Sunday, September 27, 2015

Hamstring Strain

A nagging pain develops in the back of your thigh. Was it the added speed work? Maybe the increased milage? Could it be a strained hamstring?
Conventional thought is the hamstring bends the knee. When we want to flex the hamstring our knee bends. However, during function, our muscles work differently. In running, the hamstring slows down knee extension as your knee swings forward. The hamstring muscle elongates to control the knee's motion. This is called eccentric muscle action which puts more stress on the muscle. With increase mileage or speed the hamstring becomes overworked and leads to a strain.

Before we look at hamstring, we have to assess other body regions.

Rule Out These Body Regions...

Low Back

The first thing is to rule out referred pain from the lumbar spine. When the nerves of the low back are compressed, it can refer pain to the muscles it innervates. Typically compression of the S1 nerve (also L5 in a smaller population) will refer back to the back of the leg.  Even though the pain is in the hamstring, treating it will not affect the underlying cause. The compression can be caused by a herniated disc or by a condition called stenosis. Taking pressure off the nerve is the only way to treat the "hamstring pain".

Sacroiliac Joint

Next check to make sure the pelvis is level! The pelvis can become malaligned with a mis-step off a curb, long periods of poor posture or simply imbalance of muscles. The hamstring is attached to the ischial tuberosity on the pelvis.  A mis-alignment of the pelvis will have a different pull on the hamstring causing a strain. To perform a quick screen, stand in front of a mirror making sure your feet are aligned forward. Put your hands on your pelvis with the index fingers under the pelvic bone. Look in the mirror to make sure your hands are level.

Top picture: shows level position of pelvis. Bottom picture: shows
rotated position of pelvis

***If you have symptoms of low back or sacroiliac dysfunction please go see your physical therapist.

Hamstring vs Gluteals

When the low back and sacroilliac joint are cleared, we can truly treat the hamstring. OR can we? Conventional treatment is to stretch and strengthen a strained hamstring but research shows the muscle is flexible and strong. Assuming there wasn't a specific incident, a strain muscle signifies overuse. So we have to find out how the hamstring get strained in the first place.
When we look at the function of the hamstring it is similar function of the gluteals. If the gluteals are weak, the hamstrings are at a biomechanical advantage to take over. In addition to treating the hamstring we have to consider glute strength.

Gluteal strength Test 

A quick screen for gluteal strength: Perform 10 on each side. Is there one side that's harder then the other?

Gluteus Medius - Lay on your completely on your side. Leg should be in line with the trunk. Lift leg towards ceiling. ** Make sure to not let the leg drift forward

Gluteus Maximus - Stand in front of a desk and lean forward. Kick your leg back without twisting your hip.


Single leg squat - Stand on one leg and perform a squat. Keep the knee aligned forward and pelvic level. 

Left shows good single leg squat form; R shows the knee rolling
inward and and the hip dropping

Basic Strengthening

Clam - Lay on your side with knees bent to about 90 degrees and heel lined with bottom. Keeping the feet together lift knee towards ceiling. The key to this exercise is to ensure the hips are stacked directly on top.

Side leg lift - On your side, hips stacked on top. The bottom leg can be bent for stability. Lift top leg up towards ceiling. Make sure the thigh is in line with the body. The tendency is to allow the leg to drift forward.

Bridges - Lay on your back with your knees bent. Flatten your back by tilting pelvis up. Lift the hips off the ground.

Tri-Plane Strengthening

Tri-planar Lunges with Arm Driver

Using lunges are the best way to strengthen the gluteals. Reaching our arms in different directions can isolate certain muscles. This sequence will help increase gluteal strength. Lunge forward while reaching your hands forward. Next lunge forward while reaching the arms sideways away from the front leg.  Lastly turn your arms towards the right leg. 

Lunge with reach towards foot 

Working the hamstring eccentrically is the best way to simulate it's function while running. Step back with one leg and squat back while keeping the front leg straight.

Treating the Hamstring

Hamstring Stretch 

The first couple days of the onset of hamstring pain, the focus is to decrease inflammation. Apply ice for 15 minutes 2-3 times a day to decrease inflammation and take a couple of days off from running.  After 3-5 days use a heat pack to help increase blood flow to the area. Gentle stretching of the hamstring can start.

Lacrosse Ball Massage

Using a lacrosse ball to massage the hamstrings will help restore mobility of the soft tissue. Providing compression and relaxation to the hamstring will allow improve fluid dynamics of the soft tissue allowing the muscle fibers to glide more efficiently. 

A hamstring strain can take up to several months to resolve. However, taking time off from running and performing the proper exercises can accelerate recovery. Be patient!

Stay tuned for the next post!

Tuesday, September 8, 2015

It's Plantar Fasciitis!

You get out of bed one morning and your foot hits the ground. "OUCH!" What's causing this pain? You walk around getting ready for work and the pain seems to be disappearing. "Phew", you have to go for your 10 miler after work. The next day the same thing happens. Eventually, you feel the pain every time you stand. AND even when you are running! Finally, after a week you decided to do a Google search - plantar faciitis.
You roll, you ice, you wear a sock thing at night, but nothing changes.

What is plantar fasciitis?

Plantar Fascitis is the inflammation of the fascia (connective tissue) on the bottom of your foot. It spans from the heel to the toes. At the beginning stages,  the tissue gets stretched with weight bearing however over time, with each step the tissue gets more inflamed.

What are the risk factors plantar fasciitis?

A systematic review of journal articles on plantar fasciitis was performed in 2008 and revised in 2014. The big risk factors for getting plantar fasciitis are being a runner, a person who stands for work and limited ankle dorsiflexion. We all all know you're not going to stop running or working, so let's focus on what we can change.

Limited ankle dorsiflexion
This means the ankle joint has a limited mobility to flex the foot towards the body. Ankle dorsiflexion is required to have proper mechanics while running. When ankle dorsiflexion is limited, the sequence of movement of the foot is changed, putting more stress onto the plantar fascia.
Tightness of the calf muscles ( gastrocnemius and soleus) can also contribute to limited dorsiflexion. Connective tissue from the calf spans down into the heel and blends into the plantar fascia. Limited mobility of the calf muscles can contribute to increase stress of the plantar fascia.


Ball Roll on Calf 

Most people with plantar fasciitis know to roll the bottom of their foot on a tennis ball or golf ball. However, there is a myofascial pain referral zone at the base of the calf where the muscle becomes tendon. This zone is slightly to the outside of the center of the muscle tendon junction. In a long sit position, use a roller or a lacrosse ball to roll out the area for 2-5 minutes depending on tolerance.

'X' marks the spot

Ankle Mobilization

Lace Lock method
When you can't have a therapist to follow you around, you have to improvise. Using a running shoe is the perfect substitute to assist in self mobilizations. Tie shoes using the lace lock method. Thread the lace on the same side through the last hole. Pull the opposite lace through the hoop. Tie the shoes really tight across the front of the ankle. In standing, put one foot in front and rock forward allowing the knee to bend to mobilize the ankle. Angle the knee to go over the pinky toe. Then angle the one to go over the big toe.
5 times each direction
*** Only tie the shoes laces very tight when mobilizing!!

Calf Stretch with Tri- Plane Tweak

This is a tri-planar tweak on the standard calf stretch. Stand with one foot forward and use knee to drive the motion forward. Then twist left and right. Lastly sway your hips side to side.
Perform 10-15 repetitions

Out of the box

In normal mechanics, the hip and thoracic spine absorbs lateral and rotation motion respectively as the arms swing back and forth. However, if those regions are stiff, the motion is transferred to the ankle. The ankle is forced into an over supinated position. In the supinated position the foot is unable to absorb shock putting more stress on the plantar fascia. Improving mobility in the hips and thoracic spine will take the stress off the plantar fascia.
Please refer to earlier post on stretching the hip and thoracic spine.

By addressing limitations locally in the ankle and globally at the hip and thoracic spine, you achieve a more comprehensive treatment plan.