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Craig Purdam - What about hamstring tendinopathy?!

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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]

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

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