tri-athlete- hamstring or neural??

Can anyone help me with this problem?

A tri-athlete friend of mine asked me to assess his 'hamstring strain'. He initially strained his hamstring about 18/12 ago. He recovered from this, and returned to training and competing with no problems. Then, earlier this year, after a week telemarking (in a crouched position, one foot in front of the other), he developed pain in the back of his thigh. (no trauma this time). He gets this pain every time he runs, and to a lesser degree when he cycles.When running, the pain comes on just as he to flexes his hip and begins to extend his knee as he swings the leg through (eccentric control of hamstrings). The pain does not extend below the knee or up in to his back. His pain is reproduced by neural stretch, though his neural mobility is very good. Pain is also reproduced by hamstring stretch, and hamstring contraction. Lumbar movements are full, painfree, and do not reproduce the pain. There is no tenderness on palpation of the Lumbar Spine, but he is tender on palpation of the hamstrings, especailly biceps femoris. He has good core strength, and good flexibility. He does recruit hamstrings before gluts in prone knee bend. I can find no dysfunction at the hip or SIJ.

So far, I have seen him a couple of times (usually grabbing a moment at work when we are both free, so on a fairly ad hoc basis to be honest). I have frictioned his hamstring, and followed this by contract relax stretches, and also needled myofascial trigger points, followed by stretches, and eccentric hamstring exercises. I have advised him to work on eccentric control, single knee bends with good pelvic control, neural stretches, hamstring stretches, glut exercises in prone, and working on glut recruitment. (I also mobilised L4/5 & S1 and performed passive SLR before and after, but it did not change the pain). He has been doing the exercises, and has continued to train (he won't rest), and the problem remains the same.

I am not 100% sure whether this is just a chronic hamstring strain and recruitment problem, or how much of it is neural. Why is passive SLR painful but not restricted, but L/sp clear? If it is neural we are probably aggravating the pain by stretching it? Are we encouraging the overactive hamstrings by stretching them? I am not sure where to go with him now. Any suggestions?? Does he need to rest?

Hi.

It sounds like you have been thorough.

Any eccentric exercises for hams like deadlifts?

Also, and this is not meant to be offensive, how are you sure he doesn't have SIJ dysfunction - the reason i ask is because different people have different philosophies on SIJ and its assessment.

Thanks

Hmmmm.... Just wondering but what's the status of his glute med, glute min, QF and TFL? Reminds me of my speed skaters in a way and a strong thumb (or elbow if he owes you money :p ) in these structures mimics the pain from time to time.

Did you perform your assessment (postural/biomechanical/visual) in his telemarking position? It would be interesting to see if he has good heel cord length.

Adamo

It sounds like you are being very thorough. One additional thing to check it the proximal tib/fib joint. Compare sides as there could be compression occuring at the back of the knee with excessive hamstring action as he is extending the knee. Restriction might indicate a functional issue, laxity also perhaps overactivity.

It could therefore be that the hamstring is protecting the knee in some way and had been exacerbating a secondary issue in the muscle itself. If the test for P1 is positive on mm testing with the nerve at rest then in my opinion it is unlikely to be neural within the hamstring issue itself. Also the cycling brings on pain as well (could stillbe localised pelvis/Lx with that though). It could also be a hamstring issue with a primary neural issue elsewhere. Perhaps a two person assisted slump might be a useful treatment. I used to do that with my receptionists help many years back :)

As other assisted a good elbow in a strucutr here and there with test, re-test at that time in his telemarking position/movement.

Let us know your results of further testing
8o

Given the amount of training he does, have you watched him run or cycle? If he pulled his hamstring some time ago and returned to training very early he may have developed compensatory patterns to protect the injured muscle, which have become habitual.

There was a thread recently discussing in some depth things to look out for on the bike - video the athlete from the back and the side and see what you can see. In my experience with triathletes, very often their main complaint is pain when they run, but more often the underlying problem is on the bike, on which they spend a great deal longer than they do running.

A minor biomechanical issue rapidly becomes a major problem when someone is putting in serious hours and miles on the bike, especially if they are doing hill training.

My be worth checking for postural defects like posterior rotated hip and external rotated foot also check if pirformis is hypertonic

Examening the movement one makes in cross country skiing, which is at least in Norway a part of Telemark skiing my first thought would be SI joint and/or Lower back and anything which stabilises the SI and/or lower back [for sure if one is an inexperienced Telemark skier]. If you examen the SI are you capable to examen hypermobility? I don't think so, only hypo mobility I would say. And changes only if you compare left with right which makes it possible to have 2 hyper mobile joints. Injuries of the hamstrings are not oncommon in that setting: They tend to try to stabilise the pelvis in disfunctions of pelvis movements. You write "no tenderness of the lumbar spine" How about spinal movements from T7 downwards? How about his posture? How about the stability of the back/abdomen? [SLR seems to be possitive] Hyper active muscles of the back? [e.g. Iliopsoas]? Have you performed stress tests, prolonged stress of the SI and lower back in order to reproduce the symptoms?
"He initially strained his hamstrings about 18/12 ago" Which cause? Who diagnosed it as a strain? What did he do to make it better?
I think that the likelyhood of his injury is of neural origin far greater than a pure muscular problem. In case he has a very short relief after your treatment you can almost be sure it is of neural origin.
I must agree that your examination looks sound but have a good look at the back and the SI, this after my personal experience with Telemark skiing and analysing the movements which could a lot of times mobilize the back and when one becomes tired [usualy after 1-2 hours of skiing] It might be a good sport in order to mobilize passively the back.