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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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| PHASE 1 Sub -Acute |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
| 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 |
| 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
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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| PHASE 1 - Isometrics |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
| 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
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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| Initial management – straight after obtaining injury |
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| • 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 |
| Must be competent before progressing to next exercise Pain free with all exercises is the indicator to advance to Stage 2 |
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| Exercise | Key Points |
| 1.Isometrics with quadriceps contractions – commence immediately |
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| 2.Bulgarian split squat – commence once you are able to undertake a squat pain free X 3 per week |
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| 3.Leg press - commence once you are able to undertake a squat pain free X 3 per week |
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| 4.Hip machine sideways - commence immediately when you’re able to perform pain free X 3 per week |
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| 5.RDL - commence once you are able to undertake a squat pain free X 3 per week |
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| 6.Step ups - commence once you are able to undertake a squat pain free X 3 per week |
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| 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 |
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| 9.Core exercises e.g: |
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| Graded Running Instructions - Please read below carefully |
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| • 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. • 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. |
ACL
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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| Stretching |
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| 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). |
| PHASE 1 |
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| 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 |
| PHASE 2 |
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| 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 |
| Post-surgery: Clearance to remove cast only for rehab |
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| Exercise | Key Points |
| 1.Walking practice |
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| 2.Manage pain and reduce swelling |
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| 3. Fully straighten/extend your knee |
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| 4.Regain quad activation |
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| 5.Bend/flex your knee |
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