Hamstring strain recovery

Here is my post on recovery after a hamstring injury. Check out my previous post on hamstring strains for structure, function, signs, symptoms and risk factors.

Recovery:

When a hamstring injury is suspected it is advised to seek early medical attention from a sport medicine physician and physical therapist. They will be able to identify the severity of the injury and prescribe a very careful rehabilitation program. They will also be better is assisting you with return to sport thus minimizing the chance for re-injury. I see many patients that have made a minor injury significantly worse by trying to run too soon after the initial injury. They often feel the need to “test it” with a short run even though they don’t have a pain-free and unrestricted normal walking stride.

In the early stages of recovery stretching is avoided, as this actually slows the healing process by prohibiting muscle regeneration. I use the analogy of pulling the edges of an open wound apart. We don’t do that as it slow the healing process. When many “ old school” family practitioners diagnosis a hamstring injury, they often tell the patient to rest, heat and stretch. The research shows this is definitely the wrong approach and will likely lead to re-injury.

Restricted mobility of the hamstring is addressed by moving in the pain-free range of motion. Ice will help if it is done 2-3 times per day. The duration of ice depends on how the ice is delivered./ 5-8 minutes with an ice cup and up to 10 –20 minutes with a cold pack. Early stage exercises are done in a pain-free range of motion without direct resistance to the injured hamstring (no hamstring curl machines).

When pain-free and normal walking stride is achieved more functional strengthening is added. Aggressive stretching to end range should still be avoided. Core work and gluteal strengthening are emphasized. Hamstring curl machines are avoided as this is not strengthening the hamstring in a functional manner. Exercises that work the hamstring eccentrically (contracting but lengthening) are recommended. Speed of movement is gradually introduced and is one of the last things to improve. Return to running programs begin with downhill walks and uphill jogs progressing to continuous jogging to running over several weeks.

Hopefully this is helpful. Remember to seek help early, ice, avoid stretching an injured hamstring, avoid hamstring curl machines and don’t try to return to running too early!

Let the body adjust

With further reading of the April edition of the Running Times, I found a another way for us to increase our mileage after lay off or an injury. Jack Daniels (the exercise physiologist) suggests that the old 10% a week rule is arbitrary. He recommends staying at a certain mileage for 3-4 weeks then adding approximately 10 more miles in the next week. He suggests adding 1 mile or 10 minutes to each run you do in a week. Then you would stay at that level for 3-4 weeks before the next jump. This method give s the body a chance to adjust to this stress level before a new level is introduced.

More on dynamic warm-ups

I just got my April edition of the Running Times magazine. This issue is full of some great articles, one written by Mackenzie Lobby on the benefits of a dynamic warm-up rather than static stretching. This author shares more on how static stretching inhibits muscles action. Static stretching actually relaxes muscles which is obviously counter productive when you are about to run a hard workout or a race.

Dynamic mobility exercises will better prepare the muscles involved in running to begin their work and help to avoid injury. Static stretching is better suited for post workout routines. St. Vincent Sports Performance suggests a pre-race /workout routine of slow jogging then performing dynamic mobility exercises followed by some up tempo striders.

This has been my approach for several years. I no longer do any static stretching before any work-out or race. I also avoid static stretching after a hard race or workout as well. It is my opinion that it is safer to stretch a least 1 day after a heavy load is place on muscle. Give the sore muscles groups a chance to naturally stretch during your average day. It has been my experience that runners who stretch after a hard run or race actually predispose themselves to injury.

Here is a link to view what they are doing at St. Vincent Sports Performance.

Running out of Rhythm/ my PVC story

I thought I would share a story about my heart specifically about PVCs (premature ventricular contractions). Put simply, PVCs are an extra heartbeat that disrupts the normal heart rhythm. PVCs are very common especially in athletes. Treatment is recommended if symptoms are frequent or if there is a history of heart disease.

To me, PVCs felt like a deep skipped beat in my chest. Initially I would only feel these while at rest (sitting or lying down prior to going to sleep). After I turned 40, and when training in hot and humid weather, I would notice these more often. This summer I participated in the Hood to Coast relay. Shortly after this event and during my fall training my symptoms increased in frequency. I began to notice them daily and while standing as well as rest. My MD and I then decided it was time to get some tests. I opted for a echocardiogram. This test would look at the structure of my heart. It came back normal, but it did confirm I was having PVCs.

Meanwhile, a friend had done some reading on endurance athletes and low magnesium levels. There were several reports of improvements of PVCs with making sure these athletes were getting their normal amounts of magnesium. I decided that it would be worth trying to change my diet and making sure I was getting enough magnesium. I stopped drinking coffee and started eating magnesium rich foods such as almonds and pumpkin seeds. I made sure I took my multivitamin and added a magnesium supplement to make sure I was getting my RDA. I also began my recovery month (lower training mileage. Within a month (December), I could not feel any PVCs in standing and felt very few while at rest. I had my blood tested and requested they check my magnesium levels. My blood work came back normal. In January, I began to ramp up my training. At this time I no longer feel PVCs even at rest.

The moral of this story: SEE A DOCTOR with any heart related symptoms. It is worth getting checked out even if it is just for peace of mind. When I was having my symptoms in the fall, I couldn't train hard without worrying about what was going on with my heart. Get some tests done to make sure everything is alright. Consult a doctor about your diet. There are several research articles on this subject which can be found on Google Scholar. Here are some links to easy read articles on endurance athletes and magnesium deficiency.
sri chinmoy marathon team

Simple running injury prevention tips

Check out the side bar on In Motion for a summary of past posts on simple injury prevention tips.

the runner's core exercises

In this post we have listed the key exercises which Lou & I use in order to keep up our baseline strength and mobility. These exercises load the key muscles involved with running. Each of these phases have a different goal and we try do them in this order to achieve these goals. More reps is not necessarily better. As I do these exercises, I try to think of the goal and concentrate on the quality or control of the movement. We try to do these 2-3 times per week on easy running days or rest days. In the off season, in our case winter, we may do these more frequently. Click on the highlighted words for a link to the post which will demonstrate each exercise. I will also eventually add these to our sidebar with updates for the exercises which I don't have a description. Remember give us some feedback with a comment. I never really know if anyone gets anything out of this blog.

Phase 1
Foam Rolling Goal- relax/release key muscle groups / Hamstrings, ITB, quads & hip flexors
I do 20 reps on each muscle group

Phase 2- Gently lengthen muscle groups which were released with foam rolling.
My key areas are my hamstrings and hip flexors.

Hip Flexor stretch

Lower Abdominals -This is a good way to indirectly work lengthen my hip flexors by increasing
the strength of my lower abdominals and stretch my back extensors without
actively loading my hip flexors as with the majority of Pilates exercises.

Phase 3 - With this group of exercises, the goal is to strengthen muscles by isolating the weak ones which try to get out of doing the work (primarily the glutes).

Clams

Bridging series

Arms

Phase 4 Goal- Strengthen the key muscles in a more functional way or to integrate the muscles which were stressed in phase 3. I don't do all of these in one session but rather I pick 2-3 of these. In the next workout I do the ones I skipped in the previous workout.

• Step Overs /Balancing
  
• Step Downs
  
• Lunges/Front Step up (modified lunge)
  
• Squat

Note to readers: Always consult a physician before starting any exercise program. The posts on this blog are purely for educational purposes only. The information written in the posts is the opinion of the authors and should not be taken as medical advice.

The Bridge

This is a simple exercise that will help to build functional strength in your gluteals and core.


Start with the level one bridge. Both feet are on the ground with knees bent. Toes up to minimize the activity of the hamstrings during this exercise. Contract your gluteals or buttock muscles and tighten lower abdominals simultaneously. Push through your heels and lift pelvis off of the ground slowly and under control. Lift until your pelvis in line with your thighs. Do not arch back. If you are arching you're probably going to high. Lower your pelvis back to the floor under control. Remember are to keep both sides of pelvis level as to not let either hip drop during the movement.



Once you are able to perform level one with minimal fatigue and with good form and control, move on to level two. This level is performed using a single leg. The same principles apply. Use buttock muscles or gluteal to lift pelvis off of the floor. It is important to remember while performing this movement to maintain a level pelvis. Weakness can be seen if the unsupported side of the pelvis drops during initiation of the movement or throughout the movement. Keep core tight and perform slowly to maximize gluteal activation.

This exercise along with clams and standing band exercises are a great functional warm-up before a run. We also recommend doing these exercises on off days/strength training days to increase functional strength and prevent many lower extremity injuries.

Functional Strength & Mobility / a gentle reminder

This last weekend I decided it was time to finish a remodeling job that I started 2 years ago. You know, the last part of a project that isn’t that important, just cosmetic, a hassle. I never had the time to get into it. This job required me to do some wood working and getting into work positions low to the ground (squatting and kneeling). These are not positions that I spend much of my normal work day doing. Needless to say come Monday my hamstrings and quads were feeling pretty tight and sore.

Usually, over the summer I lower my running mileage and work more on my functional strength. That didn’t happen this year. I really dropped off on my functional strengthening as I just never seemed to have the time to get it done. It was a hassle. We runners with healthy joints must keep our ability to squat and lunge (functional strength and mobility). As I approach the age of 45 this is becoming more and more obvious to me. Because my home improvement projects are becoming less frequent, I could lose this ability if I don’t continue to work on it. My running could eventually suffer. So my home improvement project served as a gentle reminder to get back to my functional strength program. GET IT DONE & DON’T PUT IT OFF!

Hamstring stretch

Hamstring stretch: Lie on back holding behind one knee with hands as shown. Begin to straighten the knee slowly until a gentle stretch is felt in the hamstring. Hold twenty seconds then let the knee bend. Repeat 3 times.
Pictures from mckinley.uiuc.edu.

This is a safe hamstring stretch as it protects the lower back and provides a stretch over the entire hamstring belly. However, it is important to be aware of each person's limitations and to recognize that not everyone will be able to straighten the leg all the way. It is very important to stretch only into light to moderate stretch, NOT a heavy stretch.

Simple injury prevention--Tip 5

Today on Take and run Thursday the topic is taking care of your feet. I find myself repeating these tips frequently during my work week so I thought I would share them with the Lounge.
1. Avoid wearing poor shoes... high heels, flip flops, or any other shoes which are uncomfortable. I know this is easier said than done, but at least avoid wearing them for long periods of time especially when standing or walking.
2. Don't continue to run in worn running shoes too long. I usually advise my patients to purchase a new shoe when the out sole of the current shoe begins to wear down or if approaching 300 miles. Get a second pair and start using them for the longer or harder runs.
3. Be careful buying a super soft cushioned shoe especially if a foot tends to over pronate. If a new shoe feels really soft and cloud like, there is a good chance it is too soft. Don't just buy the same shoe again. Make sure there haven't been any major changes to that model. Video taping running in the shoes and studying the way a foot reacts to that shoe is the best way to find the proper shoe. Compare the old shoes to the new shoes.
4. Avoid sitting on the foot when sitting! This is a very common mistake which will not only over stretch the soft tissue of the ankle but will likely cause knee, hip and back issues as well.
5. At the end of the day or run, if the feet are sore ice and take a day off. The sooner the soreness is addressed, the quicker they will heal. Too many times I hear patients that have had plantar fasciitis for over a year say, "but it didn't really hurt that bad".

I hope this is helpful.
In one week I leave for my first Hood To Coast and will be sporting a Runner's Lounge T Shirt.

Simple injury prevention--Tip 3

Learn how to read!

This week's topic in the Runner's lounge: "Take It and Run Thursday" we were asked to share the "best" of our blog. I don't know if this is my best, but I feel it is one of the most important simple injury prevention tips for all of us to learn. I also like the picture, which I took in Whitehall Michigan.

This is a re-post from March 11, 2008.

My input this week involves learning how to read your body. As the weather finally warms up and the spring races draw nearer, most of us are adding to our training. We are either adding some miles and or introducing some quality (speed). During any change in our training which requires an increase in effort, it is important to determine how our bodies are responding to this change in stress levels. We must learn to read our bodies / to be able to determine what we can ignore versus what is trouble brewing.

Here is a common scenario:

Fred ran 4-8 X's 400 in the first week and that this is the first time he has done any up tempo workouts this season. He wore the same shoes that he has been wearing all winter (250 miles) and they are showing some wear. On this workout, he felt really good and went quicker than scheduled. The next day was an easy run and he felt just a little tight. The next time he ran, his legs felt great so he pushed a little, but toward the end of the run he noticed a slight tightness or pinch in his distal Achilles. After the run, he gave it a good stretch. The next day he felt slight soreness during the day but a mile into his scheduled 10 miler it went away. At 3 miles it comes back and by the end of the run it is more of an aching pain. After he stopped, it goes away so he stretches it out some more. The next AM, Fred can barely walk as his Achilles is very sore and tight.

Where did Fred go wrong in this scenario? How could he have avoided this injury?

The biggest issue here, was his inability too read and listen to his symptoms. When he felt the tightness the first time, he should have used ice on his Achilles and avoided the aggressive stretching. But the biggest mistake was continuing to run during the long run when his symptoms got worse. I advise that when symptoms are felt during a run and they don't go away or they worsen, STOP! At least slow down and shorten the work out. ICE and avoid aggressive stretching. If the symptoms had gone away and not returned, he could have finished the work out. It still would have been prudent to shorten the run and ice. If symptoms are felt during the day just walking around, it is better to not run. REST and ICE! No running until pain-free during everyday activities. Then the return to running needs to be a short and easy, followed by a rest day. This will allow Fred to evaluate how the Achilles is handling the return to running with less of a chance for re-injury.
Learn to read your body!

Other contributing factors:
Stick to the scheduled pace especially on the first quality run of the season.
Never a bad idea to break out a newer pair of shoes when doing quality runs or long runs.

I hope this is helpful!

Hit the water!

At The Runner's Lounge, this week's "take and run Thursday" topic involves cross training.

As I begin to share my thoughts on cross training, I feel the need to remind everybody that cross training is NOT a REST day. We get quite a few victims in our PT clinic who forget this small fact. Many victims of overuse injuries like to sell themselves that a day without running equals a rest day. Face it, we've all done it. Remember that just as cross training is a great adjunct to your sport so is true rest.


Over the years I have done a variety of cross training activities. I would have to say that off road biking and swimming are my favorites. I picked these up after a hamstring injury put my running on hold. I couldn't believe the total body work out that off roading gave me. The thrill of zipping through woods on a single track trail and getting airborne reminded me of snow skiing. I was hooked! The next season, I upgraded my bike and actually entered an off road race. I would ride after work 2 or 3 days a week and really felt that this helped my running. My riding came to a sudden end with a fairly bad end over in which I fracture my clavicle. This made working at my job difficult. I realized that I was lucky that this was all I injured. Because I am a father of three and can't afford to miss days from work, I decided that I better stick to safer cross training.

Thus, I returned to swimming. This has been a great way to help my running. I don't enjoy swimming nearly as much as biking but, I do like the strength changes in my upper body & core. I have found that swimming with a pull buoy is a great way to decrease the load on my legs. I get a great cardio workout by increasing my strokes per breath. The pull buoy eliminates the need to kick and it helps to keep my legs up in the water. As a result, I don't need to swim very far to get a good cardio workout. I work my core my contracting my abdominals as I pull down into the stroke. I was swimming 2 times per week but have gotten away from this over the last year. Hopefully with warmer weather and writing about this, I will find the motivation to hit the water again.

Simple injury prevention--Tip 2

More on deloading.
I thought I would help to make deloading easier to follow with a quick glance chart.

Deloading
Miles per week	Deload week
50	37
45	33
40	30
35	26
30	22
25	18
20	15
15	11

For example: If I have been training 2 weeks at 40 miles per week with 6 miles of quality, I would "deload" my third week to 30 miles with 3-4 miles of quality and I would probably add a rest day. Deloading is a great way to allow the body recover & remodel itself. This format of 2 weeks up and 1 week down will allow an athlete to become stronger for what is next.

13 words of advice!

This week's Take It And Run Thursday is to write "13 Words About Running."
Thirteen words of advice is easy for me to come up with. As a PT, everybody knows I like to give advice.

It is as follows:
Please train smart, rest more often, listen to your body, and race hard!

Roll on!

Here is a link to a great summary article on foam rolling which, Lou & I do the day after our long runs and on rest days. I usually do this on my Quads, Hams & ITB. This helps my recovery and eliminates the need to "stretch" my ITBs.
Keep on rolling! http://www.sbcoachescollege.com/articles/Roll%20Out.html

Hamstrings

Here is a great post on Hamstring pulls written by Vern Gambetta. Here is a link to his blog. http://www.gambetta.com/blog.html

Wednesday, April 02, 2008

Hamstring Pulling Season
We have just started hamstring pulling season (AKA Major League Baseball Season) So far in first two days of the season there have bee two hamstring pulls. Do you ever wonder why? Is it the cold weather? No I don’t think so although can be a factor at times. Are they out of shape? I hope not they have spent six weeks in spring training getting game fit. Based on my observations over the years here is my take on the hamstring pull situation in baseball and for that matter other sports. Too much emphasis on static stretching in warm-up. Warm-up to stretch, do not stretch to warm-up. Flexibility of the hamstring is basically a non factor in hamstring pulls, it is dynamic hip flexibility that is important. You don't get that wallowing around on the ground in pregame stretch. Lack of sufficient warm-up. The current rage in warm-up does not involve enough movement, way too much at walking tempo, you need to build the warm-up in a crescendo to top speed sprints. Another reason is too much emphasis on linear running mechanics, very little on turns. The hamstring is a transverse plane muscle that is stressed when running a curve and on deceleration. There is too much strengthening using non functional exercises in prone and supine positions. The solutions are simple, but require understanding muscle function and compliance to a program. More lunges in all planes, step-ups both low and high, more emphasis on running turns and at least two days a week of all out sprinting outside the game. It takes time and preparation with attention to detail.

Our interpretation for distance runners. Stop doing static stretching as a warm-up! Stop doing hamstring curls for strengthening! As Vern says, we must keep our functional mobility (ability to squat, lunge and step up/down). Check out the archives on our blog for exercises to address functional mobility/strength.

More on Running injuries

Here is a link to a good post on Universal Truths about Running Injuries. I am pleased with the praise for physical therapy! I want to expand on the comment of "best PT". It is important not to automatically assume a MD or PT who tells you not to run is a bad one. I don't believe this was the intent of the author of this linked post. As I've previously posted, rest is a very important part of training but also of rehab. We must give the body time to respond to rehab without the stress that helped to cause it originally. As a PT, I often have my running patients stop running. In our current health care system, by the time they get to me it is not in their best interest to continuing to try to run through it. Most have already tried that and it hasn't worked. One of my biggest battles is to get my runners to actually stop "testing it out". I try to get my patients back to running as fast as possible but very carefully. I follow the rule of, if I feel my symptoms walking around doing my daily activities, then I have no business trying to run. I start back at a very low level/ walking then progressing to walk /jog then to continuous running. Each phase of this must be symptom free before progression to the next phase.

Please visit our other posts on strengthening, running injuries, prevention & rest.

In Line Lunge

The In-Line Lunge is one of our favorite exercises to do as a part of a structured functional strength program to supplement running/cardiovascular training. If you look at the picture of the girl running under the title of our blog, you can see the similarities between the exercise and running. Running requires functional strength in the hips, knees, ankles, and trunk. These muscles have to know how to work together to accomplish the given movement, in this case, running. Lots of variations of this exercise are out there, however, most of the time, simple is better. This exercise can also be easily modified for someone who has knee problems by making the distance between feet larger and not going down as deep. Things to watch for are loss of balance, too much forward bending, losing knee alignment (in or out), and pain. I like to do this exercise 1-2 times per week along with a few other exercises that we will discuss later. Usually, I am performing only 3-5 repetitions for 2-4 sets on each leg....again, quality over quantity. When I'm doing these exercises regularly, I feel like I run stronger and more solid.



Note to readers: Always consult a physician before starting any exercise program. The posts on this blog are purely for educational purposes only. The information written in the posts is the opinion of the authors and should not be taken as medical advice.