[Physio Discussed] Making sense of hamstring injuries with Adam Johnson and Scott Hulm

In this episode, we discuss hamstring injuries. We explore: 

• Relevance of the mechanism of injury
• Role of the BAMIC classification system
• Imaging in hamstring injuries
• Differential Diagnoses of hamstring pain
• Essential objective tests
• Key rehabilitation strategies

Want to learn more about hamstring injuries? Scott Hulm has done a brilliant Practical with us on hamstring injury assessment and treatment where he goes into further depth on this topic. 

👉🏻 You can watch his practical now with our 7-day free trial:
https://physio.network/practical-hulm

Adam is a physiotherapist who has been working within professional football for fourteen years, with half of this time being within a Premier League first team environment. As a result of this experience he has a keen interest in the management of lower limb muscle injuries, particularly the hamstrings and Rectus Femoris. Adam has also has an interest in research and has had three articles published within peer-reviewed journals.

Scott is a sports physiotherapist and biomechanist. He is completing a PhD at the Australian Catholic University’s SPRINT Research Centre, where his research focuses on biceps femoris long head structure–function relationships using advanced MRI, applied biomechanics, and muscle modelling. Scott also works in elite Australian football as a senior physiotherapist and rehabilitation lead at the Western Bulldogs Football Club.

If you like the podcast, it would mean the world if you're happy to leave us a rating or a review. It really helps!

Our host is @sarah.yule from Physio Network

👏 Become a better physiotherapist with online education from world-leading experts:

https://www.physio-network.com/

Transcript

Introduction

SPEAKER_00 0:04

What differential diagnoses should always be on your radar in the context of hamstring strains? And which subjective and objective signs really matter, and which ones don't? And how should hamstring strains be classified to guide rehab and return-to-play decisions? Today on Physio Discussed, we're unpacking hamstring injuries with two world-class clinicians working at the very top of professional sport and applied research. Scott Holm is a highly skilled sports physiotherapist with a strong interest in injury prevention, rehab, and athletic performance. He has completed a master of high performance sport and is currently undertaking PhD research focused on hamstring strain injuries and high-speed running biomechanics. Scott is a senior AFL rehabilitation physiotherapist at the Western Bulldogs, where he plays a pivotal role in optimising athlete recovery and return to performance. Adam Johnson is a physiotherapist currently working full-time at the Everton Football Club in England. He has over 14 years of full-time experience in professional football, including roles at Brighton and Hove Albion and Stoke City. Adam has been heavily involved in short to medium-term rehabilitation of muscle and ligament injuries and has published multiple peer-reviewed research articles. You're going to absolutely love today's episode. It's filled with plenty of clinical gems. I'm Sarah Yule, and this is Physio Disgust. Well, welcome Adam and welcome Scott to the podcast today. Thank you very much for having us. It's great to have you both talking all things hamstring injury and hamstring strains. So I think it's right that we start at the very beginning and just going to clinical practice. So I'm curious, in your clinical practice, how do you both go about diagnosing a hamstring injury or a hamstring strain? Perhaps Adam, we'll start with you.

SPEAKER_01 1:59

Obviously, within the elite sports setting, there's generally quite a lot of pressure to make that diagnosis quite early. So, and we would be lucky enough that that we would see a lot of the mechanisms and be able to go and refer back to them. So we would generally get that kind of early picture of a mechanism of injury, whether it's an acceleration, a maximal sprint, is any curve running involved, those sort of things. Again, generally we'll be able to get the video footage. So we'll be able to review it. And then on the bed, really, it's about getting those early, early signs. Is there any loss of range, any loss of strength? And then again, I think if you look at the literature and a lot of it would suggest it it's probably quite relatively easy to pick up if someone's got a hamstring strain, where the difficulty comes is trying to figure out how big and significant that injury is and exactly what structures are involved. So I think again, with the pressures that are involved, we would generally look to utilize MRI imaging relatively quickly within our practice to support what we're seeing in our objective findings and give confidence in that diagnosis and then be able to give a prognosis off that. So a lot of our decisions will be, as I said, relatively acute. We'll see that person quite early on when they're still probably quite symptomatic, and then lead them down that path of utilizing the correct imaging processes.

SPEAKER_00 3:24

Just in terms of obviously mechanism of injury is very relevant and you've got the luxury of video playback, how much weight are you putting on mechanism of injury and immediate symptoms versus what you might find objectively?

SPEAKER_01 3:38

Yeah, I think again, if we're always going to have warning signs, if we say it's a game and someone's gone for a maximal sprint and they go down and they're unable to continue, that's going to be one of our kind of key signs that would lead us there. Again, where it becomes maybe challenging is those cases who present to you in the treatment room with those kind of low-level symptoms that have maybe progressed over a couple of days. And again, I think there's some recent stuff come out from the guys at British Athletics to suggest that they're they're the real warning signs. And are they structural injuries? Are they precursors to structural injuries? And what can we do about that? So I think again, reading that that paper in the last couple of weeks has really resonated with me in terms of just because someone's functional and maybe assesses well and objectively looks okay, really listening to that subjective that they're giving you to understand and pick up that clinical picture as early as possible to try and see what might contribute further down the line. So trying to take everything in subjectively as well as objectively to give you that picture and really flag up those lower level injuries if you can before they progress to anything more significant.

SPEAKER_00 4:54

Yeah, great. So you're getting that the whole picture. And Scott, what are your thoughts?

SPEAKER_03 4:59

Well, Adam summed up pretty well. I think definitely in our elite sporting world, it is fortunate to have the video footage. And I think someone's linking that, and certainly in terms of location of injury, seems to be a really crucial piece of the puzzle. I think now we're starting to have a better understanding of probably the structural locations and some of these tricky sites. So definitely sort of add to the clinical assessment is those palpitary locations, particularly, for instance, if I'm seeing uh you know a particularly high grade sprinting mechanism with sort of internal tubial rotation, and we're seeing that distal side as the as the side of injury and palpitary soreness. Now we've already got a pretty high degree of concern for sort of that distal oponeurosis and these T junction type injuries, and alternatively those high, so long length eccentric sort of actions, uh, maybe with a level of hip abduction, the high grade proximal semi-mem sort of evolution injury. So, like just trying to place those mechanistic elements with some of the clinical features, particularly in terms of location, I think is something that certainly jumps out at me, which then certainly helps guide our imaging process from there to exactly identify sort of the the level of injury from a severity point of view, the tissue involved in terms of are we are we looking at a free tendon type injury, either from an evolution or a rupture point of view, or are we starting to look at some of these eponetic injuries, intramuscular or this distal eponeurosis involving the T junction? So just trying to place those together. But I think Adam's point around sort of these acute on chronic type injuries, we don't tend to often categorize them in that manner, but certainly in our fields, I think where the training demands can be so high and and match congestion at times, depending certainly on the sporting pursuit, trying to navigate where our athletes may be starting to show signs of, I guess, overload or fatigue or at a subcellular level of failure. And then as a result, can we look to identify those those low grade type injuries? And there's a great scope of these that diagnosing is obviously our our primary sort of role in these acute instances, but yeah, can we strategize a way to prevent some of the more high severe, the high grade, you know, particularly severe type injuries?

SPEAKER_00 7:28

I was going to dive into that classification component a little later on, but how do you go about classifying those hamstring strains in your practice? And what are your thoughts in terms of as clinicians, how specific do you think we should get prior to sending for MRIs imaging?

SPEAKER_03 7:47

I'm probably biased in this space with my interest in around the poneurotic sort of involvement in sort of my practice. Obviously, similar to Adam, we we utilize MRI pretty readily. Uh, and as a result, that sort of certainly helps to guide us uh along the BAMIC, sort of the British athletics classification system. And certainly that helps to start to build out what sort of tissue type we're certainly the the level of the lesion is occurring in. As I was sort of alluding to, I think our understanding around probably exploring that in a little bit more detail is probably necessary now. In sort of our practice, we tend to use a little bit more of dynamic ultrasound approach, particularly maybe at that distal eponytic site. MRI tends to undersell maybe the severity of those injuries. And we've certainly had instances where MRI would suggest a lower level injury where we were concerned about the sort of the level of that severity based on some of the findings from the MRI. We went to dynamic ultrasound, we went to a surgical approach and arroscopically or surgic from a surgical perspective, the the severity was certainly more extensive. So we know that there's still limitations to some of these things to trying to build out the whole picture. But I tend to blend a BAMIC approach with certainly some of the work that's done certainly from Barcelona and Carlos Perdre and certainly his work through the use of sort of alternative imaging approaches to try and classify sort of the level and type of maybe tenderness or poneotic injury.

SPEAKER_01 9:23

Just to agree with that as well, it's a similar, similar thing. And we would utilize over the years has been much more understanding of what that means, not just within the the kind of medical space, but our players would be very conscious and aware of what those gradings are, that they kind of have an understanding of that, which is a positive and a negative. It it helps with explaining that'll be the first question they ask when the report comes back. Well, what grade is it? Is it a a C because they know that that means significantly longer rehab time and anything when they hear those kind of three, four C's and they understand the implications of that around time loss, then the negative is that's a a really big band to just put people in. Not all three C's are going to be the same, as Scott's kind of touched on. The the location of it has a massive implication. And also, again, around some of Scott's work, even just uh the direction of the tear, is it longitudinal, transverse? There's so many different bits that are going into it that I think we're trying to understand more on. Again, within this elite sports setting, you're always trying to minimize time loss and trim as much time as you can. But with that comes knowing the ones that you also aren't push and you have to respect and respect that those tissue healing times. So I think that's definitely useful. And I think we would look to utilize dynamic ultrasound. I think the issues of that is it's a lot more user-dependent and kind of open to misinterpretation or missing things, whereas that MRI is a little bit more consistent now that the BAMIC classification's been used so consistently for so long, we have a little bit more confidence in that. I think as kind of staff and players and a group, we understand what that means. So it'd be very similar to what Scott said, just to build on those points a little bit.

SPEAKER_03 11:15

Yeah, I just want to jump in. I was the Adam's point there around the player involvement and and even educating other staff around that. As soon as the tendon or the eponeurosis involved, everyone is completely aware within the the four walls of the organization to try and educate on, yeah, yeah, not all tendiness injuries are are the same and and and not all are going to have to miss the extensive times. And and the bias at that, obviously that we have to navigate as clinicians, I think is certainly something to be cognizant of. And no doubt we'll talk to some of the clinical and features and criterion-based approaches where it is a real blending of these skill set and knowledge base, because just to suggest that we have a this level of injury out, particularly maybe like a tenderness site, indicates this level of time miss is probably underselling sort of the interpretation around trying to pull a multitude of clinical, as we've alluded to, subjective objective features there and all that imaging data altogether to at least put a framework around when we're returning this athlete to play.

Return to Play Post Hamstring Injury

SPEAKER_00 12:24

And no doubt this is probably a larger question here. But Adam, you also spoke before about the decision process of who you might push versus who you might take a more conservative approach. And Scott, as you've mentioned, not all tendon injuries are created equal. What's your decision process in terms of who you do push and who you don't? And then how do you navigate that conversation with the players or with the patients?

SPEAKER_01 12:52

It's a real challenge, and had some recent conversations around these, not just with hamstrings, but it might be ankles or whatever. And it's about understanding the player and their demands. And I think if your conversation around a 35-year-old centre back in football who has been around the game, understands their demands, understands how to manage themselves and won't be exposed to huge volumes of high speed running, will very rarely hit sprint distance, maybe in a the tactical setup that you're in, versus your 19-year-old star striker who is going to be achieving repeated maximal velocity output, high sprint distance, and that utilizing that as their game, those decisions have to look very different. And what your level of kind of acceptance of risk is has to be very different. And again, all those things like timings in the season. What are you looking at if this is someone who is in preseason and has the whole season ahead of them, the chances are you're going to be a little bit more cautious around that to try and minimize the risk of re-injury and have them fully fit throughout the whole season, versus someone who, again, is looking end of season, cup final, etc. All those scenarios that we talk about are the things that come into play. That's where some of the subjective comes in around players' appetite for risk as such, or appetite for being aggressive around again, previous experiences. This will look very different for someone who has had two, three hamstring injuries in the last 18 months versus someone that is, again, halfway through their career, 26, 27, never had this before. And again, you're thinking, okay, that this may might be due to external factors. And we, if we can manage those a little bit better, we can manage them through versus someone who has got a kind of chronic injury history, and you're not going to need time to really address that and make those changes and get them in the best place to minimize reinjury risk. So I think that's a lot of the conversations that we would be having with the management, with the player with us as a medical department is okay, what's contributed to this and what do we think is a successful outcome for this player? And again, as kind of Scott's not as touched on, not just looking at it as this is a 3C or a 2B, it'll be six weeks or 12 weeks. It's okay. Who's the player in front of us? What's led them to this? And again, have they had neural symptoms in the lead up to it? Has there been factors that we need to work on? Has there been issues with muscle soreness before? Or is this just a one-off incident that we understand why we think that's come about?

SPEAKER_03 15:43

Adam's point's brilliant. In terms of the athlete in front of you, and obviously the injury history and the demands of the game and the demands of that particular player is absolutely first and foremost. How do we look to get this athlete back to those peak demands? And obviously that looks a little different for everyone. But I certainly I do still come back to just some of the pieces around okay, what type of lesion are we dealing with there? I still think that plays a role here, and there's certainly aspects of tissue healing and a respect of elements into the type of lesion that would influence when I would might push and pull, and that certainly that would look very different for very different types of lesions. And again, locations may play it play a role with that. And then that's then starting to drive what are some of the other features that this athlete's shown me before in terms of that might be muscle architecture, some of their clinical strength outputs, where have they been particularly poor? Where are they strong? What else have we been able to explore with them? We might even have a little bit more about from a morphology point of view, what they look like. Does that play into some of their risk profile? But just to add to, I guess, Adam's overall point is it's all about building this risk profile and then providing key stakeholders. This is sort of the cumulative effect of all these pieces, and this is what we are proposing. And then as a result, like particularly as a medical and a high performance team, we make decisions based on that and go to work in the rehab space.

SPEAKER_02 17:16

What's an easy way to improve your assessment and treatment skills? Introducing practicals, where you can watch video recordings showing exactly how top experts assess and treat a range of conditions. It's the fastest way to develop your practical skills and enhance your clinical reasoning. Treat your patients like the experts do with practicals by Physio Network. Click the link in the show notes to try it for free today.

Education in Hamstring Injuries

SPEAKER_00 17:41

I think you've both summarised that marvelously. And it sounds like, as it never usually is, a yes or no and a straightforward answer, but drives home the importance of understanding that full patient profile and making a patient-led decision based on the evidence that you have in front of you. Let's zoom in a little bit more on what you're actually seeing and hearing in the room. And at some point, Scott, I'd love to hear your thoughts on how you actually explain the physiology in terms of those tendon injuries versus the muscle injuries. Because as we know, the the education that we give to the patient can often reinforce the adherence to the treatment as well. Well, actually, I might ask that question now.

SPEAKER_03 18:24

To be honest, there's nothing better than a great diagram and visual representation for athletes. So generally that's where I tend to lead a lot of those questions in terms of we'll often utilize the MRI. And then I'll I'll tend to illustrate that in terms of a more sort of muscle tendon schematic and trying to explain to athlete where their lesion or injury is, then provide some context around, you know, for instance, as if it is that T junction site, I'll illustrate why we suspect, particularly if we're seeing a splitting type lesion, where we see an extension of kind of the T junction like protrusion along the epimyceal border. That might be something that we would suggest is a little bit more concerning and therefore explain why we might take a little bit longer in the early stages before, for instance, these athletes know a lot about their training demands, why I might take them into sort of some longer length, either testing or training positions early, why I might protect some of that MTU length. Kind of again just using that visual representation and kind of connecting that with things that they know around I said exercise or testing procedures that we would often do. And then as a result, the athlete is completely aware of. So yeah, connecting those types of things really as simply as possible.

SPEAKER_00 19:40

Yeah, fantastic. Thank you. Do you have anything to add there, Adam?

SPEAKER_01 19:45

Again, just building on that, I totally agree. I think they were imagery around it works really nicely. So, again, just those kind of different examples around if someone's got a big intramuscular tendon injury and there's some loss of tension in that tendon. And just that ability to explain and demonstrate that to the patient, the player, to show, okay, let's compare this side to the injured side. And we can see that loss of tension, that waviness, and that understanding that, okay, that that tendon isn't going to be able to provide the scaffolding and the elasticity that you need it to provide. And this is what we're trying to work towards, and utilizing those re-imaging periods throughout the process to show how that's progressing and continue to try and gain that ongoing buy into the rehabilitation to be able to show, okay, this is this is where it started. This is what you had originally, this is how we're progressing through. And this is how you're adapting to the work and the loading that we're giving you in hopefully a positive way. Again, to give confidence that, okay, I've seen that before, and I can see how that's progressing, and I can see how that's going to allow me to function again within my return to sport. And again, as you go into those criteria-based approaches through to high speed running, sprint distance, max velocity exposures, trying to provide them the confidence from the real obvious imagery and understanding of what they've involved to guide them through that process. So I definitely think imagery is a really good way. Obviously, one of the skills is to try and be able to explain it to everybody that you have to be able to explain the same injury to the medical team, to the manager, to the player, to the agent, all those different stakeholders within the process. But images and diagrams help with that to kind of level the playing field so everyone's seeing and understanding, hopefully, the same information.

SPEAKER_00 21:39

Yeah, absolutely. Understanding the how and the why, and then set the expectations. I'm curious, before we move on to the next question, do either of you have any regular analogies that you use or usual descriptions you roll off?

SPEAKER_03 21:54

My athletes would just say that I always bring out my three-dimensional computational models. I think I have these sort of fancy bicep spam and long head and short head on showing them, and I'm sure they're more sick of seeing them than anything. But that's generally more than a good analogy. But yeah, I'm just uh I like to jump in and give them a bit of a demonstration.

SPEAKER_00 22:19

Yeah, great. What about you, Adam?

SPEAKER_01 22:22

I think a lot of mine would be around like the what are the demands of it. So again, that like really driving home the what that tendon is going to have to do, for example, is it nice and elastic? Is it compliant with what we need it to do? Trying to break down so using those kind of keywords rather than anything else, and then leading that through into the rehab exercises and going, okay, we're doing this because we want to change the elasticity of this structure, or because we want to provide load to this certain area, and just trying to keep using keywords so they they see the point of everything that they're doing and not going too kind of maybe in depth with every single exercise. But today is a day focused around this, or this morning we're going to really focus around X kind of keywords and try to utilize that and give themes to everything that that we're doing. So it'd be more those kind of rehab-based themes throughout the process that hopefully they they would see and not get bored with, but kind of understand constantly what we're trying to achieve and see the can continuity and progression throughout the process.

SPEAKER_03 23:27

And the elastic band model, I think, is like a such a nice one for athletes to grasp from a tender's point, is it will often use that in terms of snipping the theroband into ways to demonstrate like how the lesion might be presenting again the longitudinal kind of split along the intramuscular tendon, such a nice example of why if you keep loading that structure, it's just going to keep peeling apart. So hence why, again, when you lay that onto the rehab themes of why you're doing X, Y, Z, I think yeah, that's such a nice way of, I think, for athletes to really grasp that. And my argument is that that probably largely these are all connective tissue lesions. I think the idea of that like this isolated muscle injury is probably a little of an outdated model. You effectively are, you are going to fail at some point of sort of that connective continuum. So explaining to athlete that elastic bang theory is is probably preferable, yeah, in terms of trying to explain too much more outside of that.

Subjective Exam - What To Look Out For To Guide Prognosis

SPEAKER_00 24:25

That's great. It's the ultimate challenge for us as clinicians, isn't it? It's making the how do we make the complex simple without losing the integrity of what we actually need to say. And I know that often that comes with both of you probably explaining the same thing in a thousand different ways and having a feel of what lands and what doesn't land, and so refining it over time. It's our, it's our never-ending journey. So let's dive in a little bit more, going to the subjective side. You've already mentioned mechanism of injury. What other things might you listen to in the patient's story that will influence what you then go on to measure objectively or what might influence your prognosis? I know that's a large question, but Adam, we might go to you first.

SPEAKER_01 25:12

Yeah, so I think one of the one of the key things, again, within the literature, and it's a really difficult one, is that kind of link between maybe some low back pain or neural sort of symptoms. And I think again, where the research not is lacking, but where it's very difficult to research this sort of area is to respectively understand that is difficult to kind of get a big sporting cohort where, I don't know, you're assessing slump tests every day or at least weekly to try and understand what is that a risk factor? Because we know that it's something that's there post-injury. We see it, whether that's where the bleeding or scarring post-injury around the nerve, has that led to it before? Is there something further up that chain or along that chain neurally that's contributed to it? So that's definitely something that that I would always be asking and trying to understand from a subjective point of view. Have you felt anything in the lead up to this? Because we're likely to see, as I say, positive slumps or straight leg raises with hip internal rotation afterwards, we're likely to see some of those neural signs after. Is that a symptom of the injury that they've sustained, or is that a predisposing factor that we need to consider within our rehabilitation and trying to address that again in those patients we might see with recurrent injuries? This is definitely something that that I'm looking to consider. And what can we do to try and probably dampen down that kind of neural sensitivity that's we're maybe seeing as part of the rehab process again? So that that's a really key subjective questioning line that I that I would always go down because I think you don't want to just assume that that's come about because of the injury, and then you're addressing all the other structural things respecting all the kind of healing processes and the timelines that come with that. But actually the the main thing that was there prior to it you haven't addressed, and then you're always heightening that risk of of re-injury further down the line. So, yeah, for me, that that kind of neural component or how that's referred, or low back pain, and what's going on at a disc level within the lumbar spine, what kind of structural components are there that might increase the risk of re-injury or reduce the risk of a successful rehabilitation process. So, yeah, definitely that for me.

SPEAKER_03 27:41

Yeah, for me, it uh sort of made me think of some of uh Matt Wollin's great work, sort of in injury prevention space, which is really around touch points and respecting this idea of niggles. The thing is with elite sporters, they've all got niggles. So this idea of having these constant dialogue with your athletes and touch points, and that might look like you know, wellness or monitoring in different organizations, that might be how our conversations align after training, after games, after a whole range of different aspects, I guess, of the sort of the weekly business. But yeah, how how do all these touch points feed into to the how the athlete is responding to said training load and game loads? That's a really big piece. And because as Adam alluded to, within the literature, it's a really challenging space. But then that sort of feeds out into the kind of the sequelae. So is there a lumbar component? Is there complaints around anterior hip tightness, abdominal groin? Is there a groin history? How that affecting some of their swing phase mechanics? Is there a recent ankle niggle that's feeding up the chain from a stance-based kind of aspect of the mechanics and part of some of their extensor kind of mechanism? So I was trying to like put all these pieces together and feed in. Obviously, we're leading all the theories here to hamstring-based injuries, but that sort of obviously that has a fallout effect in lots of different spaces. But as Adam also alluded to, is like those with a past history, those things flash in the back of your mind when these things pop up from a monitoring conversation, a sort of touch point point of view. Obviously, yeah, some athletes are more resilient and others that have had that sort of past history may be more susceptible. So really listening out, but then looking to explore from a secondary kind of injury prevention perspective and then it look where necessary, intervening and and modifying. So that's kind of, I would suggest our primary kind of approach in that kind of subjective space, yeah.

Differential Diagnosis of Hamstring Injury

SPEAKER_00 29:38

So I suppose going down that rabbit hole of differential diagnosis before we move on to objective assessments, you've spoken about clearing the joints above being the lumbar spine and considering the kinematics from the ankle. What do you find are the most common differential diagnoses when someone does present with hamstring pain? And are there perhaps one or two clues that really help you separate true hamstring strain from other pathologies?

SPEAKER_01 30:04

Yeah, no, I think it probably touches on some of the things that we've discussed, and that's where it's really difficult around as and when to use imaging. And I think there will be 100% players that that we see who, again, maybe aren't even reporting things or are reporting low-level symptoms that will have some element of injury to an extent if you if you were to image them. Again, athletes are very good at coping. They find strategies to cope with things. And whether that be their demands in training, they find ways to not cheat, but adapt and get through sessions and be able to self-manage. So I think that's where it is very difficult to really truly differentially diagnose between something that's structural, something that's not structural. And again, I think it's more about the pattern of it. We know that the big high grade ones would like to think we're not going to miss them, they're gonna have those bigger mechanisms, classic patterns, but it's more the subtle ones that I think are the real challenge for us in terms of differentially diagnosing the grade zeros and the grade ones and those sorts of things. So I definitely think that's where it's the real challenge. I think more than thinking, okay, am I going to miss a hamstring injury? It's more what level of the injury and what exactly is involved within that.

SPEAKER_03 31:27

Completely agree, Adam. I think that kind of the idea of the grade half, grade one, like that's the that's the most challenging area because a lot of these athletes we know will present with some hamstring tightness or soreness that won't go on to have a more significant injury, will continue to play, train, and effectively survive, and then we'll have others. That niggle is really something that is probably suggesting us some sort of subcellular like failure point that we're just not able to either discern from our clinical markers, from our clinical testing point of view, our subjective components and and particularly MRI imaging in in that space as well. So yeah, it's a really yeah complex sort of area, and I keeps coming back to you know that the testing element is just not precise enough in many of those cases. So it's uh it's a really hard space. But just the only other thing I have is that this idea of the neural, like the differential element is clearly that we've touched on that, but the proxhamitendon components and I speak for a lot of maybe clinicians with especially within clinics and working in different sort of local clubs, that that can present in a variety of different uh ways as well. So just being cognizant, I guess, of that masquerading, obviously, as these niggling posterior thigh pain, obviously there's uh it's clearly going to have that proximal component, but yeah, having an understanding of how that may inform your yeah your ongoing management of that athlete as well, but it's certainly just something to consider in these cases.

SPEAKER_00 33:00

Absolutely. And then presumably you're considering the language used. And do you notice consistency in terms of the descriptors people use? Burning versus lancinating versus ache, dull, those sorts of things for your tendinopathies versus your hamstring strains versus your lumbar referrals.

SPEAKER_03 33:21

The hamstring strain ones, as Adam alluded to, the big ones show themselves pretty clearly. They're kind of hard to miss, as the lot of grey ones, but that they will present with often a player will describe either, which is this isn't the horrible word, but they always say they've got DOMs. They've got DOMs immediately after training sessions, which is unlikely in terms of how that actually would uh you know work out. Tightness is often the descriptors we'll tend to see. If we are seeing Lancinating burning these types of descriptors, well, already I'm starting to suggest that maybe there's another sort of aspect to what is driving these symptoms, which might lead me along with some of the, as I said, the slum, the passive straight like rays, and some of our sort of other neural dynamic sort of testing approaches to try and clear some of those features. Yeah, but the what the big ones are pretty clear-cut. I think they're sort of hard to miss.

Objective Testing in Hamstring Injuries

SPEAKER_00 34:16

Absolutely. Moving on to then the objective component. Objectively, do you have any tests that are your non-negotiables?

SPEAKER_01 34:25

Looking at from my point of view, would be looking to understand strength because I think, like I say, they're they're good at being able to adapt and show different different ways. So I think always trying to quantify and objectify those strength markers again within our setting, we're gonna be very fortunate to have a lot of historical data. So we're gonna we're gonna be able to compare that and really understand is that their norm? And I think if you had someone walking into a clinic, that's gonna be difficult to do. You don't know their norms, you don't know where they're able to produce it in again, as Scott's touched on the the different ranges and the different lengths, the different contraction types. But one of the the other big tests for me as a kind of non-negotiable, if someone can't perform that kind of Askling's H test, that real quick, rapid, active straight leg raise, essentially, I find that as a really good marker because it's an objective marker, but also very subjective. It's trying to see how comfortable that player is. And they can't cheat that. They can maybe find different certain positions in a strength test to bias a slightly more medially if they want to stay away from that kind of lateral hamstring and just find slight little ways. But if you set up the asking H test properly with the straps and everything like that, and you're looking to get them to perform that test rapidly, they should show a lack of comfort or a lack of willingness around that. So again, if someone's come in, as we've talked about, they've got you know SOMS like symptoms that they're reporting subjectively, and we just quickly want to test that. If they're unable to perform that objective test because of a lack of kind of subjective willingness to do it, that would be a real red flag for me, thinking, okay, if they're they can't perform this bed-based test, then I'm not comfortable with them then going out and looking to perform something maximally in a functional setting because they've shown a lack of willingness in in an isolated environment and probably not going to be comfortable with them carrying that then out onto the pit.

SPEAKER_03 36:25

My only add-ons is that I tend to lean on a lot of the aspartar work and and particularly Rod Whiteley's paper around some of the clinical exam stuff and mainly focusing on the sort of the combination of palpitary soreness, there, that MH fake discrepancy, particularly in length there. I think that's a key feature. I think when I'm seeing a subjective reporting of posterior thybin acutely, palpitary soreness, and then a a loss of MH fake, then combined with a series of sort of bridge testing, and that might may or may include these really out-of-range base testing, which again we can measure from a strength point of view from a load cell or a dynamometry point of view, combining those pieces together, I think you can elucidate kind of the location of that failure point if you are going to find it. As Adam sort of the ones that clear those sort of period, those sort of testing, that testing battery, and they're kind of like still presenting pretty well, that's when you do need to elicit, I think, something that's more demanding from a velocity point of view, uh, as he alluded to. And then you're gonna feel a little bit more comfortable about testing them on field based off that as well, because I think that's obviously gonna be part of the process as well, to make sure that you feel really confident. But if they're not clearing a lot of those other basic tests, I'm starting to have a pretty high degree of concern. People ask me a little bit about this with the poneurosis involvement. I think when you are seeing a pretty notable failure point, some of those poneurotic injuries, particularly the longitudinal splits, sometimes can present quite well strength-wise, but they tend to still be quite poor from a length perspective. So I I think if I'm seeing a big deficit there, uh, especially as I said, coupled with maybe video footage, mechanistic. I understand, like when you're starting to put together all the pieces, yeah, in isolation, it gets really strange, especially if the athlete's like, well, I haven't, I can't recall an incident in that case. So yeah, it's again not so clear-cut, but it's uh that that's sort of, I think, a pretty, yeah, a rigorous approach that would look to capture more than you miss. It would be boring if it was too straightforward, wouldn't it? Absolutely.

SPEAKER_02 38:36

Want an easy way to improve your assessment and treatment skills? Introducing practicals, where you can watch video recordings showing exactly how top experts assess and treat a range of conditions. It's the fastest way to develop your practical skills and enhance your clinical reasoning. Treat your patients like the experts do with practicals by Physio Network. Click the link in the show notes to try it for free today.

Rehabilitation of Hamstring Injuries

SPEAKER_00 39:01

The last point here is I'd love to talk about what I'm sure everyone's also wanting to know, which is around rehab. So I'm curious what are both of your processes in terms of early to mid and late stage rehab, understanding that, as we've already spoken about, the diagnosis obviously will dictate and change the prognosis. But are there any consistencies across your rehab protocols?

SPEAKER_01 39:27

For me, it's I'm kind of quite a criteria-driven kind of therapist, really. So there'd be a lot of consistency through the different stages, again, almost showing why we're looking to achieve things. But I think in that early phase, again, as as has been touched on, a lot of the early ones are trying to get them asymptomatic because again, I think we have an understanding that the longer there they are symptomatic on things like pain on walking, loss of range on that NH fake, palpable test. The longer that is there, ultimately the longer we're expecting them to miss. So that's going to be a big kind of form the early part of the criteria is we can't progress into anything meaningful loading-wise, and how that looks in terms of rehab until we've got these early signs and symptoms under control. So setting a number on them and kind of going, okay, we need to get that palpable tenderness down to two or less out of 10 and make sure that's not reactive as well, kind of monitoring that day-to-day, making sure we've not had a kind of an acute or a day delayed reaction to the loading that we've got. So kind of using that in the early phases. And again, looking to progress through those criteria from a strength-based marker and looking to progress, seeing how they go and going, okay, we might be able to look to get you outside jogging, low-level jogging early doors when you're at 70, 75% of your opposite side or your preseason screening markers, because we understand that we're not actually going to be using the muscle that much at lower-level jogging speeds. Within that, we want to encourage kind of functional patterns, getting the muscle being fired in the way. Again, I think there's so much really good work coming out at the moment to show how individualized everything is and the way that people react is so individual. All our exercises are going to have completely the same exercise, gonna have a completely different outcome in all the different athletes we work with. And ultimately, the sooner we can get them functional and running or moving in the way that they move, we'll get that muscle firing in the way that they need it to fire. So trying to get that kind of rehab process as functional as possible as early as possible, but as as safely as possible, is what I would look to do. And then use those kind of gym-based, bed-based criteria as touched on, such as things like H test to give us confidence to progress through with the function. And then probably last point with me on this is around the again going back to the imaging, that fine balance between again some of the stuff that's coming out from the guys in Barcelona and Carlos around like re-imaging classifications and how healing stages and try and use those to again give us confidence or understanding, looking at edema within there, has that changed? And A, we're we're hoping that that edema's going away and regressing as we're progressing through the rehab, but ultimately using that and going, okay, there's been an increase in edema through this stage. We just need to back off at this point and use that as a criteria to understand is the muscle under stress again? Are we providing too much load too early? And using those kind of healing classifications to guide us through. But it is a challenge because that's bringing in so much information into the rehab and trying not to let just one thing guide you. And again, trying to make that bigger picture of, okay, subjectively, we're getting this information, objectively from imaging, we're getting this, objectively in the gym, we're getting this, objectively outside, we're getting this information. And where does that put them at throughout those different phases and stages to progress through?

SPEAKER_03 43:17

Yeah, completely agree with everything Adam's mentioned there. I I really like the the idea of thinking of it like at an almost like an imaging kind of like approach, like that. This got a clinical kind of testing approach, a strength testing approach, like maybe a morphology, like architecture kind of approach, like all those are feeding in across kind of those periods of the rehab Adams alluded to. Like you have that kind of protective earlier phase. Clearly, your your clinical and markers inform that in terms of as alluded to like when are you recovering from certain elements of cabaltry soreness? Are you able to clear it? It might be a simple trunk flexion. Tears it can you pain free bike, you know, pain-free walk, pain free run, and you're clearing those. And in my mind, it's in the back of, I guess, my mind, I'm thinking, what is the tissue doing in those early stages? Where are we sitting from a tissue healing perspective? Again, imaging can help inform and support either. Am I right in my decision making there? You know, is that sort of going to inform when I may use a bit more of a strain-based approach? And I kind of probably sit more that side, like, when am I going to explore more strain on the tissues that have failed? So can I protect them early? Can I progressively load them? And I'll use again imaging to help support that, but also obviously a range of exercise selection to again either protect, progressively restore, and then times exceed and try and like achieve adaptation at these tissue sites. And you're trying to do that across the phase of the rehab and trying to align all those pieces is the real fun and art of it, is like, when do I intervene in terms of an RDL-based approach, which I think we hope to put some work out pretty shortly to try and illustrate some of the demands that the MTU is undergoing in some of these sort of high degree of trunk tip flexion tasks, as well as what does that look like when we're looking at some of our more knee-dominant based approaches and kind of what is the MTU strain looking like that? What is the muscle forces that they're undergoing in these spaces? And how does that kind of look to inform when we intervene? And then we're going all the way back to the stars, kind of like the peak demands element, like when are we layering on our acceleration demands we know from a strain rate point of view, that can be really demanding. So maybe some of the constant sort of speed running in terms of velocity is probably where we tend to start with and then try and explore that a little bit later. And that's obviously going to replicate a lot of sporting pursuits, not just European or round ball football and all the rules. So trying to just overlay all those pieces of the puzzle, I guess the only things that I tend to lean on with that is a lot of the muscle morphology elements and utilizing some different technologies. Springbok analysis has been really big in this space. That really helps to inform the type of athlete I'm working with in terms of maybe where they have preferential adaptation. So that might actually look to shift my approach from what they've actually been doing to where I think they need to trend and layer in on some of the muscle architecture stuff. So looking at some vassal length, pnation angle changes is my also exercise having the effect that I think it is. That's the other piece of the puzzle because there's some great protocols and there is great guidelines out there. Like it's there for everyone to see and utilize. But the challenge is that individual piece that Adam mentioned is did this athlete actually adapt in the manner that I suspected they would? And then that kind of flips all the way back around to the imaging approach. And am I seeing the adaptation at that tendinus lesion? Adam's point around the adenous like recovery. But then we've also seen some great work from them showing that from the guys from Carlos and that the sort of Barcelona imaging team that that tendon and aponeurosis will actually have some significant adaptation. Thereby identifies at least some key time points. Now we know that probably differs for the type of lesion and the type of athlete, but that does give us an idea of well, is that a more mature-based lesion? So therefore, I can explore a little bit more from an intensity point of view that that might look like maximal glossy sprinting or the type of task that we're completing the gym. So you can hear this is the exciting piece of the job and the pieces that we're still, yeah, where it really is the art form. We clearly use in science to inform us really dramatically. But when we're working with the athlete in front of us, you've got to make a decision on that intervention. And so I think trying to utilize strategies to at least try and to yeah, review your work. You're constantly doing little pre-test, post-test sort of analyses on a variety of these different levels that I've mentioned. So I think that's yeah, kind of my approach to it.

SPEAKER_00 48:00

I feel like to summarize both of your approaches, just this magical combination of beginning with the end in mind, understanding the athlete, understanding the sport, the physiology, the muscle morphology, knowing your asterisk, signs, and the why to drive your rehab pathway. Hopefully I haven't missed anything there.

SPEAKER_03 48:18

Yeah, the beginning with the end in mind is such a is a such a great way to place it. I I think of the peak demands, Elma, I tend to use that terminology more and more. Now I think the old still used to be worst-case scenario, which seems like a little negative, but that idea of yeah, preparing your athlete for all the aspects that they need to do, and that can include at many factors.

SPEAKER_00 48:41

But absolutely. Well, Scott and Adam, thank you both so much for sharing your insights on all things hamstring today. I think there's a ton in there for clinicians to reflect on, from sharpening up our diagnoses to differential thinking right through to the rehab and what that looks like as the research morphs as well. So thank you very much both for your time.

SPEAKER_01 49:05

Thanks very much for having us. Yeah, it's been great to chat to you both.

SPEAKER_03 49:08

Thanks, Sarah. It's been yeah, it's a great conversation. Always happy to chat hamstrings,