The work of Cole Asking suggested that the further away that first indication of palpation is from the ischium, from your ischial tuberosity, would indicate the length it will take to recover. So the closer it is, the longer it takes.
SPEAKER_00:Hamstring tears are super common and the research has evolved quite a bit in the last five years around palpation, imaging, return to sport criteria, and even being a little bit more aggressive earlier. I can't think of anyone better than Nicole Van Dyke, who's a physiotherapist. He works for Island Rugby and his PhD was published in The Risk Factors for Hamstring Injuries in Professional Football Players. I really enjoyed this episode. I hope you do too. I'm Michael Risk and this is Physio Explained. Welcome, Nicol, and thank you for your time today to talk to us about hamstrings.
SPEAKER_02:Thanks, Michael, and appreciate the invitation to come on to this exciting new podcast.
SPEAKER_00:It is exciting. We're going to get straight into the diagnosis of hamstring tears. So when you have a patient or an athlete come to see you and it's a suspected hamstring tear, with your knowledge and the research, what are you testing? What are you now looking at? with that patient or athlete?
SPEAKER_02:Well, I think to a large extent, it's still the same. I know there's lots of fancy ways to do palpation, but I think palpation is still a great skill that most physios need to and continue to develop. Having a confirmation then of a flexibility deficit and strength deficit, but it really also comes together with the the mechanism of injury and the story the patient tells you. So I think we're still looking at an holistic evaluation using your subjective examination to really guide your objective examination. And in that sense, just refining the art of bringing those factors together and building a good hypothesis. And for muscle injuries, those three components, length, strength, and palpation, are usually quite common. have been fooled a few times. I think grade zeros, if I can call them that. So injuries that have no structural damage, but maybe the old word was functional injury. They often present similar, but if you recover from a hamstring injury in two days, there probably wasn't been structural damage. So I think we can still rely on those clinical skills. And then as the patient then recovers, it'll confirm our diagnosis.
SPEAKER_00:Yeah, that's really interesting already. So talk to me about palpation because there are a couple of papers that started to suggest we're not as accurate with our hands as we might be. But I do recall a paper suggesting that the area or the size of tenderness with your palpation is still relevant. Could you tell us more about that? And is that paper coming up for you? You
SPEAKER_02:know, I think the big thing around that for me at least, so you're absolutely right. I think we've often fooled ourselves in the past and we've all been through the gambit of doing PAs with our palms and the pressure of a coin, like all that nonsense we used to do.
SPEAKER_01:But I
SPEAKER_02:do think that we can still trust ourselves to understand and feel for especially gross movements. But in terms of palpation of muscle injuries, we're often looking to identify pain. So if a person a player and an individual can identify, oh, you know, that spot really hurts. That feels different to everything else you're doing. I learned some really good skills from Rob Whitey over at Ascotar. You know, just put your hands on both legs. So, give the passion, especially if this is the first muscle injury a person has ever experienced. They might not really know what you're feeling for or what to react to. So, if you're palpating both limbs, usually you can identify a painful spot. Now, The work of Cole Asking suggested that the lower, the further away that first indication of palpation is from the ischium, from your ischial tuberosity, would indicate the length it will take to recover. So the closer it is, the longer it takes, which may suggest that different tissue types are involved as well. And then I think from the work we did over at Aspitar, we were able to see that palpation was one of the clinical indicators that helped us understand how you recover, not necessarily the width, but the length of palpation seems to correct more or less with where you get to in your rehab. So when you're about halfway better, and of course there's exceptions, your length of palpation compared to the initial length of palpation should be about half as long as well. So I think there are still some broad strokes there that we can really rely on. whether you can identify, you definitely can't identify whether you've had an intramuscular tendon tear. So for the tricky ones, I reckon, and that's maybe a good point when it comes to diagnosis as well. If you're working in an elite environment, you're probably always going to get an MRI or very often some form of imaging, maybe an ultrasound then. But I think because of the high pressure environment and often it confirms what we need to know. And for the folks who are interested in this area, I highly recommend the paper by Noel Pollock and the group from British Athletics who were able to demonstrate in their elite sprinter cohorts, that definitely played a role to be able to identify substructures that were for the injury. So I think it's important to keep those factors in mind in the elite environment. For the rest of us, I think once you've identified that, it's really about your treatment and then how the patient responds to the treatment you provide.
SPEAKER_00:I'm excited to get onto the treatment. I just want to finish off on the second part of that that you mentioned, which was the strength testing. What are you looking for in strength testing when someone comes to you with that hamstring tear?
UNKNOWN:Yeah.
SPEAKER_02:Well, at a very basic level, it's just a deficit compared to the uninjured side. Now, for, let's say, run-of-the-mill intramuscular grade 2 hematase, you'd probably be able to just manually feel that one leg is less strong than the other. And initially, that muscle contraction would be painful. So you wouldn't have to do too much to elicit a painful response from what would be a normal isometric muscle contraction. Although later on, and we've often used this early on, is handheld dynamometers. Now, the very early stages, just the contraction itself is painful, so you don't register too much. But it's been really good, at least in my experience, to be able to track how patients then recover. And we do the handheld dyno, even though they might only get into the position of the break test we do later on in the rehab, to get the patient comfortable with the idea that we're going to be monitoring their strength and try to use those education opportunities so we really get a reliable, standardized way in which we test it. But of course, we're not pushing through pain. We're not trying to elicit a more painful response. Pain should always end the test, so to speak.
SPEAKER_00:We want to move on to treatment, which I'm excited for. What has changed for you in the treatment space. As an example, I actually tore my hamstring not long ago and from everything that I've accumulated over the last few months, my learning was to be a little bit more aggressive than I might have been and to start running sooner than I might have before. What are you learning about the treatment of hamstring tears recently?
SPEAKER_02:Yeah, you know, there's been some good progress, maybe. But perhaps the biggest change for me clinically over the last few years is that we've really moved to a criteria-based progression instead of a time-based progression. So, as I've mentioned, a really worthwhile paper to look at is The Making and Breaking of Skeletal Muscle by Abigail Mackey and Michael Kjar. fantastic paper to explain how muscle heals. And some of that is time-related. But in rehab, I think now what we've done is say, hey, if we have a set of criteria and you meet them, then we're very happy to progress. So Phil Glasgow, who's the head of rehabilitation at the IRFU and folks would know, say this often, rehab is training in the presence of injury.
SPEAKER_01:I
SPEAKER_02:really like that. I think that helps us shift the focus from passive treatments and pain modification to actually doing something that's necessary for the healing to occur. So it's the same way where in training we look for a stimulus that would drive adaptation. So at some point, like the weight's just not big, like not enough. You need more weight to drive a certain adaptation of the muscle if, for instance, you're looking for strength. So in our healing process, we need the stimulation that will drive the healing process for it. And often that's playing around or being attentive to the forces we're creating within the muscle that would help those collagen fibers align the right way, build the tension in the right alignment and return the player to the sport that they need to. So I think that's been the biggest shift for me is we're more attentive to the goal and the end of our rehab process. What will the player need? What will the tissue need to perform and to perform to its greatest ability? And what can we do to stimulate that process from very early on throughout the rehabilitation process? From a very practical point of view, I think, and I think this is going to become true across our profession, is we're outcome-focused. So we are trying to measure things that we can actually, we're trying to use outcomes we can actually measure to know whether we're making a difference or not. And so that can be strength, flexibility, still pain on palpation, and the presence of pain, for sure, we can at a very basic level measure that. But those other outcome measures, exposure, whether that's running minutes or time or GPS variables, if you're really lucky, but understanding, looking at those outcomes to tell us whether our rehabilitation is being successful or not.
SPEAKER_00:I like that. Talk to me more specifically about this criteria-based progression. As an example, where I would struggle clinically is probably that first phase of going from isometrics to something more challengingly eccentric, and then also going from light running to really ramping it up in towards a sprint and When you mentioned criteria-based, are there things you're looking for in the palpation or handheld dynamometer realm?
SPEAKER_02:You know, I'm going to deflect a little bit to work from Jack Hickey over at ACU in Melbourne. Jack's done some really interesting work. Now, part of it was... the question about how early can we do eccentrics? And what they, some of their patients started eccentrics, I think day three or four post-entry, but so really early on, but they had a criteria and that was, if I can call it a sub-maximal positionally friendly. So the old ham slides test and a certain amount of repetition.
UNKNOWN:Yeah.
SPEAKER_02:it was three sets of eights or something like that, three sets of six. And so once a player could do that without pain or discomfort, they were willing to allow them to do the eccentrics. The funny thing, and this was the really great results or very interesting results from Jack's paper, is at that stage, so early on, folks would have more pain with isometrics, which is the thing I usually use to say you can't do eccentrics, than they did with the eccentrics. And I think we have to understand a little bit of mass physiology and that eccentrics works differently. It works with negative energy. There's a lot more neuromuscular control involved. Arguably, there's a component of neuromuscular control, and I use the term broadly there. Apologies for the abundance amongst us. But that might allow us to use eccentrics to stimulate exactly what we want, to stimulate the healing process. So... I recommend you read Jack's papers, but it's brought in a very simplistic way. You're doing a ham slide. You're doing it in your natural units. You can do three sets of six. Do your eccentrics. You can start doing a Nordic hamstring exercise. But there are obviously, manually speaking, a host of manually resisted eccentrics you can do early on. And if the player isn't reporting pain with those exercises, I'd be very happy Now, it's the other thing that made me shift my thinking is some of the work by Cole Askling. So, Cole had the glider, the slider, and the diver, or arabesque, and those three exercises he performed at different stages. Now, Robin Vermeulen, who's a doctor and researcher, a PhD researcher at Aspen, he's going to publish a paper pretty soon in BJSM. which will be absolutely phenomenal where they introduce those exercises really early on so if you remember Carl's work it's the diver standing on one leg diving forward the slider sliding your uninjured leg out backwards and then the extender lying in supine and extending your knee at a moderate pace. And so I think all those exercises, you could argue, are low-load eccentric exercises. And that's perhaps why Carl had such phenomenal results in his rehabilitation studies. There might be other reasons, but I think certainly for me now, I consider eccentrics as our friend. And then, of course, you need to start within the category capacity of the tissue and the capability of the player or the person and then progress gradually so there's no big jumps it's trying to and that's the art maybe of understanding this using these outcome measures but using all the information available and then still making using your clinical reasoning to decide what's appropriate for the person in front of you.
SPEAKER_00:Nicol we have to wrap up very soon this is flown by I wanted to ask you what are the What are the mistakes or errors you're still seeing with your knowledge in a lot of that research space? What are the mistakes or errors or things we could do better with our real end stage hamstring rehab?
SPEAKER_02:Yeah, in some ways the answer might be easy, but I'm a bit biased because I deal with a lot of running sports and I have in my career. So I think we really have to get players to experience be exposed to the running they need for the sport they're returning to. I might also say that the shift for me has been that it's not just about running. It's not just about eccentric strength. We definitely, in sports like rugby, see that trunk control plays a big role in the injury mechanism. So we're perhaps well-suited to make sure there's trunk control. We want that neuromuscular ability or activation to have taken place. We are playing around with the force, velocity, capability, and then eccentric strength, but then at the very end, you need to do what you're going to do, and that's probably have enough exposure to high-speed running. Some of the work, again, from Rod and Morgan Williams over in Wales have shown that Folks are almost always a little undercooked when they get back into the game.
SPEAKER_01:And
SPEAKER_02:so it's also being able to mitigate, well, to manage the risk, certainly, but then to see how much can I afford to expose the player in a gradual training progression to high-speed running and running in general before they have to go into a competitive game. Now, contextually, sometimes you just don't have enough time and we're all taking a bit of a risk. But when we do have time, I think that's absolutely valuable. And really also for the guys who are coming back from re-injuries, really you have to make sure they're getting that load exposure now. Because if they don't, they end up in this cycle where the chronic rehab cycle, so to speak, where we're constantly dealing with niggles and issues. And I think it's that exposure at the end that we could do a better job for. I don't think we have all the answers around that yet, but certainly trying to do more... trying to get your player used to what they're going to have to be doing in the game is what we should be aiming for.
SPEAKER_00:Nicole, we have so much more to talk about and I'd be so excited to have you back. But for today, I wanted to thank you so much for your time, for taking us through part one of our Hamstring podcast.
SPEAKER_02:Oh, thanks, Michael. It's been a blast. That has flown by. I look forward to doing this again. And thanks to everybody for listening and keep those honeys safe.