322 | High Hamstring Strains: Pain Under The Butt

[00:00:00] Welcome to the Optimal Body Podcast. I'm Dr. Jen and I'm Dr. Dom and we are doctors

[00:00:10] of physical therapy bringing you the body tips and physical therapy pearls of

[00:00:14] wisdom to help you begin to understand your body, relieve your pains and

[00:00:17] restrictions and answer your questions. Along with expert guests our goal of

[00:00:21] the Optimal Body Podcast is really to help you discover what optimal means

[00:00:25] within your own body. Let's dive in! Before diving into the episode on high

[00:00:31] hamstring strains I want to talk about something that can really impact our

[00:00:35] hamstring health and function which is what we wear on our feet. If you're wearing

[00:00:40] shoes that don't allow your feet and ankles to work properly it can really

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[00:01:35] Barefoot Shoes. Okay so today's pearl is on high hamstring strange which is

[00:01:40] also known as proximal hamstring tendon apathy and that word tendon apathy

[00:01:46] basically just means dysregulated tendon or abnormal tendon and this tends

[00:01:52] to be more of an overuse injury and it can feel really like a pain in the

[00:01:56] butt because that's exactly where it is. It's right at the top of those hamstrings

[00:02:00] kind of where you feel that knobby sit bone that you sit on called our

[00:02:04] Ischial Tube Arosity which is where our common hamstring tendon attaches into

[00:02:08] and because it's a tendon apathy something that's overused and you know tends

[00:02:13] to develop over time, it takes time to get rid of these as well and to overcome

[00:02:19] this pain and symptoms that you're having and I know you know for we wouldn't have

[00:02:24] a very close friend where she's complained about this for a long time and I'm like

[00:02:28] this is the structure of what you have to follow and it's gonna take time just

[00:02:32] like it took time to come on. Yeah and again being an overuse injury it tends

[00:02:36] to have to do with activities that you do on a consistent basis. It's something

[00:02:41] that is highly re-eritable so you see a high rate of re-injury when people have

[00:02:49] this they seem to get better from it and then it happens again often because the

[00:02:53] rehab that they may have done you know didn't actually heal the issue the

[00:02:57] symptoms just went away but the underlying issue still remained. It can also

[00:03:02] be seen as a deceleration injury which what that means is like if you're

[00:03:07] somebody who runs a lot especially if you sprint a lot it's actually when

[00:03:10] you're slowing yourself down because that hamstring the proximal portion of it or

[00:03:15] the portion that attaches right up into your butt is lengthening as you're

[00:03:20] slowing your body down. Just want to take a quick pause from the

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[00:04:44] and when we get that eccentric lengthening where we're loading it as that muscle is stretching

[00:04:49] really quickly that is a very vulnerable place for a muscle or a tendon to be which is why

[00:04:55] we often see these types of injuries and sprinters people who you know perform sprint type activities

[00:05:01] are athletics like basketball tennis where you're changing direction and sprinting and slowing down

[00:05:06] rapidly accelerating and decelerating your body. Now when we look at recovery especially in

[00:05:11] the research we can say anywhere from 23 days to 50 weeks and there's a high recurrence rate

[00:05:17] in between so this is why we really are going to go through the four phases of you know recovery

[00:05:24] from a high hamstring strain because honoring each phase is really important to reduce that risk

[00:05:31] of having it happen again you know and so I think that's what's really important is understanding

[00:05:37] how to move along these phases and what you're really looking for in each one. Yeah it's interesting

[00:05:41] because when we start talking about this and talking about the people who are at risk you know

[00:05:46] well as people with hypermobility but again those sprint type athletes people who have poor warm-ups

[00:05:52] are cool downs people don't have great core hip coordination and I actually dealt with some high

[00:05:59] hamstring issues when I was in like middle school track because I was a sprinter and I remember

[00:06:08] I'm gonna be honest I kind of peaked athletically in middle school seventh and eighth grade

[00:06:12] because I was an early mature so I was hitting some of my like peak times in seventh and eighth grade

[00:06:18] while everyone else was still like pre puberty and then everyone else grew up and I remember it was

[00:06:24] the most devastating thing because I had this high hamstring pain when it was like the conference

[00:06:30] finals for track in eighth grade and I had basically swept all of my events when I was in seventh grade

[00:06:36] conference finals and I finished like third fourth fifth in most of my events because I had this injury

[00:06:42] but I was too stubborn to sit out so I kept doing it but thinking about eighth grade Dominic

[00:06:48] I definitely had poor core hip coordination I was a sprint athlete who probably wasn't warming up

[00:06:54] and cooling down well um and then I got an injury. Well and I think beyond just like the warm-up

[00:07:02] and the cool down you know I know especially from your history that that that core coordination

[00:07:09] you know has been something that you've kind of worked through and and really come to own I would

[00:07:15] say yeah I was gonna say still struggle with I think you have I mean a lot better grasp and awareness of

[00:07:24] it but having that maybe when you were developing as well and not having that awareness definitely

[00:07:30] as we wouldn't in middle school and junior high definitely not but that could obviously play a role

[00:07:37] and so understanding and gaining awareness of our body is so crucial and something we do

[00:07:42] in all our general health plans. Okay so now we want to spend the bulk of this episode on like

[00:07:47] the phases kind of the rehab phases that you should be going through and of course these will be

[00:07:52] slightly different depending on the severity of injury you know if it's excruciating pain or

[00:07:57] you know to the point where you have a second third degree tear versus a strain gonna be very

[00:08:03] different rehab protocols so this is more so a strain with no major tendon or muscle damage

[00:08:09] phase one as is the phase for most injuries is calm it down how do we calm that thing down

[00:08:15] this is the phase where we might need to do some sort of activity modification.

[00:08:20] Find a way to be putting less pressure less stretch and strain on those hamstring tendons

[00:08:26] paying attention to how we're sitting or standing throughout the day even

[00:08:31] and then just focusing on some of that basic mobility so some of the things that you could start

[00:08:36] to do are just laying on your back hamstring kicks feeling how that hamstring feels throughout the

[00:08:42] the range even sitting with your heels up on a wall kind of doing a wall hamstring stretch that can

[00:08:48] be very relaxing for the legs but also just start to get that hamstring to lengthen a little bit

[00:08:54] and let go. Well and we know that the first load of tension we put into a tendon is a stretch

[00:09:01] yeah it's right and making sure that we're not going aggressive this is not where we're trying

[00:09:05] to like gain the most flexibility or anything it's just starting to put a little load and tension

[00:09:11] into that hamstring and then I would say just like you said like legs up a wall but using that

[00:09:17] breath to really calm things down and send different signals into the muscle you know is so crucial

[00:09:25] and if you're doing that well if you're doing that stretch while doing that breathing you're

[00:09:29] activating the core so you're already starting to lay some of the groundwork for that core

[00:09:34] hip or that core hamstring coordination where okay I'm letting my hamstring lengthen but I'm also

[00:09:40] engaging and activating throughout my core same with hamstring kicks you don't want to be kicking

[00:09:44] your leg and holding your breath and bearing down when we're kicking and breathing feeling our ribs

[00:09:50] expand feeling our core contract all that kind of stuff because you're gonna again start lay

[00:09:54] the groundwork for phase two three and four right and I would say you know touching a little bit more

[00:10:00] on the compressive nature of things so if we have a very sedentary job how can we create things

[00:10:07] like standing more than sitting because that's putting that pressure I mean ideally we're sitting

[00:10:13] more so on our sit bones which that's right where that attachment is so how can we reduce some of

[00:10:19] that tension just from those compressive overloads of sitting so much out the day and sitting is

[00:10:26] one of the things that is a risk factor as well for leading into high hamstring strains or the

[00:10:31] recurrence of high hamstring strain so just really paying attention to like how often am I sitting

[00:10:37] what kind if I have to sit at a desk can I ask my boss hey can I bring in a ball right now

[00:10:42] so I'm sitting on something a little squishier can I can I sit on a gorgeous ball where it can

[00:10:48] take a little load off of my ischial tubes you know so how can we set up our space to look a

[00:10:54] little different during this phase one time to give your body a chance to then mold into phase two

[00:11:00] which is getting into progressive loading and now this is where we're really starting to do what

[00:11:06] are called isometric exercises so that is that is not moving but starting to create load

[00:11:13] and tension and so this can look you know as simple as your feet on a wall and starting to just

[00:11:20] barely lift your hips so you're in like a 90 90 position and you're doing a wall bridge but you

[00:11:26] don't have to go all the way up you're just starting to press your whole foot into the wall

[00:11:30] and get used to driving those heels down and feeling what that pressure is it would if you hold

[00:11:35] and take some deep breaths with your tailbone kind of barely coming off the floor there yeah and any

[00:11:40] other way that we can really get those that isometric activation in would be great to explore

[00:11:45] because again now we're starting to put a little more load do those hamstrings and how can we do

[00:11:49] it at slightly different angles like we mentioned kind of the wall hamstring stretch like can you put

[00:11:57] one of your legs up maybe the affected side on the wall and just push down into it so we're at

[00:12:02] a little more of that stretch and now we're trying to push into it or just put your leg up on a chair

[00:12:07] and then push down into it and you're going to be activating that hamstring at different angles

[00:12:12] which I also think is important that we start to train and strengthen and put load through that

[00:12:17] hamstring at different angles and going along with all of that too rather than just using you know

[00:12:23] something external we can even lay on our stomach and start to get better hip extension so

[00:12:28] get bringing those legs up and holding at a range not only are we gonna start to work that

[00:12:34] hamstring and hold still doing those isometrics but then we're gonna start to build in that

[00:12:39] intra abdominal pressure as well because rather than just getting into my low back I want to kind of

[00:12:44] stabilize it through my trunk a little bit better when I lift my legs and hold I'm getting glutes

[00:12:51] I'm getting outer core I'm getting inner core and I'm breathing and holding with that so it's a

[00:12:56] great way to start to kind of repattern this abdominal and core control for our pelvis as we're

[00:13:02] gonna go through movement which we can also use by just slowing down basic body weight movements

[00:13:09] right getting into a hip hinge in a load in an area or range of motion that feels tolerable for

[00:13:15] you right now but starting to slow it down maybe holding in different lanes and saying can I breathe

[00:13:21] from my ribcage and make sure that my ribcage and pelvis is kind of moving together as I do these

[00:13:28] certain movement patterns and starting to retrain and rebuild how you're moving. Yeah and again in

[00:13:35] this phase two when we're just starting to load and starting to go through movement being able

[00:13:41] to be more aware of that core yeah and how it's coordinated with the hips is so important because

[00:13:45] as soon as we start to load things up as soon as we start to go through movements a little bit faster

[00:13:50] that's where we might start reverting to our old patterns but taking your time during this phase two

[00:13:55] to really go through coordinate the core with the hip movement as we're in this still kind of early

[00:14:02] healing phase before we go into phase three which would be more isotonic loading or loading through

[00:14:08] movement and this is where we're gonna start to progressively increase weights doing more basic

[00:14:15] lower body exercises like squats and dead lifts and things like that. And this is where it becomes

[00:14:21] really crucial to pay attention to your range motion especially if you're a hyper-mobile person

[00:14:25] not just going right into it but slowing things down this is so huge so starting to work on that

[00:14:32] strain through that length is really important and this can look as basic as starting with

[00:14:37] you know doing some banded kicks to your bottom so whether you're standing or whether you're

[00:14:43] laying on your stomach you have yeah you have a band around your your heel and you're bringing

[00:14:48] it into your bottom and then slowly letting it release. And working on that long e-centric control

[00:14:56] but really when we're talking about that high hamstring strain again let's good for the hamstring

[00:15:01] muscles but we need to be working on that hip hinge to start to get used to that tendon reloading

[00:15:08] in that flexion to extension pattern at that hip so that's where working on dead lifts whether

[00:15:14] it's banded dead lifts you know you kind of have a band around your and you're going down into

[00:15:18] your your length your range of motion that feels comfortable in nice and slow and then standing back

[00:15:24] up you know so starting to load even with resistance bands can be a great place to start.

[00:15:29] Yeah and as you start to load and get more comfortable you're gonna progress in the weight

[00:15:33] but then you can also progress in doing single leg type activities where it might look like a

[00:15:37] reverse lunge because rather than doing a forward lunge where people tend to be a little more

[00:15:42] quad dominant in a forward lunge you can do a reverse lunge and then be pulling through that

[00:15:47] hamstring as you stand back up. You can do this a single leg deadlift or more of the

[00:15:53] Romanian deadlift where it's straight leg single leg deadlift and as again you get comfortable

[00:15:58] with the movements how can we start to increase the explosiveness right so like Jen said generally

[00:16:05] going nice and slow on the e-centric or the lengthening days of the exercise that's great but then

[00:16:11] can we explode through the concentric phase or when we are contracting through those hamstrings

[00:16:16] because that's going to start to simulate those activities like sprinting where we explode through

[00:16:20] the step the step and then want to control the deceleration when we're lengthening in that e-centric

[00:16:27] phase. Yeah and starting to build the endurance of our glutes to help assist with the hamstring so

[00:16:33] it's not always the hamstring that's doing the work and this might you know mean that we're going

[00:16:39] to have to re kind of gain that awareness and that coordination of how we feel those glutes

[00:16:45] working and that's where I really come back to this inner core concept and understanding our

[00:16:50] intra abdominal pressure because when we can start to you know get this inner core working better

[00:16:55] we get the outer core our obliques our glutes kind of working in combination so that the legs can do

[00:17:02] what they're supposed to do so getting that trunk support is so huge and so key in this rehab

[00:17:08] process and starting to gain that awareness under load under functional exercises that you might not

[00:17:14] think are core based but when we have better awareness and attention to them they really are and

[00:17:19] that's what again you know I talk about this plan a lot the full body low impact plan because for

[00:17:24] those who want to be doing strength work and those who want to be doing exercise and understand

[00:17:29] this within their body that's where I talk through these things so big I think the full body low

[00:17:35] impact plan would be like the perfect encapsulation of phase three yeah how do we start to integrate

[00:17:41] that core hip coordination start to progressively strengthen and load through the hips and then phase four

[00:17:48] I would almost say shift yourself over to the the full body high impact yeah or high intensity plan

[00:17:54] on gen health because that's where it uses more of the hit style workout where you're going to start

[00:17:59] going into plyometrics because phase four is okay plyometrics how do we start training everything

[00:18:04] we've worked on in phase one through three into more of that sport or activity specific exercise

[00:18:11] that we want to get back to whether that's running whether that's jumping playing basketball tennis

[00:18:16] whatever it may be and this generally looks like some sort of plyometric training where we're starting

[00:18:24] with two foot you know jumping and landing type exercises and then starting to integrate

[00:18:29] different planes of motion so can we do lateral jumps can we do rotational jumps again it's depends

[00:18:38] on what your goal is what are you looking to get back to and can we train that in a more controlled

[00:18:43] environment so that once we get back into the exercise or on the street running or on the court

[00:18:49] our body's more prepared and it really is like we are going to continue to talk about the these

[00:18:55] phases of treatment for almost every kind of injury they kind of play a role in in trying to

[00:19:02] focus on the same things where we're improving our flexibility or range of motion but also our control

[00:19:08] of mobility within that range of motion especially for hyper mobile people we're building our strength

[00:19:14] both in a controlled manner and building that mind body connection through isometrics and then

[00:19:20] through you know more explosive loaded type movements and then going into those plyometrics and

[00:19:26] multi-planar directions like this we always kind of follow the same pattern when we're thinking about

[00:19:32] this and this is why we say we want to honor that entire progression so that you help to reduce

[00:19:38] you know the reoccurrence of it all and when we're talking about like pain tolerances because

[00:19:43] it's not necessarily that you're not going to have pain as you're redoing and kind of learning

[00:19:48] these movement patterns again but we want to look at okay can I am I experiencing a level that's

[00:19:54] about three out of ten as I'm moving through this and it doesn't increase directly after an exercise

[00:20:01] and it doesn't increase 24 hours after an exercise right you might feel soreness but hopefully

[00:20:07] we start to understand the difference between muscle soreness and actually having that pain

[00:20:13] high into that hamstring into that glute area so having the difference between those two and making

[00:20:20] sure that we're staying at a very low level of pain tolerance you know it can help us guide

[00:20:28] okay I can tolerate a little bit more I can lift a little bit more or maybe I need a back off a

[00:20:33] little bit yeah I think that's a super important point to follow especially in tendonopathies

[00:20:39] we really haven't like damaged the muscle to a significant extent it's just the reorganization

[00:20:45] and the tendon needs to reorganize in order to ultimately kind of solve the underlying issue or

[00:20:51] the root cause of why that tendon was disorganized in the first place and we need to load that

[00:20:57] sometimes it might be minimally uncomfortable but we should be experiencing more soreness especially

[00:21:02] as we get in the later phases and I love how you pointed that out like the phases for healing or

[00:21:08] rehab of any injury in my shorthand are calm it down get it mobile get it strong coordinate it

[00:21:17] and then sport or activity specific right and if you follow those depending on how you tolerate

[00:21:24] each stage you might be in one stage longer than the other or you might progress to the later stages

[00:21:29] a little more quickly you're going to find a successful plan on how to solve the underlying

[00:21:35] issues solve the root causes so that you don't become somebody who has these reoccurring

[00:21:41] high hamstring strains and when we look at some of like the research examples of what we should

[00:21:46] be doing or what we can follow and kind of look at you know um in a study from white at all in 2011

[00:21:54] they looked at high hamstring tendon opathies and three female long distance runners

[00:22:00] and what we're really considering treatment for hypermobile but not directly um transferable to

[00:22:07] possibly everyone right but what they they saw was that all of the female runners that they

[00:22:16] looked at kind of displayed weakness in their hip abidactors which are your glutes their pelvic joint

[00:22:22] dysfunction hamstring tightness and initial tuberosity tenderness so listen looking at like the bone

[00:22:29] that was high in your sit bone kind of having some tenderness to the touch there and they really

[00:22:35] focus on active exercises like hamstring stretching and strengthening gluteal strengthening

[00:22:42] proprioceptive training so where your body is in space in gaining that awareness plus they use

[00:22:48] some assisted soft tissue mobilization um lumbopalvic manipulation which we've had a podcast that

[00:22:54] kind of highlights and indicates what you know that manipulation or adjustment really are doing

[00:23:00] within the body electrical stimulation with ultrasound which we can we should do it

[00:23:06] podcast on this I think with what ultrasound is really doing in electrical stimulation to really

[00:23:11] help to understand this but when they looked at these three runners and did and kind of follow this

[00:23:17] protocol they found that there is a resolution in the hamstring pain and an average of 13 treatments

[00:23:23] and they were able to continue to compete without restriction so you know really focusing on the whole

[00:23:30] complexity of a rehab process yeah and I would say the strengthening and the stretching probably more

[00:23:38] beneficial than some of the the work but what we know from manual work or having other things is

[00:23:44] that it helps to calm symptoms down so that you can keep working on sure and I think I like this

[00:23:51] study because it points out that not everybody is going to spend a lot of time or anytime doing

[00:23:56] a strict phase one calm it down yeah because it sounds like they they spent much time really offloading

[00:24:03] instead they just altered what they were doing it was more of the activity modification

[00:24:08] and these are runners who yeah maybe they had pain but as soon as they started doing some of the

[00:24:12] things you know maybe the soft tissue mobilization manipulation some of the electrical stimulation

[00:24:18] helped calm things down enough to the point that they could do all of these strengthening exercises

[00:24:23] the proprioceptive training that's going to really help with the coordination aspect that we were

[00:24:27] talking about so it kind of outlines a different way that somebody worked through those four phases

[00:24:33] of rehab in 13 sessions and ultimately got back to doing their activity without any restriction

[00:24:40] and we briefly mentioned gen health the platform and how the full body low impact plan full body

[00:24:47] high intensity plan could be great pieces of this type of rehab also during phases one and two

[00:24:53] you've got the hit plan or even the full body mobility plan that can really help you during that

[00:24:59] calm it down and gain mobility phase in your rehab so you could use gen health to assist and supplement

[00:25:06] through your entire rehab phase you know while you're working on hamstring strains and for a podcast

[00:25:11] guest if you haven't ever checked out the free week trial please go do that and also if you use

[00:25:17] code optimal when you sign up y'all you'll get a discount off your first month so we'll have a

[00:25:21] link down in the show notes if you are interested in diving in and checking that out.

[00:25:27] Thanks so much for joining us on another episode I hope you learned a ton to share this with anyone

[00:25:32] who you know is going through having that high hamstring strain or they continue to have it

[00:25:38] reoccurring and they're working through it send this over to them so they can understand the

[00:25:43] phases to work through and of course dive into gen health that hit plan is going to be huge

[00:25:49] so beneficial same with the full body low impact and full body high intensity as you continue

[00:25:54] to work through those phases