Recurring hamstring strains, adductor tendonitis and hernias

[scottmcniven]

Hi all,

I've had a series of 5 or so hamstring pulls in each leg over the last 8 years. All have occurred while sprinting (at my top speed, not while accelerating) -- I play ultimate Frisbee and train doing track workouts. I usually see a physiotherapist with whom I do a combination of strengthening, stretching and massage, while seem to help the recovery. But I keep restraining my hamstring nonetheless!

I had light groin adductor tendonitits over that period as well. Two years ago I developed bilateral inguinal hernias. A doctor recommended that the hernias be repaired alongside an adductor release; I had both operations 16 months ago. My recovery from the operation has been slow -- some osteitis pubis as well -- but it coming along. The hamstring pulls continue -- I've pulled each one in last two months. I'm not sure if this is connected to the hamstring.

Does anyone have any ideas or advice that go beyond the usual hamstring recovery protocol?

Many thanks,
Scott

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[Canuck Physio]

Hi all,

I've had a series of 5 or so hamstring pulls in each leg over the last 8 years.
When you say pull do you means spasm, or a muscular strain/tear, or generalise muscle inflammation and discomfort?
All have occurred while sprinting (at my top speed, not while accelerating) -- I play ultimate Frisbee and train doing track workouts. I usually see a physiotherapist with whom I do a combination of strengthening, stretching and massage, while seem to help the recovery. But I keep restraining my hamstring nonetheless!
Sounds like a muscle imbalance issue that is exacerbated while running. Have you have a biomechanics/gait assessment?

I had light groin adductor tendonitits over that period as well. Two years ago I developed bilateral inguinal hernias. A doctor recommended that the hernias be repaired alongside an adductor release; I had both operations 16 months ago. My recovery from the operation has been slow -- some osteitis pubis as well -- but it coming along. The hamstring pulls continue -- I've pulled each one in last two months. I'm not sure if this is connected to the hamstring.
THat's a lot of stuff going on. Now it is difficult to say what your key problem is, are you receiving treatment for all? Are there residual problems? Lasting effects? Deconditiong?
Does anyone have any ideas or advice that go beyond the usual hamstring recovery protocol?
Indeed, I don't think your strengthening work has developed far on enough, especially if it is not including resistance training. Specific sports training and power work assessment should be done before attempting maximum output again.
Many thanks,
Scott

As above regards.

[scottmcniven]

Thanks Canuck!

Yes, I'm getting treatment now. I'm on indomethecin for the osteitis pubis. I'm focusing my core workouts around a protocol groin injury designed for Major League Soccer players. I've got an appointment tomorrow with a physical therapist who specializes in the pelvis.

I'm curious if there's a connection between the adductor tendonitis/alignment issues and the hamstring strains, but no professionals have suggested a link.

I'll plan to get my hamstring stronger than they have ever been before returning to sprinting. I'll do the standard physio hamstring protocol and, later on, weight training.

Do I need to work in any hamstring speed exercises before sprinting? Or is power and endurance sufficient? Therapists have recommended easing into full sprints but haven't recommended any particular remedial speed training exercises.

I hadn't thought of a biomechanics assessment. I'll give that a try. Great call!

Another thought: I've read a bit about adverse neural tension and lumbo-sacral nerve roots causing hamstring problems. (Mostly they cause pain and feelings of tightness but can cause the strain in some cases. I'm not sure if I'm reading the literature correctly, here! I'll try to get someone to do the "slump test" on me.) Could any of these problems be causing parts of my hamstring to misfire, leading to strains?

[sharileedahl]

Thanks Canuck!

Yes, I'm getting treatment now. I'm on indomethecin for the osteitis pubis. I'm focusing my core workouts around a protocol groin injury designed for Major League Soccer players. I've got an appointment tomorrow with a physical therapist who specializes in the pelvis.
-Get back to us how that appt. goes and what you find out. I would expect it to be a very useful appt and provide a good base for rehab.

I'm curious if there's a connection between the adductor tendonitis/alignment issues and the hamstring strains, but no professionals have suggested a link.
-Absolutely! As Canuck noted before re. "muscle imbalance". Hamstrings tend to be under more strain if they are not getting much back up from the muscles that are more adequate for core stabilization including the gluteals. (However they can also be under strain due to weakness relative to the quads.) Adductors also assist in stabilizing the pelvis and can be under strain for the same reason. Again will be interesting to hear what you find out from your upcoming appt.

I'll plan to get my hamstring stronger than they have ever been before returning to sprinting. I'll do the standard physio hamstring protocol and, later on, weight training.

Do I need to work in any hamstring speed exercises before sprinting? Or is power and endurance sufficient? Therapists have recommended easing into full sprints but haven't recommended any particular remedial speed training exercises.

I hadn't thought of a biomechanics assessment. I'll give that a try. Great call!

Another thought: I've read a bit about adverse neural tension and lumbo-sacral nerve roots causing hamstring problems. (Mostly they cause pain and feelings of tightness but can cause the strain in some cases. I'm not sure if I'm reading the literature correctly, here! I'll try to get someone to do the "slump test" on me.) Could any of these problems be causing parts of my hamstring to misfire, leading to strains?

-I'll chime in again after your appointment. Thanks.

[rohitsawalkar.physio]

to scott

hey dont worry dude ull all be fine the advice wich u get from the forum and ur conustant physiotherapist would make ur life smooth..just a word to add
do focus on ur eccentric hamstring training drills.as also maintain ur FLUID balance drink lot of WATER..that is also one of the factor in recurent hamstring strain..
all the best ull do great..

[junior_physiotherapist]

Let's at first hope to you a full fast recovery,

Now ,In addition to above ,Generally

-be sure there is no neurological problems with sicatic nerve (supplying hamstring and adductor magnus muscle),

-full perfect biomechanic assessment.

-look for any visceral problems as burning urination,...

-how is your weight looks like!

[scottmcniven]

Thanks, all, for the advice and support.

sharileedahl: After three visits to the therapist I've learned many good exercises and stretches. The therapist is doing a lot of trigger point work on muscles on my psoas, hips, adductors, buttocks and pelvic floor. I'm foamrolling and/or stretching my back, L5S1 gap, psoas, and thigh muscles (like this one: YouTube - Hamstring myofascial release: BodySpex fitness with Jai). Lying on my back with my feet on a volley ball and my arms and shoulders off the ground, I'm doing hamstring curls and working up to one-legged bridges at various angles. (I'll switch to an exercise ball once it arrives in the mail.)

I'm working in aquatic buttkicks, distance running and this hamstring-fall thing (YouTube - Eccentric hamstring exercise) for fun.

rohitsawalkar.physio: I think a lot of the stuff mentioned above is eccentric. If you have any other suggestions please let me know! I keep better hydrated than most and I'll keep vigilant on this front.

junior_physiotherapist: I'll try to schedule a biomechanics assessment for a couple weeks from now, once I can run with some confidence. Urination feel fine and I don't think it's much nerve stuff since I can feel the muscle damage and tightness. But I am making it a priority to loosen up my L5S1 gap, which I hope will help with any potential nerve issues. I'm slender, 5'11'' and 158lbs. I'll drop 5 or so in the next month (I just took a big test, studying for which put a few pounds on me) and my target weight is around 150lbs.

Many thanks, again. Let me know if you have any further thoughts. I'll keep you updated.

Scott

[LaurensFitness]

Hey Guys

I know its bad form to jump on forums and post links to products and stuff but I was searching around to see what was on the net for hamstring injuries and rehab and found this, I think it may be of use to you. My name is Lauren, I blog at LaurensFitness.com, my Dad has written an ebook on Hamstring Rehabilitation, it's pretty comprehensive, hes pretty experienced in the industry.

I don't want to sell it to you so just check it out yourself. Here is the sales page for the Hamstring Rehab Manual, which we had to make for clickbank....and you can also go here which the bertolacci.com.au website and check out more Hamstring rehab info for free, or head to his blog at loris bertolacci

OK I know a lot of info there but I reckon it might be exactly what you are looking for, how to stop hamstring recurrence injuries. If you don't want the ebook there is plenty of info on the bertolacci site! Hope it helps.

Cheers

[alophysio]

Hi

It is bad form only if you don't contribute. Perhaps you could post some useful stuff on the forum rather than just links? Otherwise it is just a sales page. I know you mean well. I had a look at the websites - someone set up the info for you but not the sales and marketing...PM if you want feedback on the sales page. Also, from the table of contents, there are more than just the muscles listed that affect the hamstrings...

If anyone PM's you and wants more info on the stuff, it is different and spruik all you want...otherwise we try to post information for free, not looking for business. Honestly, the information i personally have posted would total in the thousands of dollars. I only do it because i feel the need "to give back" to the profession that has helped me so much over the years to become who i am. Also, there are people out there who haven't had the same opportunities to learn the things i have so i don't mind sharing what i have learnt. If i know a lot (and that is debatable), it is only because i have stood on the shoulders of giants...

But back to the original problem...

1. My impression is that the hamstrings, groin and pubic symph are suffering from pelvic, lumbar or thoracic dysfunction (likely to be pelvic or lumbar). The overactivity can cause increased tension and so lead to overstraining.

To give you an idea, i had a patient with a similar history except it was for over 10years. She had chronic 'tears' all over the place (adductors, calves, hams, quads, gluts etc) at different times, had "traditional" physio of soft tissue, electrotherapy and exercises to stretch and strengthen the legs etc. When she finally had her assessment with me, there were heaps of things "wrong" but the main problem was pelvic dysfunction which was not picked up on before. Therefore, 2 manual therapy sessions and 3 exercise sessions for proper core stability exercises led to her improvement. She now runs regularly without issues (she had to build up to it).

2. Core stability is so badly taught out there in the world that sometimes i wish it wasn't out there! Can you describe how you are doing your core stability exercises please?

Please don;t forget that training the "big" muscles like hamstrings etc is only the second half of rehab. The first half is actualy ensuring you have the joints involved able to move properly, control of the joints involved with the local stability muscles THEN be able to put the large forces through the joint.

Most people who start with hamstring strengthening are just gambling that their stability is ok... if life was as easy as hamstring rehab, i wouldn't need to keep studying!

Just find a good physio who has trained with real time ultrasound (RTUS) or reputable physios. I am developing a system, and hope to have the research to back it up, where physios can do some simple things and be as accurate as RTUS. Good physios can do it already but there needs to be research to back up the reliability and validity of the findings.

You should start to feel better within 3 treatments. Otherwise if the problem keeps coming back, they aren't fixing the main issue.

Good luck!

[LaurensFitness]

Hey,

Yep fair call, please take down the links if you feel it's appropriate. I have no dramas with that, not meaning to step on people toes.

Once again sorry. I do have a lot of info on it, I guess just not the time to write it. My apologies. Oh and don't take it as my father posting, it is actually me doing it. My bad.

[alophysio]

No problems, i am sure you meant well and we can see that.

Still would like to know what happened to the original poster!

[sharileedahl]

I haven't been able to sit down at the computer for a few days but I just had to make time for this one. Why? Because I absolutely love a good rant!!! (Thanks alophysio....actually you were quite polite with your ranting!!)
Seriously though, I do have a couple comments....

Lauren Fitness - I don't object as strongly as others to your post. It may not contribute greatly because readers have to actually buy the resource to which you are referring. However, it's always good to see what resources are available.
Looking at the table of contents, it looks fairly thorough; I just have one concern (and it's a big one). Any time a resource is aimed at the athletes as well, you are ultimately telling them it is a simple answer and they can do it themselves. Recurrent injuries are not typically simple and that's why they are recurrent. It takes someone knowlegable to do a proper assessment to make an individualized training program rather than a step-by-step rehab program.

My first degree was in Kinesiology and I can say with all honesty that I did not learn enough information to look at true "core stability", pelvis load transfer, thoracic dysfunction etc...all of which can contribute. Working with teams and therefore under experienced physiotherapists and athletic therapists, I may have had a idea that these were issues but not enough to properly assess the athlete.
With a degree and subsequent years in physiotherapy, I do have that ability (which is evolving with every client and every course) because the education is focused on the injured client rather than the healthy (which I would argue kinesiology focusses on).
So...that's not to say that I don't think that fitness trainers have a place in rehab (because honestly I think that they are trained better in the actual return-to-sport phase...unless the physio has worked with teams / athletes), I just think that there needs to be an understanding of all our limitations.

Now...alophysio...I have to pipe up about something that you said. Not to totally disagree with you but just to support our profession a little more. You said to find a physio that uses RTUS. You did qualify that by saying that " a good physio" can be as accurate but I still have concerns. RTUS is an excellent tool for those people who just don't "get it" when it comes to recruiting specific muscle groups. I don't however think people can not be rehab'd without all the fancy toys. All physios are trained to specific standards and we should not allow clients think they are being short changed by seeing a less experienced therapist. New grads come out with a great deal of knowledge and depending on their experiences in their clinical placements can have great experience to get them started. The difference between a new grad and an experienced therapist is ever improving problem solving skills and how many tools are in their tool box. What I'm trying to say is that clients should not be concerned if they are seeing a "good therapist" or a bad one. The profession itself if reputable and evidence-based. Physiotherapists need to keep up on the research and clinical expertise out there to not only know how to evolve themselves but to know when referral to a colleague is the best option for a specific client.

[alophysio]

Hi sharileedahl,

Yes, you make a good point. I was thinking about that as i wrote it but deciding to press "post" anyway.

A few points as to why.

1. I am older and more cynical. I have simply been around too long and heard too many stories of physios who have "trained" their patients in "core stability" and the patients have no idea.

Now, you might say "the patient got it wrong" and i agree - that is usually the case right? Well, when they come in with a sheet of exercises showing you what they are to do, then there is more evidence.

Then you might say "but maybe the physio explained it and didn't write it on the sheet". Again possible but when you question the patient to clarify how it is taught to them, the patient is clear on what was taught and what wasn't taught.

And BTW, i do this in a manner that tries not to undermine the other physio. I am a professional after all. Here i am annon so it doesn't matter so much.

What i do is ask the questions and don't make comments about what i am thinking...like "huh?".

Then when you actualy meet the physio and have a good old chat about physio, you realise that they really don't know what core stability is.

Also, a lot of people like Stu Magill's work because it is very much like gym based programmes but it lacks the motor control element. In actual fact, apparently (so i have heard), Stu Magill actual does teach motor control but doesn't realise it! On this sidebar, try a cocontraction brace that he advocates - that is back extensors on and ab flexors on. Now try to rotate. you can't unless you decrease the brace to allow you to move. That is motor control!

anyway, i digress...

2. You will note that i said trained with RTUS or a good physio.

Let me emphasise that i do NOT own a RTUS. I might buy one in the future to play with (see what is going when i do certain things) but not for retraining...although there is some recent research which says it might be helpful...

A good physio can train TrAb and LM and pelvic floor (PF) without gadgets. I haven't met too many who get the TrAb or PF contraction right first go. Even when you tell people a 30% contraction, they still bring in interal obliques. And i have been on many courses over the years.

Even worse, i have only met 1 personal trainer/pilates instructor/yoga instructor/GSR/athletic trainer who could do it and it was only because they were specially trained due to injury. Even worse, i have personally trained some trainers multiple times and emphasised the theory and practical etc and review with them a few months later and they go back to their old habits.

I am tired of beating my head on a brick wall. Perhaps my cynicism is unjustifed...

3. Training with RTUS actually lets you see what is really going on. i have been fortunate to have access to RTUS if i need it. I have been fortunate to have been able to play with RTUS to test different things. I have been able to validate my own palpation skills and correlate strongly with RTUS for different muscle contractions. Therefore i have confidence in my palpation skills as being accurate.

How many people take the time to do such "playing"??

How many people think "clams" in pilates does glut med? If you aren't sure, get on the RTUS and have a play. It's pretty hard to get away from the research which says that TFL is the main ABD in the hip...

4. As for my denigration of our profession...a profession that has been good to me for many many years, you are right and i apologise for that.

There are many many physios who have much better skills in different areas to me. They have good ideas on movement and exercise and soft tissue work and visceral work etc. I am a lifetime student. With each pice of knowledge i aquire, I realise more how much more I have to learn. It is only because of giants in physio (and other professions) that i have been able to learn what i have.

5. you are right, there aren't many bad physios. but one post i replied to earlier today said her physio said her shoulder pain should take 12-16 months to get better and to keep coming to physio. She already had it 18months and there was no frozen shoulder diagnosis mentioned. Even then, it should start to thaw on its own...research shows that physio is not going to help frozen shoulder get better faster. Physio is only good for helping the other areas under stress from the frozen shoulder. Based on the very little information i have at hand, i can still make a statement saying "I have NEVER told a patient to keep coming to me for 12-16 months for treatment". Never.

6. New grads. Love 'em and everyone is one to start out on but i can't hire them. My practice is too sophisticated and too specialised to take them on. I have tried in the past. I have met some recent graduates who have potential but still they were 2-3 years out of college and had done courses i wish i had done at the same stage. But they still lacked the experience i required.

The issue is time. You need time to get the patients under your hands. You need time to learn assessment skills. you need time to understand clinical reasoning better. Time is needed for learning new treatment and rehab skills.

The problem has never been intellectual ability...just experience.

7. Attitude is a problem amongst all professionals. Your patients will love you whether you are good or not to be honest so long as they get better.

I once had an employee who never did continuing ed and the patients loved him. They got better very slowly (?natural recovery?) but they did eventually. He was great at explaining what was wrong and earnt their trust and did everything a new grad would and more. He tried hard and didn't have an ego.

Then i have seen and employed physios who were "too big for their boots". They were right and that was that. How dare i suggest alternative diagnoses or question their judgement? Bad attitude. Get fired.

If we tell the patients something and they hold onto it, it is in our best interests to be "right" because if we are wrong, it diminishes our reputation in the eyes of the patient. The right way to go about it is to obviously don't back yourself into a corner but to be cautious in your words but some go the easy way, make a diagnosis and then are stubborn to let it go if they are wrong.

I am sorry if this doesn't make sense but it is currently 1am in the monrning here! Also you have hit on a nerve (can you tell?? )

8. A degree is simply the piece of paper that qualifies you to learn MORE. Too many people see it as the end of their educational journey. Graduation is the BEGINNING of the journey.

9. Lastly, about you sharileedahl. you strike me as the kind of physio i want to hire. I appreciate your comments both here and in other posts. I am guessing that you are about 2-5 years since graduating and no doubt better than i was (am?) when i was there. I only guess you re youngish becasue you are not as cynical as i am!

Thank you and look forward to more discussions over the days, months and years

Sorry to hijack this subject!

[sharileedahl]

Alophysio -
Amen brother!!! I agree with you +++ on it all. Just wanted to step in and defend the new grads out there. It is tough to have them in some positions / clinics but they need to know that they have the base skills that will get them there...sooner than later!
As for me...thanks for the job offer (haha) but I don't think my farmer husband and daughter are looking to relocate!!! Been at this profession for going on 8 years now and because of my "gypsy" lifestyle while single, I have had the opportunity to work with many different therapists in various settings...a learning experience in itself. Have to say too, that I still LOVE, LOVE, LOVE what I do which is why I can suppress some of the cynicism (but can understand where it comes from)!

Anyway...back to the original post...SCOTT - WHAT'S GOING ON??

[alophysio]

THanks for that.

Indeed. In fact, i always ask the new grads to cut their teeth in the public system where there is usually good supervision, continuing ed and willing patients