Category Archives: Injury Diagnosis

Proximal Hamstring Tendinopathy ” A pain in the backside”

To the vast majority of the population, the image of a hamstring tear will be a Sprinter pulling up in a race looking like they’ve been shot. To me, a common hamstring condition is an endurance athlete, runner, cyclist or triathlete, saying to me that they’ve got “a pain right in my ar*e” and “I’m struggling to increase my speeds as I know it’s going to go”.

It’s really important to run a full diagnostic with the evidence presented and pinpoint the cause, but invariably, the description given will lead you right to the spot, basically proximal hamstring and often right at the Ischial Tuberosity (your seat bone).

To understand what’s where, there are 3 hamstring muscles of the posterior thigh: Semitendinosus (ST), Semimembranosus (SM) and Biceps Femoris (BF) with it’s long and short heads. Proximally, while the short head of BF attaches to the femur, all the other hamstring muscles share a common point of origin on the ischial tuberosity (seat bones) of the pelvis, all covered by the gluteal muscles.  Distally, ST and SM both attach to the medial tibia while BF attaches distally close to the fibular head, lateral to the knee.

hamstrings

However, the hamstrings, being a two-joint muscle group (crossing hip and knee), when we run there are other considerations to take into account, especially during stance phase. During this phase the foot is anchored to the ground by our body weight creating what’s called a “closed chain environment”. As the hamstrings contract with Glute Max to create hip extension propelling us forwards, they also create an extension moment at the knee… rather than just knee flexion.

The Injury Itself!
The common origin point of the hamstring muscles at the ischial tuberosity of the pelvis is basically the site of injury when diagnosing Proximal Hamstring Tendinopathy. The injury is classified as a tendinopathy rather than a tendonitis, as it has a more degenerative nature rather than being an inflammatory condition.

Sufferers will complain of pain local to the ischial tuberosity when running, especially when accelerating and sustained faster paced running as mentioned before. The pain will most likely be an intense ache in nature, rather than sharp or stabbing. Due to the anatomical proximity to the common hamstring origin, the sciatic nerve can sometimes be affected (Therapist will check Glute Med and Piriformis), which can cause referred pain into the posterior thigh. Once aggravated, sitting on solid surfaces can also be uncomfortable, as can direct palpation and pressing onto the ischial tuberosity manually.

Differential diagnoses for similar symptoms can include piriformis syndrome, pelvic stress fractures and low back injuries. Thus, a proper assessment from a musculoskeletal physiotherapist or similar sports injury professional is important. Often an MRI scan will be used to support diagnosis once and for all, but this can be avoided with accurate diagnosis – depends entirely on the choice of the individual!

Treatment and Rehab:
Soft Tissue Treatment, Manual Therapy & Stretching:
Hands-on treatments providing soft tissue mobilisations to break up scar tissue and adhesions can be useful, as can transverse frictions to the affected tendon. Care should however be taken not to apply direct pressure to the ischial tuberosity itself. This sort of soft tissue work is complementary to a gradual introduction to regular hamstring stretching.

If upon assessment, pelvic malalignment (anterior innominate rotation in particular) is identified, manual manipulation to restore alignment of the pelvic bones is often useful in restoring proper hamstring function. The question of course must always be asked – where does the imbalance come from that caused the pelvic malalignment…?

Specific Hamstring Strengthening
It is suggested that the progression of targeted hamstring exercises should go as follows:
Double leg, non-weight-baring isometric exercises:
Bridge Holds
Single leg isometric (closed chain) and isotonic (open chain) exercises:
Single Leg Bridge Holds
Single Leg Hamstring Catch
Eccentric hamstring loading exercises:
Swiss Ball Hamsring Curls
Single Leg Swiss Ball Hamstring Curls

It goes without saying that these progressions depend on the pain free completion of each stage.

(“Finally, you might say”) Core Strength & Pelvic Posture Correction!

Hands-on treatments, stretching and progressive strengthening are all important parts of the any good rehabilitation plan for Proximal Hamstring Tendinopathy. However, in my experience, I find the following core strengthening element to be the key to a successful outcome.

In my experience of working with triathletes/athletes/runners who suffer from proximal hamstring tendinopathy, or recurrent hamstring strains, almost all were displaying poor ability to control their pelvic position throughout the performance of functional movements for their sport.

In virtually all cases, it seems that the recurring theme is that they fall into an anterior pelvic tilt/innominate rotation during exercise; this will put the hamstring in a position where they are chronically held under tension, or put a different way, the soft tissue is now technically inelastic and unable to contract and extend from a neutral (and stable) position.

Re-educating proper pelvic position throughout movement, and working to correct imbalances which predispose an athlete to poor pelvic posture should be treated with equal importance, because if not, increased precedence over elements of the rehab programme such as eccentric hamstring strengthening protocols are potentially exacerbating the problem. It’s absolutely vital to check for quad flexibility or a dominance (unwilling to release), and tight hip flexors.

It’s very simple to prescribe a raft of general exercises that will help build stability, but equally as important, you have to treat and deal with the individual in front of you so that the balance between anterior and posterior muscle groups must be achieved first so that all you are strengthening on a “stable” platform rather than over-exerting already (technically) weakened muscles.

Get in touch with us if you want to talk further and we’d also like to hear about the topics that interest you that you’d like us to put on the website!

Train well and look forward to seeing you soon (preferrably uninjured!)

The STNW team.

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Lower limb injuries part 2..

In part 1 we discussed common lower limb injuries sustained by long distance runners and also highlighted the fact that pronation is often blamed for these injuries. As a consequence, shoes are specifically marketed as anti-pronation and inserts are often encouraged. In part 2, we ask whether pronation is really such a bad thing?

The Benefits of Pronation

One of the simple benefits of pronation is shock absorbancy. As your foot strikes the ground, the inwards rolling on the foot allows the dispersion of energy, thereby reducing the shock. Aside from shock absorbancy, pronation can also assist performance by storing energy and using it to generate propulsion.

In the last blog we discussed the muscles which ‘control pronation’, these muscles can also be used in a propulsive manner, using stored energy in an elastic manner. Look at the video clip below and watch the foot movement as it strikes the ground. What you are seeing largely is ‘ankle eversion’ as opposed to pronation. Pronation is the rolling forwards from heel to big toe, ankle eversion refers to the inward collapse of the ankle which can be clearly seen in the last 2 frames..


Elastic / Plyometric Energy

Hopefully you saw clearly the inward collapse of the ankle under weight.. it looks almost uncomfortable and it looks like bad technique. However, it didn’t seem to do Samuel Wanjiru any harm as he broke the world half marathon record aged only 18 and went on to claim gold at Bejing Olympics in the marathon.

The muscles which control the pronation/eversion movement (discussed in part 1) are stretched as the foot collapses inwards and are able to store elastic energy. That stored energy can then be used to provide propulsion as the muscles ‘spring back’ to their original shape. The ability to store and generate energy in such a way is governed by individual tendon structure and it deteriorates with age as tendons lose elasticity.

Pronation the Performance Enhancer

I’ll stick my neck on the line here and state that Samuel Wanjiru would not have broken the half marathon record if we had inserted an orthotic into his shoe which prevented the pronation / eversion movement you saw in the video. The movement created the elastic energy needed to propel him at such speeds and without it, performances would have suffered.

Go Forwards and Pronate??

That’s not quite what I’m saying.. but the point I am making is that pronation is not necessarily a bad thing. Some running shops and podiatrists  conducting gait analysis, upon identifying that a runner pronates, make the snap judgement that the runner requires an ‘anti-pronation shoe’.  It would be wrong to make such assumptions and will have a potentially negative impact upon performance.

Some Things to Consider

1. If a runner has no injury history (in particular lower limb) and they visit a shop to be told that they pronate and should therefore wear anti-pronation shoes, that should be seriously questioned!

2. Based on age and tendon structure (varies each individual), some runners will be capable of pronating excessively and rarely suffer injury as a consequence.

3. If you have an injury which is caused by pronation / eversion, your first port of call should be rehab and conditioning so the tissues can handle the movement, store elastic energy and provide propulsion. Don’t instantly take the easy option and purchase inserts. If your injury is chronic, there will be cases where inserts are necessary as this is your only option to continue enjoying running.

4. The video plays extremely slowly, in real time the pronation / eversion movement is ‘super quick’. The stretch and energy return occurs within hundredths of a second as the foot ‘bounces’ on the ground. When you are doing rehab you should consider this, calf raises or lowering are all well and good, but the movement is slow and controlled, unlike reality. You need to include plyometric exercises in the rehab before you return to running.

5. As part of your regular running routine you should include simple plyometric exercises which strengthen all the tissues of the lower limb and encourage energy storage and return.

Lower limb injuries part 1..

One of the most common problems with long distance running is the recurrence of lower limb injuries. By ‘lower limb’ I’m talking about the stuff that goes on below the knee and this includes (but not exclusively):

1. Achilles problems
2. Shin Splints (front or rear)
3. Plantar Fasciitis (pain under the foot / heel)

Overuse injuries are created by repeated action, hence they are common in long distance runners. In some circumstances, runners may have bio-mechanical faults which make them more susceptible to overuse injuries. In other cases, it’s simply a matter of doing too much and the tissues just can’t handle the load. Perhaps the most commonly cited reason for injury in runners in ‘over-pronation’, this describes the action of the foot landing on the outside of the heel and then rolling both forwards and inwards onto the big toe. Pronation has been blamed so frequently for running injuries that we now have specific shoes and various inserts to prevent the action, but is pronation receiving unnecessary criticism?

Pronation explained

The vast majority of runners pronate to some extent when they run. If you stand with your feet hip distance apart and then start walking, you’ll notice that you don’t walk with your feet hip distance apart. It is natural to walk and run with your foot directly underneath the centre line of your body (if you draw a line from your nose, through your belly button and down to the floor, that’s where you foot will land). This means that your leg is always at a slight angle, starting at your hip, the leg angles inwards to the point of foot strike and this means that you are likely to hit with the outside of your heel.

At the point of impact, the force applied to the outside of your heel ‘flips’ your shoe (and your foot) inwards. Stand holding a running show and with your hand, strike the underside of the heel on the outside edge. The blow will flip the shoe inwards, this is what happens to your foot each time you strike the ground.

Injuries linked to pronation

As your foot flips inwards, this triggers the pronation movement. In an attempt to control both the amount and speed of pronation, there are some specific muscles  which take the majority of the strain. The tibialis posterior and anterior muscles run along the length of your shin bone. The anterior muscle is found on the front of your shin and the posterior muscle is found on the inside of the lower leg, behind the shin bone. You can generally find both quite easily with your fingers. The tendons from each pass over the inside of your ankle joint (look at the boney lump on the inside of your ankle, if you move your foot about, you’ll see the tendon moving on the boney lump).

When these 2 muscles contract, they pull up the arch of the foot and turn the ankle so the sole of the foot faces inwards, this is the opposite movement to pronation. Their main job is to control the pronation movement and as the foot rolls inwards, they are pulling back in the opposite direction to reduce and slow the pronation movement. For this reason, if your foot pronates excessively, these muscles have to work extremely hard and this may lead to inflammation of the muscle or the tendon (the tendon is the white part which attaches the muscle to the done). Inflammation of these muscles is commonly referred to as shin splints or potentially ‘compartment syndrome’.

The pronation movement can also lead to achilles problems. Generally the achilles is pretty strong when it pulls in correctly alignment, unfortunately pronation causes the achilles to twist, as if ‘wringing it out’ and this leads to damage and inflammation. Pronation can also lead to flattening of the arch and this applies stress to the tissues which are supporting the arch. one of the main structures supporting the arch is the plantar fascia, a tendon which runs from the underside of the heel bone to the forefoot, splitting into the 5 toes. If stress is applied to the plantar fascia, it can start to pull away from the underside of the heel bone, leading to a sharp pain known as plantar fasciitis.

So pronation is bad.. right?

There are various problems which are ‘potentially associated’ with pronation and these are often treated with a change of shoes or orthotic insert when they may well have been resolved with some rehab (strength and stretch). However, pronation is not a bio-mechnical fault, it is an important part of your running which has simply received a lot of bad press. Before you rush out and buy inserts for your shoes, contrary to what you might think from reading the above information, pronation can be your friend if you know how to handle it.. we’ll look at that in part 2 of the sequel.