Thigh pain - Sports Injury

Why pull your foot back with a hamstrings stretch?

by Pete Colagiuri - Sports Physiotherapist

It seems like every hamstrings stretch position involves a straight knee, a flexed hip and pulling the foot back.

So why do we pull the foot back? Necessary for the stretch, harmless habit or harmful distraction?

Hamstrings muscle anatomy

The hamstrings is actually a group of four muscles.

The upper attachment for all four muscles is the Ischial Tuberosity – the bone you sit on.

At the lower end, it attaches just below the knee with two muscles attaching on each side of the knee.

Its referred to as a biarticular muscle – “bi” meaning two and “articular” referring to joints. Its biarticular because it crosses two joints – the hip and the knee.

The stretching action

To stretch any muscle, it needs to be pulled to its lengthened position.

For biarticular muscles, this usually involves moving one joint to a fixed position and then using the other to add further tension.

For the hamstrings stretch, the knee is often held straight while the hip is gradually flexed or bent forward.

And pulling the foot back?

Therein lies the question!

If the hamstrings finishes just below the knee and doesn’t cross the ankle joint, what will pulling the foot back achieve?

For the hamstrings, it achieves nothing.

The foot movement actually tensions the Sciatic nerve, which is why the stretching feeling increases.

Keen observers will note that the stretching feeling actually moves from the hamstrings muscle in the back of the thigh to the calf muscle.

So what you’ve done is turned a hamstrings stretch into a Sciatic nerve stretch!

Helpful, harmless or hurting?

Overall it is not a good thing to pull the foot back.

It increases tension on the Sciatic nerve, taking pressure off the hamstrings muscles. That makes the intended stretch less effective.

Pulling on the Sciatic nerve can also irritate the nerve, potentially leading to pain and other issues.

However there are some athletes that can benefit from adding in the Sciatic nerve component.

Dancing and martial arts both require the leg to move into stretched positions.

So it is worthwhile ensuring that the muscle AND the nerve are both tolerant of stretch.

But for everyone else, pulling the foot back is a harmful and unnecessary addition to a hamstrings stretch.

Sharp pain at the inner thigh?

by Pete Colagiuri - Sports Physiotherapist

The typical scenario for a sharp pain in the inner thigh or groin area goes like this:

didn’t warm up properly, or cooled down after a break in play…
sudden sprint, agility or cutting movement, or a cross-body kick…
and BANG, feels like you got stabbed!

This type of injury is called an acute injury, which means it occurs suddenly and due to a single incident that overloads the soft tissue.

It causes a sharp pain at the inner thigh where the overload has occurred. It could a muscle injury, a tendon injury or even a bone injury (such as an avulsion fracture).

We’ll cover muscle injuries in this post but the same principles apply for acute tendon injuries.

The most likely culprit is one of the adductor muscles, a group of six muscles that move the leg inwards (as well as assisting with other movements).

They are:

Obturator Externus (also known as External Obturator)
Pectineus
Adductor Brevis
Adductor Longus
Adductor Magnus
Gracilis

Each of these muscles contribute to the adduction, or inwards movement, of the leg and can be injured during rapid or forceful muscle contractions or if the leg is suddenly resisted (eg. kicking the ground).

Working out the muscle injury grade

Muscle injuries are graded based on their severity. It’s a simple scale of 1-3, with a grade 1 being minor and a grade 3 being a major injury.

These grades help forecast the duration of recovery at the time of injury. But they shouldn’t be used to guide rehab progression (“a grade 2 injury should be doing xyz exercise at 3 weeks”). Progression is highly individual and should be guided by symptoms and function.

Tips for working out the injury grade

The day after you feel that sharp pain at your inner thigh, check for a bruise. If the injury causes a bruise, you’re looking at a grade 2 or 3 injury. That’s around 6-12 weeks before you’ll be back to high intensity running and agility/cutting.

Note that if there’s no bruising, that doesn’t mean it’s a grade 1. It could still be a grade 2 injury but deep within the muscle.

If it feels better the day after the injury, it’s probably a grade 1 injury or a low grade 2 injury. You could be back in 2-4 weeks.

If the injury feels worse the day after the incident, it’s probably a grade 2 or 3 injury.

What to do when the injury first happens

Don’t

Don’t panic. It’ll hurt to walk because the bleeding inside the muscle (with grade 2-3 injuries) takes up space and walking stretches the muscle, squeezing the injured area.

Don’t take anti inflammatories (Nurofen, Voltaren, Advil, etc). They increase bleeding and will extend your recovery time by weeks.

Don’t elevate it. You can’t ready elevate that part of the leg, the bleeding had nowhere to drain to and you’ll look like a goose.

Don’t stretch it. Stretching can damage the early tissue healing and increase pressure on the injury.

Don’t massage it. Massage will shift the bleeding around the injury and allow more bleeding to refill the area.

Do

Limp if you want to. If it’s more comfortable to limp, go for it. You’re best to compromise “normal” walking mechanics for an alternate method that doesn’t load the injury and hurt. It’s only for a few days.

Do compress it. An elastic bandage is great but compression tights (Skins, 2XU, etc) work well to.

Do ice it. Apply 10min of ice two or three times on the day of the injury to reduce pain. It’s not needed after that.

How to plan your rehab

Rehab for a groin/adductor muscle injury needs to follow two simple principles:

It shouldn’t hurt, and
It needs to progress in small increments

That’s it. Simple, but getting some guidance can definitely help with point #2.

Point #1 doesn’t mean that any sensation or awareness in that area is bad.

It’s still recovering so expect it to be noticeable, uncomfortable at times and mildly sore with loading. And that’s not a concern, that’s almost a necessary ingredient to ensure we’re loading the area sufficiently for recovery.

Point #2 sounds simple enough but a knowledge of biomechanics and function certainly helps. That’s why professional rehab is designed specific to your injury, sporting history and your requirements.

“It wasn’t hurting to walk so I tried a run”…

Never base a return to sport on the fact is doesn’t hurt any more! The brain will naturally adjust your movements to avoid bothering the injury. You’ll step shorter or reach your shoe in a different way.

It’s a huge step up to go from pain-free daily tasks to sports. It’s the most common reason for re-injury and extended recovery periods.

Typical progressions go from very small adductor activations, to low loads in neutral positions, then low loads away from the body and higher loads in neutral positions.

Once that’s done, you can add faster movements, higher loads away from the body and some running at easy paces.

The final step is to put it all together in fast, strong muscle activity – sprinting. On top of that you can add pre-planned agility/ cutting manoeuvres and finally, unplanned/unexpected movements.

Hamstrings tear – a diagnosis to complete recovery

by Pete Colagiuri - Sports Physiotherapist

Most hamstrings tears occur in the mid belly of the muscle, about halfway between the hip and knee
Muscle tears occur suddenly but it’s not uncommon to have some tightness or fatigue in the muscle preceding the tear
The most vulnerable actions for the hamstrings are rapid deceleration (slowing down) and rapid acceleration from a standing start

TIPS

The most effective initial management of a hamstrings tear is compression, using a compression bandage or even compression tights
Avoid any stretching or lengthened positions, including elevating the leg in sitting, during the first week after injury
The hamstrings muscle significantly increases its contribution to movement as the speed of the movement increases. All rehab programs should gradually build in faster movements in sports-specific positions
About 70% of hamstrings tears have concurrent nerve irritations, either as a causative factor or as a result of the injury. Testing for and identifying nerve issues early is crucial for effective management

MYTHS

Hamstring curls in standing or prone positions are almost pointless as the muscle is not designed to function effectively in that position
Jogging without pain is not a good indicator of readiness to return to sport. Building towards and testing rapid acceleration/deceleration, jumping and running hills are a better indication of readiness (although all testing should also include sports-specific activities)
Stretching is not an effective method of improving muscle shortening. Use strength exercises that move into lengthened positions to help the muscle adapt its length based on functional demands

Hamstrings tendinopathy – frustrating but fixable

by Pete Colagiuri - Sports Physiotherapist

Hamstrings tendinopathy most commonly affects the upper hamstrings tendon (known as “Proximal Hamstrings tendinopathy“) just below the Ischial Tuberosity (aka. the “sit bone”).

The hamstrings, or “hammy”, also has a number of tendons behind the knee which can be affected by tendinopathy, known as “Distal Hamstrings tendinopathy”.

It’s usually a non inflammatory reaction so anti-inflammatory meds will dull the pain but not help the recovery.

This condition tends to move slowly, gradually worsening over weeks or months and improving over a similar time course. It means you should stick to a rehab approach for 3-4 weeks at a time. Then you can decide if it’s helpful or needs revising.

BEST TREATMENT OPTIONS FOR A FAST RECOVERY FROM HAMMY PAIN

To help the tendon recover, it needs DAILY activity to provide some loading but avoid strong contractions, fast movements or stretching positions
- The tendon reacts positively to consistent loading, with the loading tolerance gradually increasing as the tendon recovers
- Any loading outside of the current tolerance, either too much or too little, can cause symptoms. Overload can be due to strong forces, such as lifting too much weight, or rapid force generation, such as jumping or sprinting
Identifying the cause is the key to a successful recovery
- Common causes include a loss of hip extension (leg moving behind you) or a loss of power at the ankle (reduced push off force due to issues like a sore toe, Plantarfasciitis or Achilles tendinopathy)
- The tendon capacity can be improved with rehab and general training but the risk of a recurrence of tendinopathy remains heightened as long as the underlying cause/s are unchanged
- Depending on the cause and reasons behind it, you may be able to fix the causal issue. Otherwise you’ll need to reduce its impact on hamstrings loading by training specific areas to compensate for the deficit
Other conditions can mimic Hamstrings tendinopathy but their symptoms will respond differently to certain activities. They also require a different rehab plan
- Ischial bursitis and Sacrotuberous Ligament irritation are two injuries associated with the same area of pain and similar causes of aggravation
  - They’ll both feel worse after loading in lengthened positions, such as walking up a steep hill
- However these injuries require completely different rehab and restrictions

TREATMENT MYTHS THAT CAN SLOW YOUR RECOVERY

Stretching will actually make it worse!
- The tendon doesn’t react well to sustained stretch, even though it may feel good at the time
Exercises are helpful for recovery, but performed in the wrong phase, can make it worse
- For example, deadlifts are great for strength but cause excessive aggravation in the early phase
- Hopping is great for power but will only help in the late phase recovery
- Be wary of “the right exercise”, as recommended by a friend or the web, performed at the wrong time in your recovery
Ice packs or anti-inflammatory meds can be helpful to settle symptoms. But they give a false sense of improvement despite not contributing to tendon healing

Here’s an example of a good early phase exercise to provide some load to the tendon without irritating it:

WHAT ELSE COULD IT BE?

Hip impingement
- Impingement can cause a deep dull buttock pain that may be mistaken for a hamstrings tendon issue. Both impingement and hamstrings tendinopathy are aggravated by running and hip loading. One differentiating factor is that hamstrings tendinopathies are often painful with direct pressure, like during on a hard bench seat.
Hip labral tear
- Similar to impingement, this condition classically causes pain at the front of the hip. However in some cases it may refer pain to the buttock. A sharp catching pain is an indicator that you may have a labral issue rather than a hammy issue.
Hip osteoarthritis
- Hip OA is more painful after prolonged rest, similar to a hamstrings tendinopathy. However OA will cause a loss of range in the hip and general stiffness.
Deep hip rotator overload
- This muscle fatigue issue affects the smaller muscles surrounding the hip joint. It causes an ache and stiffness after activity and prolonged rest. It may coexist with hamstrings tendinopathy and can be addressed with massage or trigger point work.