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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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