YouTube Transcript:
Craig Purdam - What about hamstring tendinopathy?!

what I want to do today is in this last
session and now it's after the afternoon
break and but you can't can all relax a
little bit I'm not going to be
controversial or anything like that so
sorry Twitter oh this is really a
clinical paper and it's probably a
marriage of two great interests of mine
tendinopathy and also that of chronic
hamstring issues and this is pretty much
this the group that I'm trying to cover
here and I guess I'm going to try and
share with you more from a clinical
perspective and whatever we do have out
there in the literature of how we might
approach these particular patients so
the way we go I'm just gonna go a little
bit on Anatomy and Anatomy is boring but
Anatomy still is the basis of so much
that we need to consider so again I'm
not going to read through all this but
one of the really interesting anatomical
features in this quite complex origin of
the hamstring anthesis is we have this a
protuberance ligament here which is I've
seen series with the biceps the biceps
tendon and semi men semitendinosus has a
variable tendon in fact quite often it's
actually just muscle tissue that inserts
into the bone so and it really is very
variable between people but the the
interest the one of greatest interest to
us of course I'm sorry is the
semimembranosus tendon which is quite
flat but it arises deeply from up here
it's deep and lateral and there is
actually a little speculation at the
moment that and you consider it's
probably in flexion and some adduction
where there can be a sort of twisting
and compression that area a little bit
like um jewelers alluding to with the
plane Taurus but as I say that's just a
little speculation at the moment but
there's certainly a lot more to learn
about so many facets of this area it's
an area that's been hard done by in the
literature there aren't a lot of
articles are there so we're pretty
limited in what we know in this area
what we do know and again these are from
surgical series is that there's some
variability in what people wear people
report the pathology to be that limp
onin
it's mostly from semimembranosus
Bernardo thinks there's a distribution
across both biceps tendon and and the
others as you see there so and again
that could be just variations in their
their client group the article we did
with Tom Goom
I think pulls out the fact that we're
dealing both with compression and we've
heard a lot about compression today till
then with others
shear forces and tensile forces and it
is this combination of forces as you
know the hip joints put in all sorts of
I hope you didn't get that one but in
all sorts of funny angles within sport
and of course then this place is quite a
deal of variable stresses through this
quite complex and pieces and it is truly
an enthesopathy if you like it is at the
tendon bone junction as you see there
there's decided to be some breakdown of
of the of the delineation between the
tendon and the subchondral bone there's
bone edema and insertional cliffs and
also in my second last point there it's
the typical tendinopathy that the Jill
alluded to in her last presentation you
know the increased ground substance
changes in collagen changes in 10mins
cells so no surprises there now there's
a startling a mission in this particular
one which I'll explain in a moment but
the typical presentations I've seen most
recently in the desperate and dateless
group that I have as well Jill they're
obviously the more Australian
footballers and and the rugby men so
both of whom do a lot of work in deep
flexion or racking over the ball or
those things but but we see it less in
our you know in the round ball soccer
type football I think because they're
generally more upright but that's in the
group that we see middle-aged female
runners are a big client group and I
think they have some
a couple of elements in their
presentations that I'll try and allude
to during the day
these non-athletic women and a bit like
the non-athletic
Achilles tendinopathy is that they're
not always helped with the load load
based approaches but it's certainly
worthwhile as Rogers last point in his
presentation that a lot of what we do
end up seeing are these desperate and
dateless non-athletic people sometimes
all they need is a bit more load on
their tissues and get them back into a
zone where their tendons might be a
little more capable I've had a lot to do
with race Walker's and hamstring
tendinopathy is endemic within that
group but my bigger mission talking to
says in early today of courses the 20
odd years that spent with our sprint
hurdles group and so sprinters and
hurdlers are a very large group of these
presentations here so apologies for that
omission a big challenge is that there
are a number of pain so a pain sensitive
structures or enum structures that can
present with pain in the general ischial
region and so the main thing is for us
to try and work through in a very
systematic and very accurate way if you
like through our normal exam history and
examination is to which structures might
be involved and this area more than any
other tends to have its own individual
presentations it's certainly not one
that you can give an exercise sheet to
and off you go because there's this
incredible mixture of presentations that
include or exclude neurological or
sciatic nerve impingement sore issues
with the other my tennis areas which
I'll explain in a little more detail the
history of onsets generally insidious as
you know and you know this well but the
two big groups that you want to try and
elicit pick out pretty early are those
that have had an over stretch injury
this occurs in rugby league football
rugby union football as well as their
rocking or the water skiing accident or
the overstretch in tennis and these are
the group that Carl asked Ling wants to
bring forward because of course
we do need to know whether they have
either complete or partial tears of the
semimembranosus and they take a lot
longer to heal as those of you read
those articles it is also a common sight
for the in fact off quite often the
initial presentation for ankylosing
spondylitis so that the the young male
who often has quite stiff hips and or or
back and has you know pain in in their
back at night and and other portions of
their presentation that's certainly
something that you need to consider too
so and these all happen you know it's
not as though their era tees and we need
to forget about them these present to
all of us and you're all primary contact
practitioners as I'm aware how these
athletes present with their pain
localization or covering the resultant
slides will also talk about low response
tests a little different from what we
have earlier we're going to examine
through this area I won't spend time on
this we really want to hone on the
hamstring tendon and lastly considering
imaging and as to Jill's point earlier
like imaging is not something we do
first but it is something we might do to
complement how our our clinical
examination and and really you know it
all has to make sense so the imaging
changes need to marry up with your
clinical findings not uncommon ly as
people age that we'll see either
age-related changes or load related
changes in or around the anthesis which
may not necessarily have anything to do
with the pain they're presented with and
all in all that comes down to clinical
reasoning and you're all great
clinicians that's why you're here that's
why you're sports physios and this area
I think as much or more than most other
areas can really challenge and excite
and I really enjoy seeing this area as
you probably guessed so the pain sites
the typical pain site of course for our
hamstring enthesopathy is just a little
lateral and and so they posterior to the
ischial tuberosity and as of
consistent sight both to where they will
direct their their pain until you the
way their pain is is predominantly but
there are subtle differences from this
that often direct us to other structures
the most common is people who get vague
aches slightly lateral to that and it
may travel up and down a bit and be a
little inconsistent in the way it
presents not uncommon ly that's more
these peripheral entrapments of the
sciatic nerve anywhere between through
the lists from acidic notch all the way
down to as it passes under biceps we see
an adductor Magnus either a trigger
point type problem or they can get a
true enthesopathy
and there is a true little tendon in
there described by obey which I have on
a subsequent slide we get a lumbar spine
referral which is pretty vague and
whatever we can have a biceps tendon
disruption out from the common tendon
here and we also have a little lesion
that we see in semitendinosus in its
posterior fascia which can sometimes be
be of some interest to us because it
will refer pain here to intents and
purposes it presents like initial issue
but you come up with you know negative
provocation of the site itself and
generally negative radiological findings
too so it's a matter of trying to pick
all these things apart and then put them
back together now provocative tests were
described in the article with Tom Goom
and will generally start with things
like a hamstring bridge does that
produce our pain how much pain do we get
adding new internal rotation and if that
increases their pain we we're pretty
suspicious that it is that
semimembranosus portion of that common
tendon because of course that's picking
up the the medial group to get a high
level provocation of compression
actually then going to things like
arabesque another test that I like is
that of
catchy O's group who uses three stretch
tests but I think the third is the most
provocative when we're looking for
something to really nail the hamstring
tendon where he takes people into
maximum hip flexion and then adds quite
fast in the extension and whether that
reproduces the pain in in and around the
the hamstring emphasis so they're things
that were able to use they're things
that of course we can come back and
utilize his reassessment as well I've
discussed the the imaging and this is a
normal hamstring in thesis here and this
is an abnormal one here so that the one
of the first signings when sightings one
sees is this breakdown of the normal
antha seal plate here so that rather
being a really sharp margin it is
actually blurred and lost we've got a
little bit of intra tenderness edema
we've got some para tenderness edema as
well bone edema is not unusual and we
might imagine a little bit of bone edema
here but the other reason we can use mr
and mrs generally the the modality of
choice is that ultrasound is it's pretty
difficult to pick up and and really
delineate between too many of these
structures so it's more these axial
Emma's which are probably our favorite
Hernando in both Luis Perez described
these fibrous bands that exist on the
deep surface of gluteus maximus can wrap
around the psychic nerve and be tethered
in any way there and and and this is an
issue they're not always visualized on
the on the EMR but they are something
that gives us real problems with these
Sider contraptions which is a whole
other syndrome of itself but I'll be
alluding to it a couple of times in this
presentation just the last one I didn't
cover here is a delamination these are
pretty rare but I'm going to look on the
normal side so it's the people who
really tear away the origin of the
hamstring away from the in thesis so we
see a pretty clear line of fluid in and
around this area
these 10 these are rare but David young
one of our surgeons suggests that they
have a very poor conservative response
and a generally best manage to
conservatively I'd be interested in
other people's opinions on them so I've
alluded to the differential diagnosis we
need to consider and and the first one
obviously these side ignore entrapment
so I've probably covered a fair bit of
that but I urge you all to read the
articles on the deep gluteal syndrome by
hell Mart and he he brings forward a
suite of tests that are pretty nice for
only quotes both the sensitivity and
specificity of those tests to be able to
determine whether that's more
provocative than what any of our
hamstring type tests might be and as you
can see we can have em treatments
anywhere along that tunnel my I've also
discussed this that so the article by
obey which many of you might be
interested in that that they certainly
do occur and are easily picked up and
it's a person who comes in and and you
say Oh where's the pain and they're
going immediately quite medial to the
hamstring tendon so I think that needs
to be a first line of suspicions
there are a number of areas of sort of
trigger points or you know Maya
tenderness strains or call it what you
will that do present through the
external rotators the the gluteals and
others and these are all I not a typical
pain generators whether they're the
primary issue or not is is always one
for great debate and but but the big
issue as we sorry I'll just go back but
the big issue that we have is that not
uncommon ly with a more common chronic
presentations that we're dealing with
more than one pathology we may well have
a truly hamstring tendinopathy but
having to manage areas within you know
the gluteal muscle group the external
micro rotator muscle group and all the
site ignore other structures is is not
uncommon there's a number of rare
syndromes that
that we need to consider at times when
we're not getting our clinical results
with others and certainly in our
desperate and dateless group that we
might spend quite a bit of time trying
to tease out these particular things
which time is going to prevent me
spending too much time on those today
but but I urge you to consider these
when you've exhausted the top three or
four and you generally start there so
they're there stretching a Vulcan
fractures often the avulsions obviously
occur in youngsters but we see people
post a Vol'jin in their 20s and 30s
wanting to sprint or play football and
get ongoing issues from perhaps they're
really of options so that's another
group here as well okay so here's what
we're here for which is to be able to
share and it's probably the only tendon
we're able to share quite the whole
approach to in terms of the
rehabilitation so I'll go through the
four stages you've heard all this before
so what are we going to do we're going
to unload the tenant well how do we do
that well we take out the things that
provoke it in training well what might
they be well it might be our hurdling it
might be our sprinting it might be our
accelerations it might be our change of
direction so depending on the sport
they're the things that you're going to
be looking at first can you take those
out the other thing you can do is of
course is rather than participating in
whole sessions you can drop them back to
half a session so these are all means
pretty simply of unloading the tendon
but of course just resting or unloading
is not where we need to get to we
actually need to get to actually
reloading the tenon the other thing is
I've said is unloading compression so
it's anything of trunk on hip flexion
and lastly and again we've how many
times have we said this today team but
going through the kinetic chain so what
are the ways of actually sparing the
load on the hamstring emphasis and of
course the synergy between the the
gluteus maximus and the hamstring is is
probably the primary thing we need to
consider here we're then going to
strengthen up our muscles again no big
going to take out something there but
don't poke the bear is a term that we
use and we weren't going to use today
but because bears are so there's a part
of Boone on day so so it is taking the
the tendon to a point where you actually
are going to poke the bear and actually
increase its symptoms so that was where
it came to but of course you're all
going to understand that answer because
you probably poke bears more than we do
and lastly of course the progressive
loading and that's what I really want to
share with you today so we've mentioned
in others the this monitoring the
progress with the provocative test that
24 hours after your high load sessions
it's all the same here so again this
should be sit back relax enjoy the ride
and nothing did that you haven't heard
already today Evan I showed you this
slide and this is really about finding
positions that we're going to get our
early isometrics in so we really don't
want to be getting pain with the
isometrics or mate we may get a little
pain but when we retest with our
provocative test afterwards which might
be a hamstring bridge we want to know
that isometrics have actually reduced
their pain maybe not to zero in the
single session but one or two sets of 45
second holds of one of these has
actually changed their pain that gives
you reassurance and also your patients
reassurance that the hamstring tendon or
n thesis is a part of this our big
challenge early was how do we get big
forces into a hip neutral sort of
position and so we started with things
like having a we call this a trunk
extension machine or some call at a
Roman chair now we can do double leg
holds with weight but we really as Jill
alluded to and ebony that we want to get
to single leg holds pretty early to get
friends Bosch eventually gets to people
in this sort of position plus seventy
plus body right pretty much but we tend
not to take people that high but of
course you'll go as high as you need to
or isometric holds in a machine their
issue is that most people don't have
these machines at home
and we want to do them four times a day
so then what do we use we use our long
legged bridge and you can actually get
them to just bias it to the affected
side and that that way you're actually
able to be reasonably effective and you
get pretty fair loads early so that's
some that's what you would be using at
home and anytime they can't get to the
other equipment we can use an internal
rotation bias if you really think that
it is the semimembranosus portion the
second stage was about strengthening the
muscle Jill talked of this earlier today
I'm not going to tell you how to
strengthen muscles you do this all day
every day but you know the principles
that what we want to do is sets that
induce lactate so you know three or four
sets with it up and where it's three or
four seconds up three or four seconds
down and you're doing six to eight reps
so that the overall duration is about 60
to 70 seconds that's going to induce
your lactate partial recovery cow again
we need to do it at least three times
sessions a week and we need to have a
know it's not just a single exercise
it's a suite of exercises that really
tackle our hamstrings there your options
we might after listening to every knee
and other since were a lot so I really
like using isometric Spree session to
train our brain to get maximal
activation of our hamstrings so this is
a very important part we might also use
TNT as a means of utilizing that so
again let's adopt all of these things of
course if we need to strengthen gluts
and other things we'd be doing that in
the same session - Jill had this in in
section three doesn't matter whether
it's late stage two or a section three
it doesn't matter but here we're
starting to re-introduce compression
okay so we're getting exercises where
we're not doing fast movements initially
we're doing fairly slow movements but
we're starting to introduce that
compression of trunk on the trunk on hip
we were stunned
what happened there where we're starting
to get increased flexion and increased
compression at the
to join so we can do things like just
lateral sumo squats and we can gradually
increase compression and gradually
increase compression as you do it that
makes a lot of sense I use the sled drag
the sled push quite a bit where we can
do just repeated pushes we can weight
the sled up and I'll show you what that
looks like later but of course we can
then get more and more hip flexion as
their symptoms are telling you they can
tolerate so we can really grade our
compression quite nicely and that's why
I like these exercise it can be quite
accurate with the way that you add add
compression walking lunges are another
good way so again all these things that
you know well and it's only very late
stage that you might look to provoke
them
if this sport requires it to have to go
into full deep hip flexion so they might
go to a single or double leg leg press
but if the sport doesn't require don't
do it because it's just going to add
pain add length to rehab that you really
don't need to do stage 3 adding speed
same principles that we spent all
morning talking about so controlling
range early and in fact often you'll
bring them back out of their range a bit
as you're starting to add speed so what
are things that we might do for the
hamstring tendon things like box jumps
things like faster sled you know where
we're starting to really push along and
I'll show you what this looks like by
far more athletic people on me
we did some analysis in that same group
that we talked about before
I love scooters I'll have run throughs I
love accelerations so all of these
things three-day load cycle again you've
learned about that before so this was an
analysis of doing this sled and that
what's happening at the and again you
know these these quite well but what's
happening in the sled at the when we
sorry when we do a slow sled a fast lead
and then the third step of an
acceleration and you can see here not
much difference in the tensile force but
the big difference is in the rate of
loading and the rate of loading with our
fast lead is pretty much where we get to
with Maksim
acceleration in highly trained sprinters
highly trained runners so that we know
that what we're doing in the gym we can
increment between here and here to take
us all of where we need to get to so I
think that can be reassuring too so now
we're getting becoming more informed in
in this sort of exercise we do one thing
we did find in this testing though is
that we need to consider the friction if
we have less friction here of course we
get less less peaking force and we can
gradually add friction as your way of
loading that tendon Stage four again
just looking for activities that's going
to take them all the way back to their
sport the really important thing is
don't overload these incremental things
that we all we need to do as a little
bit so that can get back to whatever
sport they need to do the really
important thing is that once they resume
sport or resume the training take out
all these high load activities Duke
showed you I think a slide where when we
added high load activities there were
eccentric exercise in fact to people who
are already training that of course they
in fact got worse and the same happens
here so really important in this
sequence that we remove some of our
other loads as we're working back into
sport kinetic chain we know well and I
guess I've alluded to before the big
thing is gluteus maximus is the big
synergist with hamstrings and in fact I
discussed our middle-aged running women
and and so many of them when we see them
actually are quite strong in their
hamstrings but their big problem is that
all they use is their hamstrings and
they often have their if we ask them to
do a hip extension they can't fire their
gluteus maximus at all I'm talking at
all and so so much of the approach is in
fact trying to strengthen their glute
max through thrusters and other things
rather than spending all their time on
the hamstrings so I did want to make
that point we've got a rig now that we
use is a force transducer down here and
a strap we were actually able to
quantify hip extension strength and look
at the relationship beat them side to
side and also its relation to
the flexor strength as well so we're
starting to get some normative data with
that which you'll see in their coming is
same picture so overview it's a
multi-modal approach to management and
that sometimes work in concert with our
doctors we're looking at using
medications and/or injections to hit
some of these other pain generators to
really clarify the picture for us so
that we can get back to concentrating on
the hamstring tendon and its
rehabilitation at a time that really it
is about effective tissue loading hand
quite considered loading over time these
things do take time the hamster this
hamstring anthesis is generally not slow
to rehabilitate but none of them are and
it is really about lots of accumulating
load over time and I've said that so
happy endings there's two things that
really worried us so introducing
compression too early and sometimes you
need to back off that keep going through
other progressions and then reintroduce
compression later and then this elastic
function in the late phase it's an area
that again is can become a bit
intolerant and this relationship and I
didn't spend and I can't spend time
talking about the site ignore but
there's almost another lecture you could
give around strategies further SciTech
nerve and settling that down which is
not uncommonly needing to do in your
rehabilitation here so that's it for me
again thank you very very much for the
experience and mr. chair back to you
[Applause]