Racquet sports - Tennis/Squash/Badminton - Sports Injury

3 most common reasons behind a recurrent hamstring injury

by Pete Colagiuri - Sports Physiotherapist

Recurrent hamstring injury is one of the most common issues we see in any field sport like football or hockey.

So why is the hamstring muscle so prone to repetitive injuries?

We’ll go through the 3 most common causes of recurrent hamstring injury and how to fix each one.

Reason 1: Inadequate rehab

It seems obvious – not preparing adequately for a return to sport makes you more prone to recurrent hamstring injury.

But the issue doesn’t lie in a lack of motivation or bailing early on rehab.

It’s a problem with not knowing WHEN your rehab is completed.

Is it when you’re pain-free? Back to normal strength? Back to running?

More often than not, rehab is incomplete because the hammy seemed fine so you stopped.

Solution 1: Better testing

Ensuring that your hamstring injury rehab is complete involves three aspects of testing.

1. Connective tissue testing

This assesses if the muscle has its length and bounce.

You can cover muscle length with a standardised muscle length test, like a sit and reach.

You can test connective tissue elasticity with a plyometric test, like a three hop for distance test.

Note that the 3 hop test also tests aspects like strength so the result isn’t purely based on elasticity.

2. Muscle strength testing

You can compare it to your unaffected side but remember that the other side has been out of action as well.

For this assessment, it depends on your equipment.

There are fancy machines that can isolate hamstrings but for most, a simple single leg barbell deadlift does the job nicely.

You’re looking to lift the same weight on both sides, with good technique for each rep.

You should be able to complete around 90% of the reps as the unaffected side over three sets.

3. Technique testing

This assesses your muscle firing patterns and coordination for any sport-specific movement that loads the hamstrings.

This might include running, jumping and kicking a ball.

This testing is to ensure that the brain is controlling the hamstring muscles effectively and not putting it at risk by being over-protective.

You’ll need another set of eyes to watch you throughout each movement, preferably someone trained in techniques like a coach (remember that a great player probably only knows their own technique and may not be a great assessor).

Perform the different techniques at game intensity (after a warm up).

You should also perform them while fatigued as that’s your riskiest time in the game.

So warm up and go through the individual techniques.

Then conduct some high intensity fitness training followed immediately by the same techniques.

Your observer is looking for altered muscle patterns, both fresh and then while fatigued.

Reason 2: It’s not a hamstrings tear

Another big reason behind recurrent hamstring injury is that it’s not actually a hamstring injury.

Seems odd but there are a number of other injuries that behave exactly like a hammy tear.

There are also a number of secondary injuries that can co-exist with a hammy tear – basically you get two injuries at the same time and the more subtle secondary injury is missed.

Most of the injuries in this category involve nerves.

You can have an irritated Sciatic nerve alongside a regular hamstring strain.

You can have a primary Sciatic nerve tension issue that behaves exactly like a hamstring tear – it’s even sore to push on!

Then there’s lower back referral. This can be due to a nerve irritation or even referred pain without nerve involvement.

Lastly there’s a few vascular (blood vessel) conditions that can cause recurrent hamstring injury symptoms but these are quite rare.

Solution 2: Confirm the diagnosis

This might be done with a second opinion or with imaging like MRI.

I wouldn’t recommend ultrasound as it lacks the detail we need to exclude some of the conditions associated with recurrent hamstring injury such as nerve issues.

MRI can be expensive but it’ll save you plenty in the long run.

Reason 3: Biomechanical issues with your technique

There are a number of biomechanical reasons why hamstring injuries occur.

It might be a longer stride length or poor pelvic control during jumping.

If that’s the case, the hamstrings are always vulnerable and recurrent hamstring injury will follow.

With each injury to the hammy, the technique issue may worsen due to strength, length or inhibition issues.

This sets up a cycle of recurrent hamstring injury that drives you nuts!

Solution 3: Technique assessment and modification

For this solution, you’ll need one, or ideally two, sets of eyes on you.

Select experienced and trained coaches rather than good players – coaches are trained in technique, players only know their own technique and they’ve never seen it from an observer’s perspective.

Start by assessing the technique that matches your injury scenarios.

If you always get injured jumping for a ball, look at your technique for that.

If it’s sprint starts, look at a variety of start positions and directions.

Then reassess each technique with fatigue – just smash out a hard 10min of cardio then re-test.

For each technique, you’re looking for errors that make you more prone to recurrent hamstring injury.

If you find those errors, design exercises and/or drills to fix them.

If you don’t find anything obvious, you can still modify technique to reduce hamstring loading.

Is it normal to have a split Tibialis Posterior…

by Pete Colagiuri - Sports Physiotherapist

For every ankle MRI we order, it seems that a decent number of them are coming back with a split Tibialis Posterior tendon (also known as Posterior Tibialis tendon).

So it begs the question, is that the cause of pain or is a split Tibialis Posterior tendon a normal finding?

How common are traumatic Tibialis Posterior tendon tears?

It’s difficult to find much info on how often this tendon is injured in acute, or sudden, injuries.

One small study reported that around 1% of ankle sprains ended up with a Tibialis Posterior tendon tear.

How accurate are MRI and ultrasound at diagnosing split Tibialis Posterior tendons?

Interestingly, MRI and dynamic ultrasound have similar levels of accuracy for diagnosing Posterior Tibilais tendon splits.

MRI and dynamic (or in motion) ultrasounds will accurately diagnose a split Tibialis Posterior tendon in around 72% of cases.

Static (or stationary) ultrasound is still good but not quite as accurate.

Is inflammation around the Tibialis Posterior tendon a common MRI finding?

Short answer is yes – around 33% of ankle MRI will show some degree of inflammation around the Tibialis Posterior tendon.

More interesting though is the correlation to symptoms.

Of the 33% of MRIs with inflammation around the tendon, around 70% of those people don’t report any symptoms in the area.

So it appears that, while inflammation around Tibialis Posterior tendon is moderately common, it’s often not a cause of pain or symptoms.

Is a split Tibialis Posterior tendon normal?

From what we understand of anatomy and its variations, some people can be born with variations in tendon structure. But it’s not the majority of cases.

Others can develop splits in their tendon due to continuous loading, such as in marathon and distance runners.

That group is harder to quantify as there’s no studies on the topic.

The last group is the acute injuries – sudden tears of the Tibialis Posterior tendon.

As we reprted above, this group makes up less than 1% of all ankle sprains. So they’re not common either.

Does a split Tibialis Posterior tendon cause pain?

We know that inflammation around the tendon is common (33% of cases), yet symptoms associated with the inflammation are less common (pain reported in less than one third of cases.)

We also know that for a split tendon to be reacting, it will most commonly produce some sort of inflammatory response.

So a split tendon without inflammation is unlikely to be the cause of any symptoms.

$fibula stress fracture$

Do I have a Fibula stress fracture?

by Pete Colagiuri - Sports Physiotherapist

Fibula stress fractures are less common that Tibial stress fractures and much harder to detect!

That’s because the Fibula isn’t like other leg bones – it’s not a weight-bearing bone!

Most leg stress fractures happen due to forces associated with ground impact.

But Fibula stress fractures are unique – the injury occurs due to muscles pulling on the bone.

What are the symptoms of a Fibula Stress Fracture?

The first warning sign is a vague pain on the side of the calf.

It feels similar to an overworked or sore muscle.

That can get confusing because the most likely cause of lateral calf pain IS an overworked muscle.

Initially it only feels sore after exercise.

The more intense the exercise, the greater the post session soreness.

Next phase of the injury, the soreness begins to last longer.

What used to resolve in a few hours now takes longer that 24 hours to disappear.

In the last phase before a stress fracture, we often see the symptoms become more constant.

The intensity may vary but it’s still aching day and night, regardless of exercise.

How is a Fibula Stress Fracture diagnosed?

The first step for most people is a clinical diagnosis – that is, getting assessed by a doctor or physio.

The is usually enough to suspect a Fibula Stress Fracture but not enough to CONFIRM a stress fracture.

From here, imaging is needed to get a confirmed diagnosis.

MRI is the best option, but also the most expensive. It can see bone reactions as well as cracks in the bone. It gives the whole picture.

X-ray is not sufficient as it’ll only see a bone that has already cracked. Even then, it’ll only spot it if the crack is at a particular angle (relative to the image).

Bone scan is helpful as it shows the bony reaction around the stress fracture. It can’t see the fracture itself but it’s good enough to confirm a significant bone reaction.

CT scan shows a much more detailed picture of the bone but, like an X-ray, will only see a bone that’s already cracked. It can’t spot the reaction that’s the immediate precursor to a fracture.

What’s the rehab plan for a Fibula Stress Fracture?

Fibula stress fractures tend to occur because of the actions of FHL (big toe muscle) or Peroneals (lateral ankle and medial foot stabilisers).

The first step in the rehab is to back off the causative activity.

That doesn’t mean rest!

You can still keep active, provided it doesn’t cause pain or load on the stressed bone.

Then you’ll need to add in a strength program to maintain muscle function while you’re not as active.

Lastly, you need to rebuild the causative activity.

For example, if faster running has caused the problem, it might be linked to FHL loading.

You can return to running after 4-6 weeks but you’ll need to back off the pace.

Over the next few weeks or months, you can gradually return to fast paced running as the bone adapts and strengthens.

It’s important that you listen to your body and give yourself enough recovery time between training sessions.

Remember that you’re recovering from reduced activity, so you can’t flick a switch and be back to normal in a week.

What’s causing my deep hip pain?

by Pete Colagiuri - Sports Physiotherapist

If you’re experiencing deep hip pain, you know just how frustrating it can be!

Trying to find a diagnosis feels like finding a needle in a haystack.

So is there any way to figure out what’s causing the pain deep in your hip?

More importantly, is there a quick way to reduce the pain or get rid of it?

Finding a diagnosis for deep hip pain

The difficulty with getting a diagnosis is that one pathology will often generate other issues.

So while your first problem might have related to the hip joint, it very quickly becomes a joint + muscle + tendon issue.

That means any treatment targeting a symptomatic area might not be effective as they’re missing the underlying cause.

Top tips to identify the main cause of your hip pain

So here are the best questions to consider to diagnose your deep hip pain:

1. Is it worse first thing in the morning or after a prolonged period of inactivity?

This indicates an inflammatory component to the underlying issue.

These diagnoses include hip arthritis and hip muscle tendinitis/tendinopathy.

2. Does it flare up during high intensity exercise (eg. running) or hip strength exercises?

Pain during exercise tends to indicate a component of overload.

These diagnoses include muscle fatigue and bone stress injuries.

3. Is there a prolonged effect from taking anti-inflammatory medication?

This means that the pain stays reduced for days/weeks after you’ve stopped taking the meds, not just while you’re on them. This confirms an inflammatory condition rather than just a pain-relieving or masking effect from the meds.

These diagnoses include hip arthritis and hip muscle tendinitis/tendinopathy.

4. Have you lost range of motion in your hip?

You might notice that it’s more difficult to reach your shoelaces or that you can’t bring your knee to your chest on the painful side. A loss of range is usually an indication that the hip joint is involved.

This includes diagnoses such as hip osteoarthritis and femoroacetabular impingement (FAI).

5. Does the pain extends further down into the leg or up into the lower back?

If the pain radiates from the buttock down into your leg or hamstrings, that can indicate nerve involvement, referred pain or hamstrings muscle pathology.

Diagnoses in these categories include sciatica, referred lower back pain, nerve root compromise at the lower back and hamstrings tendinopathy.

6. Do you have pins & needles or numbness into the leg?

Tingling or numbness in the leg, anywhere from the back of the thigh right down to the foot, is almost always an indication of a nerve problem.

These symptoms are usually the results of a compromised or pinched nerve in the lower back.

Treatment for deep hip pain

Once you’ve identified the possible underlying cause from the questions above, you need to carefully plan your management strategy.

If there is a possible involvement of nerve, with tingling, numbness or referred pain down the leg, the best plan is to seek proper assessment with a health professional. This type of injury is difficult to self manage and can become a more significant problem if not addressed.

When the joint is part of the underlying cause of your hip pain, a combination of exercises and medication give the best results.

Over-the-counter medication is limited to short periods of use due to the likelihood of side effects. Seeing your doctor for prescription medication is a better option as it can be used more consistently for longer periods.

The exercise approach needs to focus on building hip strength without irritating the symptoms. Because the “no pain, no gain” approach often causes more trouble than it fixes and worsens inflammatory reactions.

Muscles and tendons respond well to loading – more specifically, to strength exercises.

The trick is striking a careful balance between doing enough to stimulate improvement without doing too much and irritating symptoms.

Start with a simple collection of exercises that seem like they’re challenging but comfortable. It might be a little boring to start with but it’s a necessary building block.

Every two weeks, make the exercises slightly more challenging and monitor your symptoms. If you experience of flare up when you first change exercises, stick with it for another two sessions.

If the pain is getting gradually worse or the soreness after exercise is not improving, drop back to the previous program. Then you can try a different set of exercises after a week or so.

If you experience repeated flare-ups, or if you don’t seem to making progress, speak to a health professional to diagnose your injury and design and appropriate program.