BLOG

"Tons of Useful Information"


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

10 views0 comments

Introduction


Just hurt your back?!


Everyone will have an episode of Low back pain in their lifetime.


It hurts like a lot you feel like you can't move...


Believe me when I tell you I understand your pain , I had these episodes myself in the past and it is not fun...

-

We (healthcare professionals) used to think that this meant that we should just lay around and NOT MOVE until the pain went away. And to be honest, this is very tempting because many times laying down is the most comfortable position!


However, we now know that you should try to KEEP MOVING and doing what you can, even within the first few days of aggravating your back.


Sure, finding positions that relieve discomfort is important, but you don't want to be spending ALL of your time laying around! This can actually limit your recovery



The most important thing to be aware of is that the majority of acute low back injuries or flare ups tend to resolve in about 6-8 weeks on average, no matter how horrible they initially feel


So don't worry...you'll be fine!


Today we analyze the most common mistakes people with back pain do.


Most of these mistakes and ingrained in myths or popular beliefs that people follow but Science has shown that these myths are incorrect. Learn how to properly manage your back pain for a quicker and long-lasting recovery.


We will finish with a simple routine all my patients with Low back pain do at the beginning of the treatment.





MYTH # 1 Rest Is the Best Thing for Pain Management



In the past, doctors used to tell patients to get bed rest to back pain. . Today, I'm here to tell you that this is no true! Several studies now show that bed rest can actually make back pain worse. Instead, manage back pain through movement.

In most cases, moving around or low impact sports like swimming, and walking will help keep you limber and get you through back pain better than resting.






MYTH # 2: My back hurts because of my Arthritis



Arthritis is inflammation of one or more joints that typically causes stiffness and pain. And that’s true! BUT there is no way to know exactly if arthritis is the direct cause of back pain. Studies have looked at the x-rays of people with arthritis and many people have no back pain!






MYTH # 3 : Activity avoidance , you can't lift weights

Back pain should not stop you enjoying exercise or regular activities. In fact, studies found that continuing with these can help you get better sooner!. If you do activities including lifting weights, you should better unload, modify or adapt your exercises but no avoiding doing that! Initially, you may need to reduce the amount of load and then progressively increase the load or intensity, as your body gets better. With time and proper control of exercises for your body, you can get back to normal activities.





MYTH # 4: An MRI is not necessary before starting physical therapy.



A good therapist will identify your problem and will help you manage your pain. The MRI provides a therapist a little value in terms of finding the right exercises for you! If you have any pain, start physical therapy as soon as possible




SIMPLE EXERCISES FOR MANAGING LOW BACK PAIN


🎥 Modified Curl-up.





Hands under the low Back for support. Keep one leg extended.

Begin by stiffening the Abdominal Muscles, elevate elbows, maintain neutral neck and simply raise head and shoulder off the ground slightly.




🎥 Side Plank or Bridge.




Begin lying on your side with your knees bent, propped up on your forearm. Your elbow should be directly under your shoulder.

Engage your abdominal muscles and raise your hips up into a side plank position, keeping your knees on the ground. Hold this position, then return to the starting position and repeat.

Make sure to keep your core engaged during the exercise. Do not hold your breath or let your hips roll forward, backward, or drop towards the floor.




🎥 Side Lying Open Book Thoracic Rotation with Knee on Foam Roll




Begin lying on your side with your bottom leg straight, and your top leg bent at 90 a degree ankle, resting on a foam roll. Your arms should be straight and together in front of you on the ground.

Slowly move your top arm away from your other arm, bringing it to the floor behind you, and rotating your upper trunk. Next, bring your arms back together, and repeat.

Make sure to keep your top leg on the foam roll.




🎥 Bird Dog.





Begin on all fours, with your arms positioned directly under your shoulders.

Straighten one arm and your opposite leg at the same time, until they are parallel to the floor. Hold briefly, then return to the starting position.

Make sure to keep your abdominals tight and hips level during the exercise.




Conclusion:


  • Rest, expensive MRIs will not help you much.

  • Research shows that active movements as early as tolerated is the treatment of choice for Low back pain

  • After an episode of Low Back Pain, patients need to recover the ability to lift weights even from the floor

  • Physical Therapy is the best initial choice for people with back pain


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 receiving 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”








#whitebayphysicaltherapy #lowbackpain #Soccerinjuries #westonsoccer #westonlowbackpain #westonflorida #westonfloridaphysicaltherapy #daviefl #coopercityflorida #pembrokepinesfl #miramarflorida #weston #physicaltherapy #southwestranches #westonfitness #livinginweston

16 views0 comments


Introduction


Treatment of Achilles tendinopathy requires a comprehensive approach including pain control exercises, then strengthening followed by power and finally a well rounded return-to-play program to restore strength and function to this affected tendon.

In this blog, you will learn the main exercises we use with soccer player recovering from an Achilles Tendionpathy


Should I rest the Achilles or Loaded ?


Many soccer players may think that they need to ‘use’ the tendon ‘less’ in order to improve the pain and reduce the symptoms, so they rest or reduce the activity significantly and the pain usually gets better but here is the catch, once these players return to practice the pain comes back almost immediately

In our approach to Achilles Tendinopathy, the key is to fully rehabilitate the tendon by using the tendon more. More means progressive loading of the tendon to increase its resilience for the sport activity.


What are the best exercises for Achilles Tendinopathy?


Build plantar flexor capacity !!!! Do all types of calf raises


We discussed above that in Tendinopathies, loading the tendon is the way to improve this condition.


The goals is a progressive increase in loading the tendon through rehabilitation exercise that ultimately will include what is known as ‘heavy slow resistance’ work that typically is performed in a gym setting with appropriate resistance.


I like to see soccer players being able to do heavy gastrocnemius and soleus work in a gym (targets 1.5x body weight soleus seated calf raises & 0.3-0.4x body-weight standing calf raises aiming for 3x 8 reps with good control.


Of course even though the goal is to go heavy on the tendon, we cannot start with heavy stuff because it will most likely irritate the tendon and create more pain.


The logical progression for this exercises is to build up capacity with Isometrics first, then isotonics (full Range of movement) , then eccentrics (emphasis on the movement down of the calf raises ) and finally plyometric exercises with all types of jumps to challenge the super important and ultimate function of storage-release mechanism of the tendon )



Isometrics


Isometric contraction is a very powerful type of muscle activity in which the muscle contracts quite strong but there is no movement at the adjacent joint. Isometric exercises help with pain in the tendon as well as with the develop of force.

Isometric contractions are used early in the treatment process for these reasons.



Bilateral Calf Raises - Isometrics




Setup

Begin in a standing upright position with your hands resting in front of you on a wall.

Movement

Slowly raise your heels off the ground and hold that position. Start with 5 seconds and build it up until you can hold for 45 seconds . 5 repetitions and 3 sets are recommended .

As you get stronger you can add weight to this exercises with a vest or backpack



Unilateral Calf Raises - Isometrics



Setup

Begin in a standing upright position with your hands resting in front of you on a wall.

Movement

Raise your heels as high as you can then Bend one knee up to 90 degrees and hold the weight of your body on the opposite Foot raised , hold that position . Start with 5 seconds and build it up until you can hold for 45 seconds . 5 repetitions and 3 sets are recommended.



Isotonics Exercises


Once you are able to manage the Isometrics without a flare-up in pain or symptoms we start loading the tendon progressively in the full Range of motion available. Adding a step to the equation allows for more demand on the tendon fibers.

It is very important with these exercises below that you control the pace of the movement and go from one end of the movement to the other. This is how we will show the tendon where to align the newly formed fibers of collagen : “in line “ with the force which makes the tendon more resistant to the load.


Calf Raises on Step



Setup.

Begin standing at the edge of a step with your heels hanging off the edge. You may hold onto a stable object for support.

Movement.

Raise up onto the balls of your feet, then slowly lower your heels down off the edge of the step and repeat.

Tip.

Make sure to maintain your balance during the exercise. Keep your movements slow and controlled. Use the following pace: 3️ seconds to get to the top position, hold for 2️ seconds, 3 seconds to return to starting position. You can start with 3 sets of 5 repetitions and progress to 3 sets of 8 repetitions and finally to 3 sets of 10 repetitions as long as you can maintain the quality of the contraction.


Bent Knee Calf Raise on Step



Setup

Begin standing on a small step or platform with your heels off the edge, holding onto a stable object for balance.

Movement

Bend your knees, then raise both heels up, and lower them down slowly. Repeat these movements.

Tip

Make sure to keep your back straight and knees bent throughout the exercise. Keep your movements slow and controlled. Use the following pace: 3️ seconds to get to the top position, hold for 2️ seconds, 3 seconds to return to starting position. You can start with 3 sets of 5 repetitions and progress to 3 sets of 8 repetitions and finally to 3 sets of 10 repetitions as long as you can maintain the quality of the contraction.





Excellent… by doing calf raises Am I cured ? ….

The answer will be NO... YET....


Building plantar flexor capacity is just part of the treatment. Once you have more control of your calf muscles we need to reproduce the demands on the tendon. Tendons are like springs. Let’s say you are running and every step you take you absorb your own weight in the foot and then you push your body forward to continue running. This load absorption and release is the main function of the Achilles Tendon.






So in order to get completely better, strengthening only will not be enough and you need to reproduce and train this energy storage-release mechanism.

To recreate this, Therapists use what it is called Plyometrics exercises intended to simulate this function. Examples of Plyometrics are bilateral and unilateral leg jumps , quick calf raises , box jumps and other.

Plyometrics are high level exercises need to be done by a therapist to properly choose the right doses in order to avoid irritation of the tendon



Ankle Plyometrics - Double Leg and Single Leg Ballistic Heel Raises


Set Up

Stand up on the ball of your feet

Movement

Do Quick Rebounds mid amplitude

Then switch to one foot only and repeat mid amplitude heel raises

Sets of 10 reps


Load Management



When returning to the activity in this case playing soccer, you must do it gradually. Knowing exactly what brings out your symptoms will empower you to make the right adjustments for the healing process to take place.

Movements that create high loads and use the tendon as a spring (jumping or sprinting activities for example) increase cell signaling and can create the over-response that sparked the pain you are feeling. Therefore, start with walking and jogging session, followed by jogging only session, changes of speed (50-75-90 %), cuts 45-90-180 degrees, speed and agility drills, ball possession drills until you can practice a whole week without irritation of the tendon. If during the progression there is pain after the activity of the morning after it means the pain you’re experiencing is your tendon telling you it is not tolerating the loads you are placing on it. It is there for a reason. Listen to it.

For such cases, try changing one variable in your training program and see how your tendon responds. For example, if you currently train seven days a week, decrease the frequency by dropping one session. If you can’t sacrifice one day of training, you must make a change to either the amount of high intensity loads or the total volume of your training. Regardless of which variable you choose, only change one factor at a time and wait to see how your body responds (everyone will be slightly different so there is no golden rule).




Finally...Should I stretch Tendon Pain?

Despite what you may have learned elsewhere, we do not want to stretch an Achilles tendon injury!

No matter what form of tendinopathy you may be experiencing, stretching should not be a part of your rehabilitation program.

Remember that Insertional Achilles tendinopathy injuries occur due to high levels of compressive load to the tendon against the calcaneus bone. Stretching your calf muscles will only serve to add more compression (and lead to more pain) on the already injured area.

While there is less cause for concern for those dealing with a mid-tendon tendinopathy injury, research has not shown any benefits to stretching whatsoever.

Instead, if you do have limited ankle mobility or you feel tight in your calves, you can safely perform soft tissue mobilization to the calf muscles with a foam roller or massage stick. Foam rolling has been shown in research to improve ankle mobility without placing harmful compressive loads on the tend




Conclusion


  • Achilles Pain from Tendinopathy is very common in Soccer players (see statistics at https://www.ncbi.nlm.nih.gov/pubmed/23770660)

  • In this Tendinopathy there is an imbalance between the amount of load that the tendon in receiving and the tendon's capacity

  • Weakness in the calf musculature is the main reason for Achilles Tendinpathy.

  • Physical Therapy can help by building Calf Raise Capacity to improve the strength of the calf and reinforce the remaining of the healthy tendon.

  • A combination of Isometrics, Isotonics, Eccentrics and Plyometrics exercises is necessary for a safe and pain-free return to play process

  • Education in Load Management and a strategy to progressively load the tendon without (or minimal) irritation are also mandatory if you want to play pain-free



Do you have other questions about Achilles Tendinopathy?

Do you want to know if Physical Therapy can help your particular case ?



Give us a call at 754 244 2561 and we will help you answer these question and even we will schedule you a Free consultation


Visit www.wbsphysicaltherapy.com for more information

on how to talk to a Sports-Certified Specialist

and start getting better today...



#achillestendinopathy #achillespain #whitebayphysicaltherapy #calfpain #calfStrain #PulledMuscle #Soccerinjuries #Soccercalfinjury #westonsoccer #westoncalfpain #westonflorida #westonfloridaphysicaltherapy #daviefl #coopercityflorida #pembrokepinesfl #miramarflorida #weston #physicaltherapy #southwestranches #westonfitness #livinginweston

64 views0 comments