Week 2 Lecture 2A Flashcards by Michael Obi

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Quads are stronger than hamstrings by a (1/3 / 2/3) ratio.

2/3

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The Point: 
strengthening hamstrings (increased/decreased) injury risk

decreased

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Isometric hamstrings at 20 deg flexion and 60 deg flexion.

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If you have a hamstring injury, (sagittal/frontal) plane movements will be the most affected so you start with (sagittal / frontal plane/transverse) plane activity and then progress to sagittal plane

sagittal; frontal/transverse

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Hamstring strengthening, core stabilization and agility work is probably the best thing to do for hamstring recovery.

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Hamstring Rehab

Phase I goals
Protect healing tissue
Avoid excessive active or passive lengthening of hamstrings
Minimize atrophy

Phase II goals
Regain (90%/pain free) hamstring strength
Develop neuromuscular control of trunk and pelvis

Phase III goals
Symptom free during (most/all) activity
Normal conc and ecc hamstring strength through (90%/full) ROM and speeds
Improved neuromuscular control of trunk and pelvis with sport specific movements

Phase 1 - Create a healing environment for the hs – don’t stretch it, but engage the hamstrings in noncommittal ways

pain free; all; full;

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Phase 1

(Sagittal/Frontal) plane movements

Frontal

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Criteria to progress to phase II

Normal walking stride (with limited/without) pain

Performs dynamic frontal plane movement (with limited/without) pain

Pain-free isometric contraction against submaximal resistance during (supine knee extension/prone knee flexion) (90°) manual strength test

without; without; prone knee flexion

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Treatment Strategies

Hamstrings work…

 In open chain:
Decelerate knee (flexion/extension) at end of (stance/swing) phase

In closed chain:
In stance to facilitate hip (flexion/extension) at initial contact and knee (flexion/extension) during terminal stance (running)
The hamstrings and rectus abdominis are decelerators of pelvic anterior tilt throughout stance.

Consequence of short RF, weak RA?

extension; swing; extension; extension;

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Sagittal Plane

Work through swing phase with focus on (Limb/Pelvic) control

Pelvic

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Sagittal Plane

Eccentric hamstring work with Pelvic control

Simulate (initial/terminal) swing phase

terminal

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Criteria to Progress to Phase III

(Almost full strength (4/5)/Full strength (5/5)) (with limited/without) pain during prone knee flexion (90°) manual strength test

(Limited pain/Pain-free) forward and backward jog, moderate intensity
Unilateral sagittal plane activity (with limited/without) pain

Full strength (5/5); without pain; Pain-free; without;

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10 most efficient hamstring exercises from a biomechanical perspective https://www.youtube.com/watch?v=Wl8KZNnTlPw&t=1s

Cool

Exercises that target eccentric hamstring strength at (shorter/longer) muscle length (important for sprinting).

longer

Stabilize pelvic tilt - prevent (anterior/posterior) pelvic tilt Stable core allows development of (smaller/larger) forces at the hip and facilitates an efficient transfer of power during sprinting.

anterior; larger

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Criteria to progress Return to Sport Full strength (with limited/without) pain: (Limited pain/Painfree) maximum effort manual strength test in each prone knee flexion position (90° and 15°) Normalized H/Q strength ratio _% limb symmetry hamstrings (95%/Full) range of motion (with limited/without) pain Replication of sport specific movements (at/near) maximal speed without pain: Able to sprint Hop test: _% limb symmetry

without; Painfree; 85; Full; without; near; 85

LSI

Grade (2/3) to tendon/ligament is a complete tear. It will be up high around the isch tub and come off of the bone.

MOI: Extreme forceful hip (flexion/extension) with knee fully (flexed/extended) Pulls them forward and their hips drop back. Knees are locked up and they go into hip flexion. Slip and fall and slide - leg out in front and knee extended Foot gets caught – head over heels

flexion; extended

Better repaired (acutely/chronicly) – wait too long = harder to repair When it domes off of the bone it starts to contract towards the distal part where it is attached and it shortens up. Outcomes are good overall and people do well. Very low rerupture rate.

acutely;

Putting it back on the ischial tuberosity Sewing tissue back under the bone – don’t want to tear it. Think what would damage the repair that was just done. Avoid hip (flexion/extension) and knee (flexion/extension).

flexion; extension

Pt in a knee brace so they don’t go into knee extension, some are in a hip brace so they don’t flex the hip.

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Rehab Progression Overview: Phase 1: protection (surgery to _wks) Limited WB ROM limits?: Knee extension possibly (tension on repair?) What motion(s)? Hip (flexion/extension), knee (flexion/extension) Combined motions (hip _____+ knee _____) Brace Try not to ruin the surgery Limited WB – put them on crutches, unload them and shorten their stride with AD ROM Limits – if it was repaired with tension ROM limits will be higher. Avoid hip flexion and knee extension

6; flexion; extension; flexion; extension;

Have them (flex/extend) their knee as they get up

flex

Phase 2 (Wks _ - _) Progress WB / gait Progress ROM Hip flexion (knee (flexed/extended)) Knee extension (hip (flexed/extended)) Neural glides No resisted hamstrings yet!! No hamstring stretch yet!! Everything takes 6-8 weeks to heal except for the scaphoid and a couple of other bones. Blood supply, age, bone quality, diabetes, smoking, activity level before the surgery influence healing times. When starting to restore ROM – do it one piece at a time – hip flexion with the knee flexed. Knee extension with the hip extended (heel slide). The sciatic nerve is next to the hamstring insertion – a lot of scarring is possible. They might get stuck so have to do neural mobilization. Nerve pain going down their leg – think sciatic nerve.

6-9; flexed; extended

Phase 3: (_-_) Months

3-4;

Phase 4 (_-_) months return to sport activity Functional strength progression Plyometrics Running Return to sporting activities is typically allowed at _-_ months postoperatively

5-9; 6-9

Proximal Hamstring Tendinopathy Middle aged athlete History of hamstring strain MRI: partial tearing / degeneration Scar - tendon thickening Weak hip extension with flexed knee prone: Poor (hamstring/gluteal) control / activation ``` Hamstring cramping (unilateral bridge) Tender to palpation at IT ``` Proximal hamstring stretch (decreases/reproduces) pain Weak hip extension with knee flexed in prone – testing glute max Tender to palpation in the isch tub Proximal hamstring stretch – good test to do to rule in or out

gluteal; reproduces;

Eccentric hamstrings – good for organizing scar tissue at the insertion of the HS Lower cross syndrome – Tight hip flexors, tight trunk extensors, weak glutes, and weak abs. Injection is good to use in conjuction with the rehab. PRP – get all the RBCs condensed and they reinject it (evidence isn’t great).

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External – outside, caused by thickening in the lateral structures. Greater trochanter bursa could be inflamed. Tissue snaps as the tissue moves from flexion to extension. Internal – movement from flexion to extension Intra-articular – labral tear and they’ll describe clicking as the primary complaint

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The Snapping Hip (Coxa Sultans) Internal and external cases will (not likely/likely) report snapping and symptoms (in front of/behind) hip or (medial/lateral) thigh - Patient can often self-demonstrate these findings with activity The intra-articular case will more likely report “clicking”, with a (primary/secondary) complaint of joint pain

likely; in front of; lateral; primary

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Possibly (gluteus medius/gluteus maximus), inflamed GT bursa

medius

Stretching – abductors, hip flexors

abductors; flexors

Often don’t need surgery Take out the bursa that is irritated or causes pain

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True piriformis syndrome involves the (pudendal/sciatic) nerve so there are nerve symptoms, there is pain in the butt

sciatic;

Radiates down the back of the leg

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Cause Spasm or shortening of piriformis muscle that causes compression of _____ nerve Why spasm: Direct trauma: Hematoma, scarring “wallet neuritis” Overuse: Lumbar / SIJ pathology Crosses SIJ Si joint instability or hypomobility can irritate the piriformis and the sciatic n.

sciatic;

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Either stretching or activating/or both with these tests FAIR – Positive with pain Frieberg – reproduction of pain

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Leg held in position of ER (static position) (Short / hypertonic piriformis) Resisted (Adduction/Abduction) (activates piriformis) Hip flexed + test = pain

Abduction;

Surgical release is uncommon US doesn’t work Soft tissue mobilization – people are tender, don’t want you poking in that area because it is sensitive

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People love to stretch it, have to tell them to tone it down if they stretch aggressively – keeps the sxs irritable.

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Another Theory Excessive Adduction and IROT: Weakness of (hamstrings/ glute max/medius) Lower crossed syndrome Glutes are ineffective Greater eccentric load may be shifted to piriformis muscle Results in irritation of _____ nerve Causes greater load on the piriformis if glutes aren’t doing its job

glute max/medius; sciatic

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Hip (adductor/abductor) weakness as an associated finding in piriformis syndrome Treatment: Hip strength and movement re-education

abductor