Linked to the British Journal of Sports Medicine Blog: No more poker face, it is time to finally lay our cards on the table

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Brett Fisher
6 years ago
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1 Hamstring Rehabilitation Programme Linked to the British Journal of Sports Medicine Blog: No more poker face, it is time to finally lay our cards on the table Andy Rolls

2 Day 0 Injury occurs Limited initial assessment, we saw it happen we know where the pain is, there is no need to assess other factors at this time Cryotherapy via Game Ready 20 minutes Cryotherapy via Game ready again if possible 20 minutes Compression bandage, figure of 8 with zinc oxide over area of local tenderness Encourage Pain free walking, small steps Compression on until bed time, off to sleep in If travelling this can be difficult Removing it for sleep, prevents any potential over compression issues Day 1 Assessment Location of painful area Strength assessment Subjective assessment Any pain on walking, is my first question, I think the answer to this gives an indication to speed of progression, take and record VAS on walking Ask about how the injury came on, tightened up, came out of the blue, anything prior to injury in game or before game Anything in back, neck, other joints Objective assessment Palpate the area and draw around the painful area, record measurement. If VAS on walking or on prone active knee flexion is 6 or above my objective assessment will be very gentle and only just and just elicit pain If pain is 2 or 3 ish I will be more aggressive in my assessment Size of area gives an idea of tracking, and what needs to be resolved, if there is marked bruising I may photograph the area to monitor progress If any of these strength tests are painful (VAS 6+) I stop at that level but if the VAS of 2- I try to do all tests 1. Supine 90/90 Test isometric I start with test 1 as 2. Prone lying, knee at 90 degrees its easy and allows isometric you to gauge how far 3. Prone Lying knee at 30 degrees along the 9 tests you isometric will go. I always like 4. Prone, Concentric knee flexion to start isometrically 5. Add manual resistance to number 4 and progress from above there. 6. Add eccentric component to above test Record pain levels 7. Bridging on a bent knee and a straight and location leg 8. Bridging on a Single Leg 9. Pertubations to a slightly flexed SL bridge

3 ROM/ Flexibility assessment With the strength test above I start at number 1 and work my way through to number 9 stopping if the pain increases. For ROM /flexibility I do all 3 tests 1. SLR with and without neurological bias 2. Shift test with the hip fully flexed passively straighten the knee 3. Slump testing Compare sides and record range and location of pain Day 1 Treatment Aims of treatment Create an environment for optimum healing, get the player walking and moving pain free asap without aggravating or disturbing the healing area, show the player that we are going to be respectful of the injury but still aggressive and positive in our rehabilitation. Treatment then consist of; Cryotherapy Game ready 20 minutes at the start of the day and at the end of the day Hivamat I will use the hivamat, on the entire hamstring for approximately 30 minutes. (Deep Why? Firstly, anecdotally I feel this treatment helps in the first 3 days, Ossilation secondly and perhaps more importantly I cannot ask the player to come in for Therapy) assessment and ice alone, I want to be seen to be aggressively doing something! So the Hivamat is an early intervention that I am happy will not aggravate the healing area. Massage Around the area to try and drain the area but not directly over the area, this is somewhat of a time filler as it is so light it probably is doing very little physiologically, but mentally it be very important especially with players from around the world who feel hands on treatment is essential even at this early stage

4 Day 2 The player will come in to be assessed as previously and treated as above, on day 2, I will start to assess the SIJ, the lumbar spine and the Hip mobility and if required I will treat these areas as required. Then at as near to 48 hours as possible the player will have an MRI Scan. The MRI scan will give us a grade, the actual grade of the injury will not change greatly what I do as I will use objective markers to gauge its progress rather than time, but it will rule out a complete rupture and it will help us give a rough time to those who need to know. The scan is also carried out because within football at this level it is expected by the players. This pattern of treatment continues until walking is pain free and most ADL are pain free, perhaps the odd sensation when he does something new, running upstairs, bending forward quickly are allowed when we start active rehabilitation Progressing Rehabilitation I use 3 main markers to allow me to progress my rehabilitation work 1. Subjective symptoms on walking, stairs, general movements (ADL) 2. Hamstring squeezes at 90 and at 30 degrees knee angle on a force platform or on a pressure cuff, we are lucky we already have numerous data points prior to injury. 3. Weights able to lift on the Glut ham machine 4. Other none hamstring exercises compared to pre injury weights Subjective Hamstring squeezes Isometric Other s My aim will be to eventually have 6 hamstring muscle exercises (2 isometric, 2 hip dominant, 2 knee dominant) and I will build up to this gradually, If the injury is distal I will start with isometrics and proximal / hip dominant exercises,

5 If the injury is proximal I will start with isometrics and distal / knee dominant exercises. For me the isometric exercise progressions are the most important and I look to progress these more aggressively than any other exercises. A Knee Dominant Prone knee curls not loaded progressing to manual resistance throughout range B Knee Dominant exercise Sliders, these come in later as we will talk about as they have a large eccentric component C Isometric Hold Roman Chair or Glut Ham hold machine D Isometric Hold Bosch Planks E Hip Dominant Hip Pull downs F Hip Dominant Gluteal bridges progressing to Hip Thrusts May occasionally use kettle bell swings Level 1 Entry Criteria to start Level 1 Gym work Subjective No pain on walking, No pain on stairs, occasional sensation on certain movements Hamstring squeezes Not Done yet Isometric Test Double Leg Bosch Plank Pain free Other s A Knee Dominant B Knee Dominant exercise C Isometric Hold Glut Ham Hold Machine Double Leg, Body weight D Isometric Hold Bosch Planks Double Leg, Body weight E Hip Dominant F Hip Dominant

6 Level 2 To progress to level 2 gym work Subjective Hamstring squeezes Glut Ham machine Other s Completed Level 1 rehab with no reaction No pain on walking, No pain on stairs, No pain on any movements at all Within 10% of each other, so symmetrical but weak compared to best ever scores Able to do Double Leg, body weight static holds 6 x 30 seconds Right Left** Right Left** 90 degrees 90 degrees 30 degrees 30 degrees Average Day As the example above shows this injured player on day 2 shows that there left and Right symmetry is very good but the strength figures at both angles are low compared to this players average As I said earlier If the site of injury is distal I introduce the hip dominant exercises at this stage If the site of injury is proximal I introduce the knee dominant exercises at this stage Level 2 Gym Work A Knee Dominant Prone knee curls Active Con and Ecc B Knee Dominant Sliders, Concentric Only exercise C Isometric Hold Glut Ham Hold Machine Double Leg, Add weight D Isometric Hold Bosch Planks Double Leg Introduce Single Leg E Hip Dominant Hip Pull downs Emphasis on Concentric F Hip Dominant Gluteal bridges Double Leg

7 Level 3 To progress to level 3 gym work Subjective No reaction at all to previous work Hamstring squeezes Still symmetrical and strength showing signs of improving Glut Ham machine DL Static Holds 25% of Body weight and upwards 6 x 30 seconds Other s Right Left** Right Left** 90 degrees 90 degrees 30 degrees 30 degrees Average Day Day The example above shows that the symmetry is being maintained and the strength is gradually increasing at the 90 degree angle, as the player become more confident and stronger Level 3 A Knee Dominant Prone knee curls Manual resistance to eccentric component B Knee Dominant Sliders, Concentric and eccentric exercise C Isometric Hold Glut Ham Hold Machine Double Leg, Add weight Introduce Single Leg D Isometric Hold Bosch Planks Double Leg, Body weight Single Leg introduction E Hip Dominant Hip Pull downs Concentric and Eccentric F Hip Dominant Gluteal bridges Double Leg Single Leg Introduction

8 Level 4 To progress to level 4 gym work Subjective Hamstring squeezes Glut Ham machine Other s No reaction at all to previous work Still symmetrical and strength showing signs of improving (although in this case the 90 degrees have improved and the 30 degree have not) DL Static Holds 50% of Body weight and upwards Once either the hip or knee dominant have reached pre injury strength the one furthest away from the injury site are decreased and more mobility work is started Right Left** Right Left** 90 degrees 90 degrees 30 degrees 30 degrees Average Day Day Day So at day 10 the tests at 90 degrees have increased a lot, are symmetrical when left and right are compared and they are with in average levels however both the 30 degrees knee flexion are lagging behind, so I increased the reps and sets of the isometric holds, and decreased the hip dominant work, and at this stage I add in up downs on a roman chair Level 4 Activation Isometric Hold Bosch Planks Double Leg, Body weight Single Leg introduction B Knee Dominant Sliders, Concentric and eccentric exercise C Isometric Hold Glut Ham Hold Machine Static Double Leg, Add weight Single Leg, Add weight Add in up downs for DL + SL Isometric Hold Glut Ham Hold Machine Dynamic DL + SL with Body weight E Hip Dominant RDL Add weight to get to previous level F Hip Dominant Hip Thrusts Add weight to get to previous level

9 Once the 2 hip dominant exercises have got to their pre injury weights, reps and sets of these are decreased to maintain strength rather than increase Movement progression Table for Hamstring Muscle Rehabilitation It is always difficult to discuss movement progressions in a case study because all players are so different and some players need more time in certain areas than other players, I roughly use the table below but it is hard to use objective measures to progress the movements. So I start movement progressions once a level 4 strength session has been completed and progress these as each stage is finished. So I try and complete the green work at this stage. This is a table I put together a while ago, I use it regularly because I think all of the work involved is important is successfully rehabilitating a hamstring injury, however in this honest piece of work I must say I never start at the top and work through all levels as time pushes me too hard to achieve this, however I start at the top and try to do as many as possible, also in my current job I have to pass the player over to other professionals once I am happy that pitch work can begin so it is difficult to change and adapt this as required 1 1a Low Intensity 3x1 4x1 Side Stepping + Grape Vine Arabesque Walking * * * * * * Proprioception Progressions * * * * * * * Hip Mobility * * * * * * * * * Low Intensity * Forwards/Backwards and Sideways Thoracic Mobility * * * * * * * * Moderate Intensity 4x1 4x1 Side Stepping + Grape Vine Moderate Intensity 4x1 4x1 Forwards/Backwards as move Sideways Hurdle Mobility * * * * * * Arabesque Walking with a Twist * * * DB DB SAQ on Aerofloor 10m 20m High Knee marching * * * * High Intensity Side Stepping, Grape Vine, FBSW 4x1 SAQ Warm Up * * * * Pitch Runs 40% 50% Crash Mat Running * Jump Progression * * *

10 Uneven Ground Running * * * Backwards Running * * * Single Limb balance * * * windmill, DB Stair Running Progressions 1@t 2@t Fall forward start drills * * Lunge walking with toe Touch DB * * * Agility Runs 40% 50% 50-70% Change of Direction Drills 40% 50- Max 70% Total Distance + High * Intensity 70% Sprint Distance 125% * Explosive starts * Integration/ Sprint when fatigued *

11 Level 5 To progress to level 5 Activity Subjective No reaction at all to previous work Hamstring squeezes Strength has improved to pre injury level (days 25 and 29 have done this) Glut Ham machine DL Static Holds 75% of Body weight and upwards SL static Holds 25% of Body weight Other s Right Left Right Left average Day Day Day Day Day Level 5 Gym Work Level 5 Movements Activation Isometric Hold Bosch Planks Double Leg, Body weight Single Leg introduction B Knee Dominant Sliders, Concentric and eccentric exercise C Isometric Hold Glut Ham Hold Machine Double Leg, Add weight Single Leg, Add weight E Hip Dominant RDL Add weight to get to previous level F Hip Dominant Hip Thrusts Add weight to get to

12 Once the level 5 gym work has been completed twice and there has been enough time to recover the emphasis moves to movements. The end stage of rehabilitation depends very much on the player; What is the total distance he covers in a match? What is the distance he sprints? What is the distance he high speed runs? How many sprints does he do in a match? How many high speed accelerations and decelerations does he do in a match? How does he normally recover post match, this will tell you the days rest you need between sessions? When you know all this you can design your running program, I start with ticking off total distance my first session is a self paced run or jog at a steady state with no accelerations or decelerations to cover about 50% of the players total distance (4 x 8 minutes gives about 6km), then a day recovery then outside again to repeat the first session with perhaps 5 x 8 minutes. 1) First objective is total distance, 75% of the individuals match total distance 2) Then I aim to tick off high speed run distance 3) Finally it s the individuals sprint distance and number of sprints (I always try to over cook sprint by doing at least 125% of total distance and number of) 4) then explosive work and then work under fatigue Total Distance + High Intensity * 70% Sprint Distance 125% * Explosive starts * Integration/ Sprint when fatigued * Conclusion I allow a good period of time early on to allow this injury to settle, Once settled I am fairly aggressive with the progression of my hamstring exercises, I use objective data to inform me when to progress this work By using objective data and not time I feel we don t necessarily get the player back quicker but I feel the player does return better! Training used to be used to get players fit but under current pressures the emphasis has changed to being game ready almost before training ready, I think objective measures help control this.

Part A: Running. Max 5 mins. Slow run forwards 5m and return x 2. Hip out x 2. Hip in x 2. Heel Flicks x 2

Part A: Running. Max 5 mins. Slow run forwards 5m and return x 2 Jog straight to the 20m line. Make sure you keep your upper body straight. Your hip, knee and foot are aligned. Do not let your knee buckle