Lets start with the basics- the term “hamstrings” refers to a group of three muscles that run along the back of the thigh- the semimembranosus, semitendinosus, and biceps femoris. As a group, these muscles generally act to extend the hip (bring the thigh backwards in relation to the trunk) and flex the knee (bring the lower leg back and up toward the glutes). Hamstring injuries commonly occur more slowly with overuse, or suddenly with forceful eccentric contraction. (The term “eccentric” contraction means that the muscle is lengthening under load). Common complaints after a hamstring injury can include pain, tightness, increased discomfort with motions that lengthen the hamstring, and walking with a “stiff legged gait”.
In the following few paragraphs, I will walk you through the general progression that I like to use when helping people return to functional and athletic activities after a hamstring injury.
Step 1- Calm down discomfort
This can be done in many ways including:
-Dry Needling
-Body tempering
-Isometric exercises
-Foam rolling
-Soft tissue mobilization
These interventions are useful for decreasing discomfort, and allow for improved activity tolerance for a period of time immediately afterwards. In other words, once pain has decreased, people are typically able to work through a greater range of motion and activate the hamstrings more. Dry needling and body tempering require help from someone that knows what they are doing, like a licensed professional, but soft tissue mobilization, isometric exercises, and foam rolling can easily be done on your own. One thing that I like about using isometric exercises is that they allow you to continue working the hamstrings while also decreasing pain. A couple of the isometric exercises I like to use are listed below. The key with these types of exercises is to hold the desired position for a prolonged period of time, up to 45 seconds if possible.
Isometric long lever bridge
Isometric elevated bridge
Step 2- Bridging
Once pain and discomfort has decreased noticeably, I like to then start working through some modified bridges. Bridging is a good way to start to move the hamstrings a little more while minimizing the lengthening that occurs through the muscles. This is because the knee can be held in a static position while the hamstring muscles are lengthened/shortened across the hip joint. (Only getting stretched at one of the two joints that this muscle group crosses). This is a good way to reintroduce smaller amounts of mobility, especially during a period of time when lengthening the hamstrings might still be irritating. Bridging is usually done to target the glutes, but this exercise can be modified to make the hamstrings pitch in more. To target the hamstrings during this exercise, move your heels out away from the glutes. This takes some of the work off the glutes and shifts it down to the hamstrings.
Long lever bridge to single leg progression
Elevated bridge to single leg progression
Step 3- Lengthening/ mobility work
Once we know that bridges are tolerated well, it’s a good time to try light exercises that will require lengthening of the hamstrings across both the hip and knee joints. These exercises can be easily modified to keep the movement within what feels tolerable. Ideally, you will start to notice decreased discomfort with successive repetitions as the nervous system allows the muscles to lengthen more. A couple of my favorite exercises to accomplish this are listed below.
Banded primer
Hamstring slider
Step 4- Loaded eccentrics.
Once lengthening the hamstring across both the hip and knee is tolerated well, I will then move into eccentric loading of the hamstrings. Here is where you really start to get a lot of bang for your buck, as you start to rebuild the strength and resilience that will help you return to your prior level of function and decrease the risk of future injury. For this, I like to use different hinge movement variations, starting out by drilling proper technique within tolerable/available range of motion, and then progressively loading this movement. Some hinge progressions are shown below
Hinge with dowel
(focusing on proper technique, and maintaining contact at the tailbone, back of the head, and the portion of the spine between the shoulder blades)
Goat Bag Hinge
RDL
Deadlift
SL RDL
Step 5- Plyometrics
Once we know that the hamstrings are strong and tolerate loaded functional movements well, it is time to speed up the movements/rehab exercises performed and introduce more athletic activities. Some of my favorite exercises for this phase of rehab are listed below
Banded KB swing
Russian KB swing
Hamstring slam
Hamstring medball kick
Step 6- Athletic activities
Once plyometric movements are tolerated well, it is now time to start re-introducing more sport specific activities. Activities that fall into this category depend on the person, but include things like sprinting, cutting, and jumping
Important things to keep in mind through the rehab process-
Keep discomfort within tolerance-
Allow discomfort to help guide you throughout this process. Typically, performing exercises that feel tolerable, even if they feel somewhat uncomfortable, will help you
make sure that you are pushing your limits. I typically tell people that “tolerable” discomfort is usually rated as about 3-4/10 pain or below. Pushing your limits in this way will help you do enough to create the adaptations necessary for recovery without flaring up your discomfort. If an activity causes your discomfort to rise above this level, or to a level that you would consider “intolerable” then you should back off. Additionally, I tell people that if their discomfort starts feeling worse with each set/rep, then that specific activity may be too much, and I would recommend modifying the activity if possible. If this is not possible, then they should simply move on to the next exercise they had planned.
Along these same lines, it is important to keep in mind that just because you may be experiencing pain or discomfort, it does not mean that you are causing further tissue damage. This is another reason why I recommend operating within “tolerable discomfort”. For more info on this topic, I recommend reading Dr. Brandon Vaughn’s blog post on our site – “The Pain is in Your Head!” and watching the animated video at the bottom of the post, which can be found here: https://vertexpt.com/2019/09/09/the-pain-is-in-your-head/
RELATIVE rest
The key word here is relative. Rest does not mean sit on the couch until your hamstring feels better. A passive approach to recovery will only cause you to become weaker and more deconditioned, increasing the odds that you suffer another injury. Throughout the rehab process, it is important for people to continue to perform activities that do not increase their discomfort. It is important to prevent a hamstring injury from causing you to become deconditioned or weak in other areas. Because of this, it is crucial that you continue doing things within your normal fitness program or daily life that are tolerated well such as upper body exercises, squats and lunges within a comfortable depth, biking, walking, household responsibilities, yard work etc.
Rate & maintenance of progress
Sometimes within a short period of time, people are able to work from the initial phases of this rehab progression to the later stages very quickly. I commonly see people that are able to work all the way from step 1 to 4 in one PT session. However, this does not mean that 2-3 hours later they will able to get off the couch and pick up where they left off. For a period of time, it will likely be necessary to use pain relieving interventions or lower level activities in order to warm up before more challenging ones. However, as your tolerance to higher-level activity improves, you will likely find that you don’t need to spend as much time on lower level exercises and things aimed toward decreasing pain. Furthermore, it may be a good idea to hold onto the exercises and pain relief strategies that work well for you, and continue to use them as a warm up or recovery tool. Different people will respond differently to various interventions, and take different amounts of time to fully recover. This is due to a number of different factors. Because of this, it is important to stay patient, figure out what works best for you, and continue pushing the limits of what feels tolerable until you are back to 100%.
Questions? Thoughts? Feel free to email me at casey.powers@vertexpt.com
Casey Powers PT, DPT
Blood Flow Restriction (BFR) Training has been one of the most important recent additions to the worlds of orthopedics and sports rehab.
How It Works
By partially restricting arterial (“fresh”) blood flow to a working muscle, we can restrict the amount of oxygen available to that muscle. Exercise in an anaerobic environment (“lacking oxygen”) forces the muscle to produce higher amounts of lactic acid. We can “trick” the muscle into thinking it is working hard, giving you that deep high-intensity workout burn, while only doing very easy exercise. That build-up of lactic acid causes not only causes increased muscle fiber recruitment, but also causes the body to increase production of Growth Hormone (GH), and subsequently Insulin-Like Growth Factor 1 (IGF-1). These 2 hormones are extremely beneficial for rehab. Growth Hormone increases collagen synthesis throughout the body, which is a clear advantage when rehabbing an injured tendon or ligament. With larger, stronger tendons, it also doesn’t hurt to have larger, stronger muscles – IGF-1 has been known as a major driver of muscular hypertrophy.
They physiologic gains don’t stop there! Myostatin is a gene in the body that limits muscle growth. (Myo = Muscle, Statin = Stays the same). By downregulating the myostatin gene, BFRT can help the body grow more muscle, which is very important during rehab from some injuries and surgeries.
Why it is Relevant
There are 3 different types of muscle fibers in skeletal muscle:
- Type I, which are aerobic, slow twitch and low-force producing. Think “endurance” fibers that are small, but long-lasting.
- Type II X, which are anaerobic, fast-twitch and high-force producing. Think “explosive fibers” that are large, strong, and get tired quickly.
- Type II A, which are somewhere in between. They are fast-twitch, but medium-force producing and partially aerobic (though exhaust faster than Type I fibers).
Type I fibers are utilized for most of the low intensity things you do during daily life. You don’t need to access Type II fibers until you are doing high intensity sprints or heavy lifting. Using BFR allows us to access the Type II fibers during light activities, which directly leads to increased muscle strength and hypertrophy despite not being able to load the muscle adequately (due to pain, post-operative status, etc.). This will expedite the rehab from orthopedic surgeries, and will also help maintain muscle mass while dealing with various overuse injuries.
A study performed by Park et al. in 2010 showed that walking with blood flow restriction applied to the legs led to an 11% improvement in in VO2 Max over just 6 weeks. This experiment was done on Division II Basketball players, not un-trained individuals. This has major implications for endurance athletes rehabbing an over-use injury – keeping a high level of cardiovascular function during times of limited capacity is crucial for returning to peak performance.
Blood Flow Restriction cannot (and should not) replace heavy loading during rehab, but can act as an intermediary supplement with similar effects until heavy loading can be safely performed.
There are only two reactions to “core exercises” – either you LOVE them or you HATE them. The muscles that are commonly referred to as the “core” are the front abdominal muscles – the rectus abdominis (6-pack), transverse abdominis, and obliques. They’re what everyone wants, but are incredibly hard to achieve without a strict and clean diet…or an incredibly high metabolism. What’s not commonly thought of as the “core” though, are the OTHER muscles and structures that make it up. The core is made up of your respiratory diaphragm at the apex of the abdomen, the abdominal muscles in the front, the lumbar paraspinal muscles in the back, and the pelvic floor muscles at the base. These groups together help keep your body strong and stable, as well as performing other duties we won’t touch on here. And these muscle groups can be exercised in a myriad of ways – both the traditional “core” exercises (such as crunches) and not so commonly thought of exercises (such as squats). What I seek to do with this blog is hit on 4 commonly performed exercises that strengthen the core and how they impact the pelvic floor. These exercises are: low front planks, sit-ups (butterfly), bird dog, and squats.
Low Front Plank
The plank is great for activating the spinal muscles as well as the abdominal muscles. However, is an exercise that brings to mind a “NEVER do that” connotation. Many believe that due to the impact this exercise can have on the pelvic floor, it’s an exercise that should NEVER be done. But I don’t believe that are true “nevers” in life. Planks can really help wake up the abdomen – whether used as a warm-up or a strengthener. To say you can “never again” do a plank is ridiculous. But at the same time, jumping into a 5 minute plank 2 weeks postpartum is also ridiculous. It’s something that needs to be consistently performed and increased at a safe progression.
The reason the pelvic floor can be affected is because of possible pressure created on it while in the plank position. If your abdomen and low back isn’t taking the brunt of the demand, then your pelvic floor may take on more of that work. So, rather than jumping straight into an “as long as possible” plank, maybe do short intervals first – making sure the pelvis is tucked and there isn’t sag in the low back. Then progress from there!
Sit-Ups
This is what first comes to mind when trying to predict what others will think of when considering “core” exercises. What I think of first when I consider a sit-up in a workout is “why do I want to add a sit-up in?” If it’s because I want them to get better at sit-ups or because they have a sit-up test coming in the future, then I’ll likely throw it in there. If it’s because I want them to feel like they’re really moving, but also be able to slow down the amount of movement, then I’ll likely throw them in there. If the reason is because I want to do core work, I might choose another exercise that will bank in on more muscle groups at the same time.
The sit up will target specifically the abdominal muscles – and possible the hip flexors depending on how you’re set up in this movement. It doesn’t really activate the low back or the pelvic floor as much – meaning it won’t assist in co-contracting different muscle groups. Because of the increase in intra-abdominal pressure, it also means that if you’re not strong enough for this exercise it will put more pressure on the pelvic floor. If the pelvic floor (like with the plank) isn’t ready for that demand, then it’ll cause issues (either in incontinence or eventual pain).
There’s some concern with diastasis recti with sit-ups. With a diastasis recti, there’s a split in the rectus abdominis muscle – what is traditionally considered the “6-pack muscles.” This occurs in 100% of women in the 3rd Trimester, due to the amount of space required for the growing fetus. However, in most women it either resolves completely or is asymptomatic. Diastasis remains in 32-46% of women, causing pelvic floor dysfunction or low back pain. However, what we’re looking at when deciding on if sit-ups are appropriate is the absence or presence of that pelvic floor dysfunction or low back pain. In the absence of low back pain/pelvic floor dysfunction, with a baseline strength, and with having a benefit to performing sit-ups, then get it!
Bird Dogs
Bird dogs is one of my favorite exercises for “core” – it encompasses so many parts. It challenges balance, it challenges the abdominal muscles, it challenges the low back muscles. It’s versatile, you can add so many things to it – from combining bands to weights to increasing hold times. You can add pelvic floor contractions with it, and add pelvic floor relaxation to it. Like I said, it’s incredibly versatile!
The biggest benefit there is to adding a bird dog in, whether as a warm-up to ensure the low back and abdominal muscles are firing well before getting into movement, or as part of a core-circuit, is that it enhances co-contraction behaviors in the muscles. This muscular co-contraction means everything is going to work and move together better. With the core being made up of specifically 3 different muscle groups – this is vastly important when considering a “core” workout.
Squats
Squats are likely the least-thought of core-exercise. However, studies show that squats – especially heavy squats – increase the activation of low back muscles (especially the lower portion of the back). And that activation of the trunk musculature on heavy squats, creating a ballooning effect, can increase the stability within the squat. However, now that we’re getting into heavy squats and the intra-abdominal pressure pattern for heavy squats – it’s a great time to talk about what happens to the pelvic floor with this activity.
When the breath is held in the lungs, the diaphragm is kept in a descending position. Because of its relationship to the pelvic floor, that means the pelvic floor is held in a stretched position throughout the movement. Like any other muscle group, if it’s held in a stretched position it has a harder time contracting and assisting to hold up. Meaning that incontinence within this movement is likely – or pressure creating prolapse – due to the forces on the pelvic floor. Does this mean it will definitely happen to you? NO! But like everything else in this blog post, you have to train for that. You can’t move from squatting 105# to squatting 300# and not expect things to fail out on you or at the very least to have some sort of issue. It also means that you need to train specific motions within the squat to keep your pelvic floor from failing (which in itself would be a separate blog post).
SO! We’ve gone through the 4 core-muscle strengthening exercises that I chose. What do you do with this information now? Use it! Plan your programming with your core in mind – plan your patient’s exercises with the core in mind. What the core actually does, what muscles actually make it up, how it works in conjunction with other muscles, and the multiple ways that the core can be challenged. A body goes through a myriad of movements throughout the day – and most of the time they aren’t the exact same movement. Meaning you, your patient, your athlete – their life is variable, and as such – their exercises need to include variability!
References:
Gluppe, S., Hilde, G., Tennfjord, M., Engh, M., Bo, K. Diastasis Recti Abdominis in Postpartum Primiparous Women: A Randomized Controlled Trial. Phys Ther, 2018; 98 (4): 260-268
Ko, M., Song, C. Comparison of the effects of different core exercises on muscle activity and thickness in healthy young adults. Phys Ther Rehabil Sci; 2018, 7(2), 72- 77
Tillaar, T., Saeterbakken, A. Comparison of Core Muscle Activation Between a Prone Bridge and 6-RM Back Squats. Journal of Human Kinetics, 2018; 62, 43-53
Olsson, A., Kiwanuka, O., Wilhelmsson, S., Sandblom, G., Stackelberg, O. Cohort study of the effect of surgical repair of symptomatic diastasis recti abdominis on abdominal trunk function and quality of life. BJS Open, 2019; 3: 750-758
Garcia-Waquero, M., Moreside, J., Brotons-Gil, E., Peco-Gonzalez, M., Vera-Garcia, F. Trunk muscle activation during stabilization exercises with single and double leg support. Journal of Electromyography and Kinesiology, 2012, doi: 10.1016/j.jelekin.2012.02.017
Hamlyn, N., Behm, D., Young, W. Trunk muscle activation during dynamic weight-training exercises and isometric instability activities. Journal of Strength and Conditioning Research, 2007; 21(4): 1108-1112
In the first two parts of this shoulder impingement series, we reviewed shoulder impingement pathology and how to address mobility restrictions commonly seen with this condition. As you may recall from the first post, shoulder strength and stability are also potential contributors to shoulder impingement. It is not uncommon to see someone suffering from shoulder impingement who has full range of motion and great mobility but lack the strength to support the motion, especially when under load (like overhead pressing). This inability to adequately support the shoulder can contribute to mechanical changes within the joint and surrounding tissue which can then lead to injury. In this article we will go over some exercises and drills for common stability issues that may contribute to shoulder impingement.
Posterior Shoulder Strength:
It’s common to see an imbalance between the front (anterior) and back (posterior) shoulder muscles. Strengthening the back deep rotator cuff and scapula muscles can reduce this imbalance and improve general shoulder mechanics. Below are some of our favorites. Other common gym exercises to work on posterior shoulder strength include reverse flies, face pulls, pull-a-parts, and high rows.
Load Bearing Stability/Balance:
Being able to train the shoulder under load is important to return to sports and overhead weighted activities. Oftentimes, strict overhead pressing is painful for those with shoulder impingement. Fortunately, there are different ways to load the shoulder and provide a similar strengthening stimulus. Loading the shoulder and pressing also engage the serratus anterior muscle, an important scapula muscle. The video below shows some examples of loading the shoulder and activating your serratus anterior using your body weight, kettlebell, or barbell.
Chaos:
One important function of the rotator cuff muscles is to help stabilize the ball in the socket. A great way to train these muscles and challenge the shoulder is by increasing instability (“chaos”) through the use of bands and hanging weights. These exercises also often let those with pain under heavier loads to complete an exercise with less weight but still be greatly challenged. Below are some of the ones we like to use in the clinic. Be careful though as they are generally more challenging than they look!
Kettlebell Carries:
What’s more functional than carrying weight around? Not much. And certain kettlebell carries are great for strengthening the posterior shoulder, upper back, and rotator cuff muscles. Below are a couple variations you can try with kettlebells. You can get a similar effect by using dumbbells, barbell, or sandbags.
Not everyone will have similar benefit to each exercise as each person has different strength and stability limitations. For example, one person may have a large imbalance between the anterior and posterior shoulder muscles and may benefit more from focusing on those posterior muscles. Someone else could have great overall strength but have issues with keeping a good overhead press position. This person may benefit more from overhead carries and chaos exercises. Unfortunately, it’s challenging to tease out specifically what you need. If you find yourself unable to do so, I recommend seeing a physical therapist who can further evaluate and identify areas of weakness.
If you feel you have some shoulder weakness and dealing with shoulder pain, I hope this post has been useful. Please reach out if you have any questions!
