The Dreaded Hamstring: Pathophysiology and Rehabilitation Tips

by Joshua J. Stone, MA, ATC, NASM-CPT, CES, PES, FNS
Article originally posted on http://athleticmedicine.wordpress.com/
Follow Josh on Twitter http://twitter.com/JoshStoneATC

How many times are we going to see an athlete suffer from recurrent hamstring strains? How many times are we going to see delayed recovery from a mild hamstring pull? Unfortunately, it’s going to continue, because some health and wellness specialists (ATCs, PTs, and Strength coaches) are looking in the wrong area. Read the following conversation I had between myself and a concerned parent of an athlete (the parent also happened to be a chiropractor).

‘What are you doing? Why are you not treating the hamstring?’

Because it’s not the hamstring.

‘What?!?  When an athlete says “I was running and I felt a pull I the back of my leg…. it feels really tight.” you are going to tell me it is not a hamstring strain? Please! Can you please just treat the hamstring?’ 

Well, technically yes, it is a hamstring strain, but it is not the hamstring – which is why I am doing this.

‘What? techinically it is, but it isn’t? That makes no sense. I evaluated him myself. MMT was 3/5 for knee flexion w/ external rotation, hip extension was 4/5. Passive Hip flexion was -40 degrees when compared bilaterally. There is point tenderness over the proximal musculotendinous junction and you still say its not the hamstring.’  

Well, technically yes, it is but no – its not the hamstring.

‘Fine, enlighten me, what is it?’ 

The hamstring is what hurts and what is injured, but the problem and what needs to be fixed is not the hamstring.

‘My son needs to play and you are not doing your job to help him get back. I am informing the athletic director.’ 

** This actually happened and yes the athletic director was notified. He backed me up (after a conversation). Such is the life of the athletic trainer.**

Now, before I swarmed by an angry mobs of chiropractors trying to beat me with sticks, this is not about chiropractors – this is just one example of the trap that many health care practitioners – Athletic Trainers, PTs, OTs, RKTs, DC, MD, LMTs, etc – fall in to.  Many practitioners are too concerned with ‘the what‘ rather than ‘the how‘ and ‘the why‘. I think Athletic Trainers (especially students) do this too often. Even though I am writing about it today – I do this myself. We keep fixing what hurts – not how and why the injury is occurring. Athletic training rooms are not just first-aid triage and pain-relief centers. Athletic trainers are to relieve pain, prevent pain, and optimize function (amongst other things).

What is the traditional therapeutic approach to patellar tendonitis; Rest, ice, ultrasound, massage, cho-pat strap? All viable and great for triage, but it may not fix the problem. Maybe we should apply MWM to the ankle and improve ankle dorsiflexion, that might fix the problem and relieve pain.

********Back to the dreaded hamstring and my conversation with the parent / medical professional********

This particular parent was upset and did not understand why I was not addressing the what. In my defense, I was dedicating some time to fixing the what – using ultrasound, massage, PROM, etc – to facilitate proper tissue healing. However, I knew this would not fix the problem, thus I was focusing most of my attention on the why and the how. In this particular instance (and most hamstring injuries) I needed to correct human movement dysfunction (poor neuromuscular recruitment, suboptimal arthrokinematics, and altered length-tension relationships). This will fix the problem and go a long way in prevention of re-injury.

Let me explain the breakdown of optimal function – or lack thereof:

Secondary, to pattern overload or prolonged static posturing many individuals suffer from chronic hypertonicity and mechanical shortening of the psoas.  A chronically tight psoas will cause altered reciprocal inhibition of its functional antagonist, the gluteus maximus. What that means is the overactive psoas muscle is telling the nervous system to turn off neural drive to the gluteus maximus.

With this muscle imbalance an abnormal force coupling occurs yielding poor arthrokinematics in the form of an anterior pelvic tilt. Because of the hamstring’s proximal attachment to the ischial tuberosity an anterior pelvic tilt will cause the hamstring to migrate superiorly and posteriorly, essentially lengthening the muscle. If you recall from your applied kinesiology course, muscles have optimal length tension relationships – a zone where maximal muscle force can be produced. The longer or shorter a muscle is, the less the muscular force can be applied or tolerated.

In addition to this, with the glute inactivity caused by altered reciprocal inhibition, a muscle must make up for the glute’s loss of functional ability. So now a synergistic muscle must help with the glutes ability to perform hip extension. Which muscle is going to this? You guessed it – the hamstring.  This is called synergistic dominance – the hamstring (synergist) must dominate the movement of hip extension.

If you recall from above, the hamstring is working in a lengthened and suboptimal position. Coupled with this it is being asked to do more work. So, when we are applying the greatest amount of muscular tension – eccentric contraction near end ROM (such as sprinting) – the hamstring fails. Commonly it fails near the proximal attachment secondary to a line of pull change.

Back to my opening questions:

  • Why do we see so many hamstring injuries? Because health and wellness professionals are not identifying or intervening to correct human movement dysfunctional patterns.
  • Why do we see so many recurrent hamstring injuries? Because we are not fixing what needs to be fixed and allowing the hamstring to work inefficiently.
  • Why are we seeing delayed recovery? Because we are using antiquated rehabilitation techniques. We are focusing on the hamstring when the problem exists elsewhere.

Correcting movement dysfunction and optimizing function will fix the problem. This is so much easier in the long run. I am sure practitioners will disagree with me or have some refuting evidence. Recently there has been a slew of research published discussing the effectiveness of high-intensity eccentric hamstring strengthening on the prevention and rehabilitation of hamstring injuries. Yes, eccentric hamstring exercises work, but why? They work because you are making the hamstring more tolerable and able to function with poor mechanics. Essentially, you are just making the chain a bit stronger. Again, this is not fixing the problem.

Is the US Government Responsible for the American Obesity and Chronic Disease Epidemic?

by Joshua J. Stone, MA, ATC, NASM-CPT, CES, PES, FNS

This blog entry originally posted @ http://athleticmedicine.wordpress.com/. Entry courtesy of author.

Chronic medical conditions is the leading cause of death in the United States. Nearly half of all adults have at least one chronic medical condition. Over the past 20 years there has been a significant rise in chronic disease. Over the past 15 years childhood obesity and diabetes is growing at an astronomical rate. Who is to blame? Nobody can really state exactly who, but  is it possible that the US government, specifically the United States Department of Agriculture (USDA) is responsible?

1992 Food Guide Pyramid

In 1992, the USDA released the first Food Guide Pyramid. The USDA obviously had good intentions, through heavy research the pyramid was developed to prevent, chronic disease, obesity, and dental carries. Over the years the Food Guide Pyramid evolved to in to more user-friendly versions, MyPyramid (2005) and MyPlate (2011). Despite making the guides more user-friendly, the USDA did little to evaluate data and change the science supporting the pyramid.  Unfortunately, the USDA got it completely wrong. Since the ’92 Food Guide Pyramid was released there has been a dramatic increase in chronic disease and obesity. Has the Food Guides failed the American people?

Let us evaluate the guides. The ’92 version has grains, fruits, and vegetables filling the bottom two rows of the pyramid, accounting for 20 of 26 possible servings. The 2005 version is much of the same, with a large portion dedicated to carbohydrates, but like the ’92 version, the largest portion is dedicated to grains. The 2011, MyPlate is simplified for the consumer, but again indicates most of your plate be comprised of carbohydrates. In fact, when you breakdown the percentages the guides recommend the consumer eat approximately 75% of calories from carbohydrate sources. What is wrong with this you ask? Well, below I have outlined 5 reasons why the USDA might be responsible for the rise in chronic disease and obesity.

Five Reasons Why the USDA Might Be Responsible for the American Obesity and Chronic Disease Epidemic

Reason #1: Misleading information

The guides suggest grains (bread, pasta, rice) account for the largest portion of carbohydrate consumption. The guides do not state 100% whole-grain. To the average consumer, this gives the impression that refined breads and pasta is a fantastic option.  So, the lay person, goes to a restaurant orders a plate of spaghetti and a side of garlic bread, and thinks -’this is a healthy low-fat meal’. After all, according to the guides this meal is well within the guidelines set forth by the USDA.

Additionally, the original guide said 6-11 servings of breads, grains, and pasta / day. Servings is key, because most individuals, myself included, grossly overestimate what constitutes a serving. Another note on servings: it gives a range of servings; 6-11 servings. This tells the consumer that you must have a minimum of 6 servings of grains. This misleading information has led to over-eating and over-eating of the wrong foods.

Reason #2: Satiety

Countless studies have correlated carbohydrate intake to increased hunger, specifically foods with high glycemic index (1, 2, 3). Primarily because of the insulin and blood glucose spike caused following the ingestion of carbohydrates. Newer research indicates that a higher than normal protein diet may actually be the reason for their partial success in inducing weight loss (4). Weigle, et al, found that the subjects felt more satiated with high-protein diet (5). In addition, Weigle’s team found total caloric intake decreased with when consuming more protein (5). There are two theories behind protein’s ability to increase satiety: 1 – High protein foods take longer to digest and leave the gut. 2 – Protein may impact our the hunger and satiety hormones of ghrelin and leptin. So the USDA is telling us to eat foods, that physiologically trigger us to eat more.

Reason #3: Insulin

When we eat carbohydrates insulin is released by the pancreas to begin glucose uptake from the blood. Insulin’s job is to take blood glucose and facilitate storage of glycogen  – our primary energy source. Insulin is also an indirect gate-keeper to fat metabolism, by inhibiting the release of glucagon. Glucagon is a hormone that has the opposite role of insulin. Glucagon is designed to take glycogen and convert it to glucose. Glucagon also creates glucose through lipolysis (the breakdown of fat). If we eat carbohydrates, the insulin response inhibits glucagon – thus prevents us from burning fat.

Reason #4: Elevated Inflammatory Markers

Chronic inflammation is a primary cause of most chronic diseases (6). Excessive consumption of refined carbohydrates, low dietary fiber intake, and a high omega-6 to omega-3 ratios are strongly associated with the production of proinflammatory molecules (7). One large study compared a Western diet and high protein diet. In this study, the western diet group had greater levels of inflammatory markers, including CRP and E-selectin, whereas those on the high protein diet had a significant decrease of inflammatory markers (8).

Reason #5: Importance Fat

In the original food guide pyramid it is stated that fats should be used sparingly. In both the 2005 version and 2011 version, the USDA’s guide says nothing about fat. This gives the impression that fat should be avoided. This is a huge mistake. Fat, specifically, Omega-3 fats – found in nuts, fish, and seeds – is very important. Clinical studies in adults with high cholesterol have shown that nuts lower LDL-cholesterol and improve the overall blood lipid profile (9). Additionally, frequent nut and seed consumption is associated with lower levels of inflammatory markers such as C-reactive protein (CRP), IL-6 and fibrinogen(10).

Does this indicate the USDA got it wrong and led the American people down the wrong path? I believe the aforementioned reasons have led to an increase in obesity and chronic disease in America. Is it really a coincidence that following the release of the guides there has been a dramatic rise in obesity and chronic disease? That being said, I believe in personal responsibility – I think it is up to the individual to make wise decisions. The USDA is not telling people to stop exercising. So, although I believe the USDA may have been a contributor – some blame should be put on the people.

What do you think? Can we blame the USDA’s Food Guides for steering the American people in the wrong direction?

References:

  1. Wien M A, et al. Almonds vs complex carbohydrates in a weight reduction program. Int J Obes 2003. 27:1365-1372
  2. Roberts SB. High-glycemic index foods, hunger, and obesity: is there a connection? Nutrition Review 2000. 58:163-169
  3. Arumugam V, et al. A high-glycemic meal pattern elicited increased subjective appetite sensations in overweight and obese women. Appetite. July, 2007.
  4. Astrup A, Meinert Larsen T, Harper A. Atkins and other low-carbohydrate diets: hoax or an effective tool for weight loss? Lancet 2004;364:897
  5. Weigle DS, Breen PA, Matthys CC, et al. A high-protein diet induces sustained reductions in appetite, ad libitum caloric intake, and body weight despite compensatory changes in diurnal plasma leptin andghrelin concentrations. Am J Clin Nutr 2005;82:41–8.
  6. Stehouwer CDA, Gall M-A. Twisk JWR, Knudsen E. Emeis JJ. Parving H-H. Increased urinary albumin excretion, endothelial dysfunction and chronic low-grade inflammation in type 2 diabetes: progressive, interrelated, and independently associated with risk of death. Diabetes.2002;51(4): 1157-1165.
  7. Neustadt J. Western Diet and Inflammation. IMCJ. Vol. 10: 2  Apr/May 2011.
  8. Lopez-Garcia E, Schulze MB, Fung TT, et al. Major dietary patterns are related to plasma concentrations of markers of inflammation and endothelial dysfunction. Am JClin Nutr.2004;80(4):1029-1035.
  9. Mukuddem-Petersen J, Oosthuizen W & Jerling J. A systematic review of the effects of nuts on blood lipid profiles in humans. J Nutr. 135: 2005. 2082–2089.
  10. Rajaram, S, Connell, KM, and Sabate´ J. Effect of almond-enriched high-monounsaturated fat diet on selected markers of inflammation: a randomised, controlled, crossover study. BR J of Nut.  2010: 103, 907–912.

Ramblings about the first 76 hours of the London 2012 Paralympic Games

By:  Nancy Megginson, Professor, Kinesiology

August 29th

Due to a four-plus hour delay in my flight from SFO, I arrived at London Heathrow on August with just enough time to hit my hotel and take the train out to the Olympic Park before the start of the Open Ceremonies. I have accreditation as a member of the press covering the Games for the adapted physical activity, recreation, and sport professional magazine, Palaestra, but needed to pick up my photographer bid/materials at the Main Press Center before the OC started. Once in the Olympic Stadium, I (along with over 62,000+ spectators) was exposed to an extremely original and moving OC like no other…With Professor Steven Hawking, astrophysicist, narrating the ceremonies and Sir Ian McKellan playing Prospero from Shakespeare’s The Tempest, the evening’s festivities provided moving journey on the struggle of disability/human rights and the achievement of empowerment. Over 141 performers with disability participated in the ceremonies, many of those attached to zip lines in various scenes flying high over the crowd. To usher in the official start of the Games, the Queen of England announced its opening, the Paralympic flag was raised, and the cauldron was once again lite to tell the world the 2012 Paralympics were to begin. The end of the OC was accented with fireworks over the stadium and a very moving finale song, I am what I am, performed by Beverly Knight (and others). I was moved to tears but had great excitement to what was to come in the next 12 days of competition. Got home about 1 AM still wired from the OC…

August 30

Couldn’t sleep….After a horrid few hours of sleep (time zone zombie), I got up just in time to have breakfast and head back down to the Olympic Park in the east side of greater London. What an incredible site as the train pulls into the Stratford Station! The competition buildings are very creative in their design but mold to the land like they have always been there. I love that a good chunk of the venues are located at this one site so it makes it easier to get to a variety of competition throughout the day. Athletics (track and field), wheelchair basketball (actually at two sites in the qualification matches), wheelchair rugby, goal ball, cycling in the Velodrome, aquatics, wheelchair tennis, and football-5-a-side/7-a-side (soccer) are all located here. ExCel is another main site for venue competition as is located about 25-30 minutes away by bus. Boccia, powerlifting, table tennis, sitting volleyball, judo, and wheelchair fencing competition are to be held in this large exhibition center.

Archery, shooting, wheelchair marathon, road cycling, equestrian, rowing, and sailing contests are held at other sites throughout the London area. As a member of the press, I have access to easier entrance into the park and transportation between its various venues as well as down at the other sites I mentioned.

I am blown away by the support and knowledge base of the British fans for the Paralympic Games. The competition is sold out; persons I talk with on the train to/from my hotel to the park are consistently saving they wished they had tickets. And (I know I am generalizing but it is what I see) they know about the various disability sports. You cannot believe the roar of the crowd when a British competitor is announced or medals…it is deafening! And there is constant coverage on television (one broadcasting station reported a peak audience of 11.2 million viewers), radio, and in the newspaper about the competition at these games. Compare that to no-live US NBC coverage at all only occasional highlights on its cable station and filmed Youtube broadcasts by the US Paralympics. It is shameful.

Saw my first US gold medal of the games…Jessica Long won the 100m butterfly in her class. Long was adopted from a Russian orphanage when she was 13 months old…because of a congential anomaly where her fibulas were missing in her lower legs, Jessica was unable to walk… at 18 months, her legs were amputated below the knee so she could be fitted with prosthetics. US won a total of 6 medals for today…Pretty exciting…Enough…I need to sleep; it is 4AM and I am beat.

August 31

Little sleep again…grrrrrrrr. Breakfast and back to the park. I wanted to check out the Excel venues today and was able to cover/photo the US vs. China women’s sitting volleyball team, poked my head in at powerlifting, and watched judo. I headed back to Aquatics to watch a wounded Afghanistan veteran, Brad Snyder, compete in the men’s 100m freestyle finals in his division. He was blinded less than a year ago in an IED explosion. He won the gold metal and had a number of fans in the stands who were there to support him. I was so proud/happy for him that I was cheering in the photo area (sorta a no-no). The playing of the US anthem for his gold medal ceremony had an additional connotation that was not lost on any American in the venue at that moment. Jessica Long also got her second gold in the 400m freestyle finals…US earned a total of five medals for today’s competition. Got home early at 1030 and went to bed at midnight…maybe tonight I will get some ZZZZZs.

Sep. 1

Yea!!!!!! Got some sleep. Headed out to the park to check out what I wanted to cover today. I decided to focus on athletics later in the day and took a few hours to go by the underground (Tube) to one of the largest outdoor food stalls/antique faire/flea markets in London called the Portobella Market. What fun but hard to walk around! There were people and tour buses everywhere! Needed a bit of retail therapy before heading back to the competition☺ Found a nice leather jacket for 7 pounds (about $11 dollars)!

Back at the park, I hustled out to the Olympic Stadium to get a good photo position because of the upcoming qualification heats in the 200m T44 class in which Oscar Pistorius would be competing. Oscar (aka Blade Runner because of his ‘J’ blade prosthetics) will have participated in both 2012 Olympics and Paralympics track competition this summer. He has long been an avid proponent to allowing athletes with disabilities to compete along side athletes without disabilities. Because of this media fame and visibility, everyone here knows who Oscar is and that was witnessed tonight when a huge deafening fan roar occurred as he entered the track. There were three heats tonight with Pistorius in the last one. The first heat competition established a new world record in the 200m…Oscar answer that in the third heat with breaking (shattering) that newly established WR by over 40 seconds. The crowd went wild…more to come on this in the finals. There is a US athlete, Blake Leeper, who may be the one to give Oscar a run for his money (sorry, I just had to say that☺). Interesting note…he has the same level of disability as Oscar (bilateral below knee amputation); note to self—is if fair to have T44s compete with T43s (unilateral below the knee amputation)? Are T44s’ sprinting gait more similar, biomechanically, to sprinters without disabilities as opposed to those with asymmetrical gaits due to a unilateral amputation? I imagine this has been researched but I need to look into it.