often as you can apart from when icing. If you have pins, needles, numbness or your leg appears pale the compression is too tight and needs to be loosened. It should be a firm pressure only.
• Elevation – Keep your leg elevated when possible
• Note: do not massage your quadricep muscle for 48-72 hours.
Stretching: Aim 30 seconds daily. Quadriceps and hip flexors most important
• Quadriceps – can gently commence day 2, however it shouldn’t be painful so may be very light in early days. May be few days later if stretch changes general awareness to pain. This is important to start early as it helps maintain the length of the muscles.
• Hip flexors – can gently commence day 2, however it shouldn’t be painful so may be very light in early days. This is important to start early as it helps maintain the length of the muscles.
• Calf – can commence immediately
• Hamstrings – can commence immediately
• Glutes – can commence immediately
Strength Training Program

Stage 1
Must be competent before progressing to next exercise
Pain free with all exercises is the indicator to advance to Stage 2
Exercise Key Points
1.Isometrics with quadriceps
contractions – commence
immediately
  • Quads over fulcrum: 3 X 10 reps, twice daily
  • ½ wall squat: 2 X 10 reps, daily, 2 minutes rest between sets
  • Squat: 10 reps daily
2.Bulgarian split squat –
commence once you are able to
undertake a squat pain free X 3
per week
  • Aim 3 X 10 reps, last 3 reps should be very challenging
  • 3-4 times per week, 2 minutes rest between sets
  • Start with body weight and progress to use of dumbbells
  • Progress to 3 X 6 reps
3.Leg press - commence once
you are able to undertake a
squat pain free X 3 per week
  • Aim 3 X 10 reps, last 3 reps should be very challenging
  • 3-4 times per week, 2 minutes rest between sets
  • Start with body weight and progress to use of dumbbells
  • Progress to 3 X 6 reps
4.Hip machine sideways -
commence immediately when
you’re able to perform pain free X
3 per week
  • Aim 3 X 10 reps, last 3 reps should be very challenging
  • 3-4 times per week, 2 minutes rest between sets
  • Start with body weight and progress to use of dumbbells
  • Progress to 3 X 6 reps
5.RDL - commence once you are
able to undertake a squat pain
free X 3 per week
  • Aim 3 X 10 reps, last 3 reps should be very challenging
  • 3-4 times per week, 2 minutes rest between sets
  • Start with body weight and progress to use of dumbbells
  • Progress to 3 X 6 reps
6.Step ups - commence once
you are able to undertake a
squat pain free X 3 per week
  • 3 X 20 reps (light)
  • 3-4 times per week, 2 minutes rest between sets
  • Progress with height of step and number of reps
7.Single leg squat with heel taps –
commence once you are able to
complete a bulgarian split squat
and step up set pain free X 3 per
week
  • 3 X 10 reps – focus on control, technique and knee position
  • 3-4 times per week, 2 minutes rest between sets
  • Progress to 3 X 20 reps
9.Core exercises e.g:

Hollow holds or Hollow rocks

Stir the pot

ab wheel rollout on knees

  • Choose any core exercise/s
  • 3-4 times per week
  • Make sure they don't cause pain

RUNNING

Training considerations
Graded Running Instructions - Please read below carefully
• Based on a progressive and graded running program outlined by Reid (1993).

• Aim to run every second day with some days of cross training

• Start stage 1 when you are walking pain-free

• Progress to the next stage once you have completed the preceding stage with no pain.

• You may plateau on the same stage for a period or progress through more than one stage on the same day. Every individual will vary, depending on the grade of quadricep strain.

• If you finish one stage of run-throughs progress to the next stage straight away.
• You must start from stage 2 every time to ensure appropriate warm up, differences in recovery and to simulate fatigue.

• Every stage must be performed pain-free (some basic awareness is ok). If the pain is experienced, you must cease the running you are performing, rest, ice for 48 hours.

• Ice for 20 minutes following every session

• Conditioning can be initially maintained via upper body and core workouts, swimming and treadmill walking. Bike riding can also be undertaken once your knee is able to bend to 100 degrees. An example of core exercises to be performed are listed below, however, if you already have individual existing core exercises, continue with your own core exercises.

Running Program

ACL

ACL tear

The ACL is one of the four main ligaments within your knee joint, providing stability to the knee in both a straight position and in rotational movements. If ruptured, the ligament can be surgically reconstructed, usually using tissue from your hamstrings, so you are able to return to sport.

A stage based rehabilitation program rather than timeline will be used as every individual and recovery is different. You may be in the same stage for several weeks that is ok. Overall, it generally takes individuals around 12 months to return to sport, however this varies between everyone.

Pain and swelling are an indication of too much activity throughout your rehab. If swelling and pain increases, it is a sign that you are overdoing it and should decrease your load next session.

The below dosages are just a general aim before moving to the next level. However, if you are able to do more repetitions for some of the exercises to challenge yourself without causing increased pain and swelling, go for it. The overall aim of the first 5 stages is to recover from the surgery and strengthen muscles to prepare yourself to return to running. The following 6 stages are focused on continuing strengthening and regaining stability with functional tasks with the goal of returning to sport.

Your usual upper body and core work can be commenced from week 1 onwards to keep strong, fit and benefit your cardiovascular system. Below are some core exercises in two different phases to give you an idea of some good exercises to benefit your core if you don’t already have a regime of these. In addition, swimming with a pool buoy between your legs is also satisfactory to keep fitness from week 1 after you have recovered from your surgery. Cycle work can be commenced fairly early in stage 2, once you have adequate knee movement.

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TRAINING CONSIDERATIONS

Stretching
Stretching
Stretching of the hamstring must not be commenced till after 6 weeks if you have undergone a hamstring graft. This is to allow time for the muscle to heal. Throughout your rehab the following stretches may be of benefit daily throughout all stages, however they are not vital to complete. Hold stretches for approximately 30 seconds each.
Quadriceps
Calves
Gluteals
Hamstrings (after week 6 of rehab).

Core exercises – Post surgery while waiting for clearance
PHASE 1 
 Plank: Aim build up from 30 seconds and hold as long as you can to challenge yourself or until technique is compromised
Crunches: Aim 3 X 20 reps
Pallof press with cable: Aim 3 X 10 and increase weight as the exercise becomes less challenging
Ankle taps: Aim 3 X 20 reps

Core exercises – Post surgery while waiting for clearance
PHASE 2
Med ball twist: Aim 3 X 20 starting with a 2kg ball and increasing weight as the exercise becomes less challenging
Swiss ball stir the pot: Aim 3 X 10 and increase reps over time
Side plank: Aim build up from 30 seconds and hold as long as you can to challenge yourself until the technique is compromised
Split jump pallof press with cable: Aim 3 X 10 and increase weight as the exercise becomes less challenging

TRAINING PROGRAM

Stage 1
Post-surgery:
Clearance to remove cast only for rehab
Exercise Key Points
1.Walking practice
  • Aim to weight bear as tolerated with your knee splint and commence stair training. Upstairs, unaffected leg leads; downstairs, affected leg leads first
  • Aim progress to one crutch on opposite side to your affected knee.
  • Aim progress to no crutches.
2.Manage pain and reduce swelling
  • Follow pain medication regime you were given by the pharmacist or doctor.
  • Aim ice 20 mins every hour.
  • Aim compress injury all the time apart from when icing. If you have any pins and needles, numbness or pale skin your bandage is too tight and needs to be loosened. It should only be a firm pressure to decrease swelling in your knee.
3. Fully straighten/extend your knee
  • Aim 180 degrees
4.Regain quad activation
  • Aim 180 degrees
  • 60 seconds rest between sets
5.Bend/flex your knee
  • Aim 100 degrees knee flexion
  • 60 seconds rest between sets

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