Proximal Hamstring Tendinopathy in Soccer Players, a deep pain in the buttocks area...

Introduction

Proximal hamstring tendinopathy (PHT) is commonly seen in long distance runners and athletes taking part in sprinting or hurdles. .

It is also common among athletes taking part in sports such as soccer , football and hockey, which involves a change of direction activities.

What is Proximal Hamstring Tendinopathy ?

Proximal hamstring tendinopathy is also referred to as High hamstring tendinopathy.

It is characterized by deep, localized pain in the region of the ischial tuberosity.

Pain is usually worse during or after activities such as running, lunging, squatting .

This condition can include tendon degeneration, partial tearing and peritendinous inflammatory reactions.

The junction between the tendons of the hamstrings and the ischial tuberosity is the area affected by high hamstring tendinopathy.

The tendon’s thickness, fibrousness and poor blood supply are the causes of difficult healing

Symptoms - How does it feel ?

• Deep buttock pain and pain in the posterior thigh.

• Pain with squats, lunging,long periods of sitting, running (especially on harder surfaces)

• The pain increases with repetitive activities such as long-distance running

• Occasional stiffness in the morning may be present or when starting to move after a period of prolonged rest

• The onset is mostly gradual, not with acute trauma.

• Continued exercises and stretching can cause even more pain

Mechanism of injury

For soccer players the mechanism of injury is the same as for regular hamstring strains with the two typical mechanisms of Sprinting ( High Speed Running) or Stretch Situations.

It seems to be that age plays an important role in this condition as older players (+40) tend to develop this problem and very few cases are in the younger athlete.

Also having a previous Hamstring injury increases substantially the chances of this acute condition to become chronic and highly irritable.

Let’s review the common mechanisms of HS injuries:

1. High Speed Running

During High Speed Running the hamstrings are very active, lengthening ( getting longer) and contracting to absorb the energy from decelerating the weight of the limb and getting the limb ready to stride on the ground again.

This dual demand of contracting and lengthening at the same time is what causes the hamstring excessive “stretch” from its attachment causing the dysfunction.

2. Stretch Situations

The other reason for PHT is a repetitive stretch mechanism.

In this case the hamstrings are required to do hip flexion and knee extension simultaneously.

The most common muscle injured in this type of mechanism is the semimembranosus and its proximal attachment.

What is the best treatment for Proximal Hamstring Tendinopathy

Strengthening of the Hamstrings muscles seem to be the best approach to solver this problem

Acute Phase - Isometric Loading

Isometric exercises in positions that avoid tendon compression is proposed as an effective method of loading the muscle-tendon unit as well as reduce pain in proximal hamstring tendinopathy.

It has been reported that isometric exercises have a pain inhibitory response.

It is recommended that isometric exercises should be repeated several times per day. Symptom severity and irritability are used to determine the dosage. The dosage can be adjusted to shorter/less intense contractions or vice versa, based on the symptoms. Bridges: Hamstring Isometrics and Single Leg bridge Isometric. Start with 5-10 second holds and progress to 45 sec holds Then you can try a single leg hold variance of this exercise Other exercises in this phase could be straight-leg pull downs and Trunk extension

Strengthening Phase - Isotonics with minimal hip flexion

Once pain has settled down, the next steps in the treatment of proximal hamstring tendinopathy are:

• to restore hamstring strength

• to restore hamstring muscle bulk and capacity

For this condition in particular Heavy Slow Resistance training (HSR) is preferred instead of eccentric exercises. Heavy Slow Resistance training includes eccentric and concentric elements.

With HSR, the aim is to perform a slow fatiguing resisted isotonic exercise. Commence with 15 RM (the maximum load that can be lifted 15 times in a single set) and progress to 8 RM. Perform 3-4 sets every second/other days. Hold contractions for 3 seconds for each phase of the exercise (concentric and eccentric) with a pause of 1-2 seconds in between.

Minimize loaded hip flexion to in the early stages to protect the proximal hamstring insertion against too much compression.

Progress from bilateral workouts to single-leg work to address asymmetrical strength loss. Continue with stage 1 isometric exercises on the "off" days.

This will help with symptom (pain) management, especially if there are still symptoms present.

Other exercises can include Nordic Hamstrings and Prone Leg Curls.

Strengthening Phase - Isotonic exercises in increased hip flexion (70° - 90°)

The aim of rehabilitation in this stage is:

• to continue with hamstring muscle strengthening in greater hip flexion

• to continue with muscle hypertrophy in greater hip flexion

• to continue with functional training in greater hip flexion.

The technique is important and exercises should be performed slow and controlled.

The progression into greater hip flexion often cause pain and irritability and is important to monitor the 24-hour response post exercise with loading tests into hip flexion.

Other exercises can be Single Leg Deadlift , Step-ups and Walking Lunges.

Symptom Modification and Load Management

Training and activity modification are essential in the management of this condition especially with those cases with very irritable symptoms.

Limit pain-producing activities until the pain irritability settles to stable pain. Stable pain is mild (VAS 0 to 3 out of 10) and usually settles within 24 hours of moderate to high tendon load interventions.

One must determine what activities increase the patients' symptoms and for how long?. . Often the player will be able to continue with certain activities such as steady state running within the pain/aggravation guidelines.

Sprinting or quick starts should be avoided initially and only implemented at later stages.

Load modification options:

• Swimming and water running are good options

• Posture modification may reduce symptoms (e.g. reduce hamstring origin compression by reducing anterior pelvic tilt and hip flexion in standing)

• When sitting is symptomatic, shaped cushions are useful to reduce the compression. It allows for more weight bearing on the posterior thigh rather than the ischium

• Avoid repeated stretching of the hamstrings in the early, reactive phase

• Avoid hip flexion dominant movements such as trunk flexion and repeated lifting in the early, reactive stages

If you want to know more about hamstring injuries see our previous blog on this topic

Conclusion

• Proximal Hamstring Tendinopathy is a very debilitation condition that once chronic will affect any type of physical activity causing pain in the buttocks area

• This complex condition requires a progressive strengthening program of the Hamstrings and Glute Muscles to restore their capacity.

• Solving this condition requires a comprehensive approach to correct all deficits that can be causing the deep glute area pain .

• Research shows that a combination of Hip and Knee Strengthening exercises is the best approach to treat PHT

Lionel Pannunzio is a Physical Therapist Certified in Sports Injuries. With more than 20 years of experience helping athletes return to their sports after an injury. He is the Owner of White Bay Sports Physical Therapy and Fitness, conveniently located in the beautiful City of Weston, where he treats Soccer Player, Runners and Athletes of all ages

Finally we would like to invite you to follow us at our:

Facebook Page

Google Plus Page

Instagram Page

where you will receive information about your condition and other services we offer, always with the idea of keeping you healthy and fit to enjoy your favorite sport.

Lionel Pannunzio

Physical Therapist

Board-Certified Sports Specialist

Owner of White Bay Physical Therapy

“Keeping Athletes in the game”

#westonbuttockspain #glutepain #proximalhamstringteninopathy #PulledMuscle #Soccerinjuries #westonsoccer #westonflorida #westonfloridaphysicaltherapy #daviefl #coopercityflorida #pembrokepinesfl #miramarflorida #weston #physicaltherapy #southwestranches #westonfitness #livinginweston #whitebayphysicaltherapy

Exercises for Labrum Tears and Femoro-acetabular Impingement (FAI) in Soccer Players

Introduction

Rehabilitation for FAI and associated labrum tears , requires a comprehensive strength and conditioning program for the trunk, pelvis, hip and lower extremity.

The changes in the hip bones or the labrum are not the only important aspect of this condition.

Research shows (Frasson et al 2020) the most affected hip muscles are Hip Extensor ( Glutes ) , Hip Flexors ( Psoas ) and Hip Adductors ( Inner thigh muscles ).

In my opinion, the weakness surrounding the hip joint is the most influential problem to solve in order to improve pain and tightness around the hip joint

Treatment of Femoro-Acetabular Impingement - FAI

Exercise-based treatments are recommended for people with hip-related pain.

Exercise-based treatment should be at least 3 months duration.

Following up from our previous blog post, here you have some the techniques and exercises we use for addressing muscle weakness around the joint.

Conclusion:

• FAI is a problem of the hip joint or its components: the ball or socket of the hip

• Treatment of FAI requires a general approach with core and all aspect of the hip included.

• Research shows that FAI is a common finding among athletes and soccer players and its only when painful that the FAI becomes a problem.

• Conservative treatment with Physical Therapy for 12 weeks is the first line of treatment of this condition. In Adults ( + 40 y/o) surgey need to be considered only when the Physical Therapy has failed because of the Poor to Fair results of the Surgery in the long run

Lionel Pannunzio is a Physical Therapist Certified in Sports Injuries. With more than 20 years of experience helping athletes return to their sports after an injury. He is the Owner of White Bay Sports Physical Therapy and Fitness, conveniently located  in the beautiful City of Weston,  where he treats Soccer Player, Runners and Athletes of all ages

Finally we would like to invite you to follow us  at our:

Facebook Page

Google Plus Page

Instagram Page

where you will receive information about your condition and other services we offer, always with the idea of keeping you healthy and fit to enjoy your favorite sport.

Lionel Pannunzio

Physical Therapist

Board-Certified Sports Specialist

Owner of White Bay Physical Therapy

“Keeping Athletes in the game”

#westonhippain #hippain  #FAI #PulledMuscle #Soccerinjuries #Soccerhipinjury #westonsoccer #westonflorida #westonfloridaphysicaltherapy #daviefl #coopercityflorida #pembrokepinesfl #miramarflorida #weston #physicaltherapy #southwestranches #westonfitness #livinginweston #whitebayphysicaltherapy

The importance of Foot Strength in Soccer Players

Introduction

In soccer and actually in almost every sport, it is very important we have a well developed foot strength to support the demands of the activity.

In today's post we will talk about the different muscles involved in a healthy foot for performance and we will go through my favorite exercises to strengthen them.

Foot Muscles

Intrinsic and Extrinsic muscles of the Foot

There are two types of muscles that influence the strength in the foot:

1. Extrinsic muscles which are located in the lower leg and calf area and their tendons finish in the foot

2. Intrinsic muscles ( picture) which are the short muscles in the sole of the foot and in between the arches. These are called intrinsic foot muscles and are crucial for sport performance. Without a solid intrinsic musculature Athletes are compromising speed and power and more important expensing themselves to possible injuries.

Signs of Foot muscle weakness

• Foot cramping is an early sign that the foot intrinsic muscles aren’t coping with the load and need to be strengthened .

• People with plantar heel pain

• Chronic ankle instability patients have smaller intrinsic foot muscles

• You can improve balance in those with CAI (chronic ankle instability)by improving foot intrinsic strength

• Medial Tibial Stress Syndrome: may be related to overactive long toe flexors and weak intrinsic foot muscles.

• Toe deformities in young athletes, hammer toes, claw toes, bunions

• Therefore we need to start paying more attention to these important tiny muscles when Athletes are complaining of foot pain

Foot Exercises

1. Toe Yoga

Toe yoga drill for baseline mobility and strength for the foot

The following drills will show you how to tap into the intrinsic muscle of the foot .

These are a combination of baseline strength, coordination and mobility necessary for everyday activities.

Once you can handle this routine, you can start with more advance foot exercises.

❇️ Big toe raise, keep other toes down. Done slowly with control.

❇️ Lift the little toes and keep big toe down.

❇️ Keep heel down and raise and spread all 5 toes for 5 seconds

We are looking for quality of movement, without cramping.

Short Foot Position

Another very important exercises to control the height of the longitudinal arch of the foot and posterior tibialis activation.

❇️ Keep heel and toes on ground, try to lift middle arch to try to make foot shorter ( aka short foot position)

Toe Spreaders

For the last couple of years I have been using these Toe spreaders to improve the alignment of the foot and to improve strength.

Narrow shoes or cleats tend to bunch all the toes together, losing the ability to spread and move freely, therefore it makes complete sense to exercise the foot wearing these spreaders with the main goal of having functional feet.

Functional means a foot where all the muscles, joints and connective tissue fire up and move effectively and without pain or stiffness helps the entire body fire up and move effectively without pain or stiffness.

There are several ways to use them, just put them on and walk barefoot at home or exercises with them on like in the video here.

Strengthen your Arches

Your medial longitudinal arch is a key component in the stability of the whole lower extremity.

It depends mainly on the strength and control of two very important muscles

⁣⁣Flexor hallucis longus⁣⁣ (FHL).

In this video today we show you a great way to strengthen the FHL.

It is very important that you keep the big toe straight as you push down, do no bend it in the middle of the toe or grip into the band to isolate the contraction and avoid compensations.

Plantar Fascia Load and Strengthening

Strengthen your Arches !!!...Plantar Fascia Load and Strengthening

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Another important component of the longitudinal arch is the Plantar Fascia which helps create stiffness in the inner part of the foot and therefore support to the arch.

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The calf , plantar fascia and the big toe work synergically to propel the body forward.

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A good exercise is the one shown in this video where the calf raise is done using this device ( you can use a towel as well ) to emphasize the position of the toe into extension and load the FHL and plantar fascia simultaneously.

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Recommended 2 sets of 5,8,10 repetitions as tolerated. You’ll feel tension , burning in the inner part of the foot into the lower leg. Once you can control the exercises with your body weight you can add a backpack with weights for further loading.

As you practice these simple exercises you will develop strength and endurance in the foot which is very important for performance .

Conclusion

• Foot exercises are a good option for soccer players

• Conventional exercises usually don't challenge the foot musculature and specific exercises need to be done to develop strength in this area

• Plantar Flexion Capacity with emphasis on Great Toe strength are the main goals of the strengthening.

• Give these exercises a try for a couple of weeks and you'll feel the difference

White Bay Sports Physical Therapy is a Sports-Injury clinic that specializes in Plantar Fasciitis treatment .

Lionel Pannunzio is a Physical Therapist Certified in Sports Injuries. With more than 20 years of experience helping athletes return to their sports after an injury. He is the Owner of White Bay Sports Physical Therapy and Fitness, conveniently located in the beautiful City of Weston, where he treats Soccer Players and Athletes of all ages

#whitebayphysicaltherapy #achillespain #achillestendinopathy #heelpain #plantarfascitis #planarfascitispain #plantrfascipathy #Soccerinjuries #westonsoccer #westonachillespain #westonflorida #westonfloridaphysicaltherapy #daviefl #coopercityflorida #pembrokepinesfl #miramarflorida #weston #physicaltherapy #southwestranches #westonfitness #livinginweston