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Medscape has published another article touting the benefits of exercise in preserving mental cognition. The "new study finds that older adults who reported being the most physically active had less brain atrophy, higher volumes of gray matter, and less damage to white matter compared with their more sedentary counterparts."
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Of the many injuries physical therapists see each year, hamstring strains are notorious for being stubborn to heal. They are frustrating for both patient and therapist, as they often reappear many times in one's sporting life, especially in those sports requiring sprinting, jumping and kicking. Soccer and Australian Football League (AFL) come to my mind when I think of the hamstring injuries I've seen in both New York and Australia. Gabbe et al (2006) investigated the predictors of hamstring injury in the AFL - they make up 16% of all muscle injuries in the game. Small et al (2010) found that soccer players can miss up to 3 games per hamstring injury, and make up 40% of the muscular injuries in soccer (Yeung et al, 2009).
Why are hamstrings so difficult to rehabilitate? Sure...muscle imbalance, poor core stability, pelvic torsion, adverse neural tension can all be to blame. But perhaps we have not taken into enough consideration the way the muscle tissue was injured. Hamstring injuries are not homogeneous after all. In a brand-spanking new article Askling et al (2012) investigates the method of hamstring injury and the prognosis following injury.
Askling et al (2012) break down hamstring strain into two types: 1) Stretching injuries and 2) High speed running injuries.
Stretching injuries occur when the hamstring tendon is lengthened beyond its normal elastic/plastic tearing point. This usually occurs when the athlete's knee and foot are at their highest elevation at the end of the kick – the combination of hip flexion and knee extension. This movement puts the hamstring in a position of extreme stretch, most commonly injuring the semimembranosus tendon at the ischial tuberosity (Askling et al, 2006, 2007). Unfortunately the combination of poor rehabilitation protocols, premature return to the field and the fact the tendons located near the ischial tuberosity have a poor blood supply, lead to this particular injury having a poor prognosis.
This particular injury needs a prolonged rehabilitation period. Passive stretching should be avoided in the first week to avoid further pain and tearing at the proximal attachment. Players, trainers and coaches should be informed that although these injuries do not seem to be as severe as more distal intramuscular hamstring injuries, they take much longer to heal due to the time it takes for remodeling of the tendon to occur (Garrett el al, 1984).
Conversely, high speed running injuries to the hamstring are usually located at the muscle-tendon junction of the biceps femoris. Although these injuries usually result in greater initial pain, bleeding and functional loss, they do not require as long a rehabilitation time as the stretching type of injury. Silder et al (2008) believe the biceps aponeurosis scarring which occurs after the injury, may allow for alternative force transmission paths, and therefore a faster return to activity.
Intramuscular biceps femoris strains usually present with greater VAS pain scores, greater weakness, larger range of motion loss and more tenderness to palpation. A number of tests which measure range of motion, pain and strength can provide a good estimate of the time it may take to rehabilitate this type of hamstring injury (Schnieder-Kolsky et al, 2006).
Although these injuries heal faster than the stretching type of hamstring strain, they still need to be given the respect they deserve. High load exercises and passive stretching should be avoided with this type of injury in the initial stages of rehabilitation (Askling et al, 2012).
Again, players, trainers and coaches need to be made aware of the fact that although this injury may feel better in the initial stages of rehabilitation compared to the stretching type of strain, it is imperative that symptoms are not provoked, so as not to further prolong the rehabilitation time.
Prior to the past couple of years, I used the Sherry and Best (2004) hamstring rehabilitation protocol for my hamstring tears. I now use the below protocol by Heiderscheit et al (2010), which provides a very detailed 3-phase hamstring rehabilitation protocol. The authors note that individual attention needs to be placed on the sets/reps for each patient and adjusted where appropriate.
Any thoughts regarding this new and interesting article by (Askling et al, 2012) are welcomed.
Ice: 2-3 times/Therapeutic Exercise (performed daily):
Ice: Post-exercise, 10-15 min, as needed Therapeutic Exercise (performed 4-5 d/wk):
Askling, C.M, Malliaropoulos, N & Karlsson, J (2012) High-speed running type or stretching-type of hamstring injuries makes a difference to treatment and prognosis, British Journal of Sports Medicine, vol 46(2), pp86-87
Gabbe, B.J, Bennell, K.L, Finch, C.F, Wajswelner, H & Orchard, J.W (2006) Predictors of hamstring injury in the elite level of Australian football, Scandinavian Journal of Medicine and Science in Sports, vol 16, pp7-13
Garrett WE, Jr, Califf JC, Bassett FH., 3rd Histochemical correlates of hamstring injuries. Am J Sports Med. 1984;12:98–103. [PubMed]
Heiderscheit, B.C, Sherry, M.A, Silder, A, Chumanov, E.S & Thelen, D.G (2010) Hamstring strain injuries: recommendations for diagnosis, rehabilitation and injury prevention, Journal of Orthopaedic & Sports Physical Therapy, vol 40(2), pp67-81
Silder A, Heiderscheit BC, Thelen DG, Enright T, Tuite MJ. MR observations of long-term musculotendon remodeling following a hamstring strain injury. Skeletal Radiol. 2008;37:1101–1109.
Small, K, McNaughton, L, Greig, M & Lovell, R (2010) The effects of multidirectional soccer-specific fatigue on markers of hamstring injury risk, Journal of Science & Medicine in Sport, vol 35, pp120-125
Schneider-Kolsky ME, Hoving JL, Warren P, Connell DA. A comparison between clinical assessment and magnetic resonance imaging of acute hamstring injuries. Am J Sports Med. 2006;34:1008–1015
Sherry M, Best T. A comparison of 2 rehabilitation programs in the treatment of acute hamstring strains. Journal Of Orthopaedic & Sports Physical Therapy [serial online]. March 2004;34(3):116-125
Yeung, S.S, Suen, A.M.Y & Yeung, E.W (2009) A prospective cohort study of hamstring injuries in competitive sprinters: preseason muscle imbalance as a possible risk factor, British Journal of Sports Medicine, vol 43, pp589-594
In these financially pressing times, do you ever wonder whether that gym membership you are paying for makes economic sense? Do ever you look at your credit card statements and feel sick with guilt that you may be paying up to $160 month, but only going to the gym maybe 5-6 x per month, if not at all?
Check out my latest article in the Examiner to read more....
Patients may or may not be aware, but since 2006 in New York State, a prescription is not needed to see a physical therapist. Direct access allows physical therapists with 3 or more years of experience to see patients for 10 visits or 30 days without obtaining a prescription from a doctor. This is great for PT from a professional standpoint, as it allows us to be at the forefront of diagnosis, planning and care for individuals with acute conditions. With more power though, comes more responsibility.
Read my recent article in the examiner and feel free to comment.
Tennis elbow, lateral epicondylitis, lateral epicondylalgia or whatever you wish to call that pain on the outside of the forearm, is not easy to treat. Assuming that “tennis elbow” is not referred pain from the cervical spine, there are many treatment techniques I have encountered that aim to reduce the pain of the condition, and increase the hand and elbow function of those afflicted by it.
My recent article in the Examiner examines this topic further.....
Which provides a better outcome with respect to pain and narcotic use after ACL surgery - a cryocuff or regular ice pack? Both are routinely used during the early stages of PT after ACL surgery. A recent post on theptproject explains which is superior. Feel free to leave your comments.