Proximal Hamstring Tendinopathy
Proximal Hamstring Tendinopathy
What is Proximal Hamstring Tendinopathy?
Proximal hamstring tendinopathy is also known as high hamstring tendinopathy. It is the term for an injury to the hamstring origin tendon at its attachment site into the ischial tuberosity of the pelvis.
Who Suffers from Proximal Hamstring Tendinopathy?
Proximal hamstring tendinopathy is most common in the middle to long-distance runners and those who participate in repetitive jumping, kicking and running sports such as soccer (football) and AFL.
Proximal Hamstring Tendinopathy Symptoms
Proximal hamstring tendinopathy often presents with the gradual onset of pain and is less likely with acute trauma.
Sufferers’ often report:
- Deep buttock pain – constant and dull that is worsened with activity.
- Pain in the posterior thigh
- Pain can radiate down the thigh towards the knee along with the hamstring muscles.
Pain is always related to loading the hamstring muscles and increases with repetitive action activities such as running and football codes. In some cases, pain can be elicited with the compressive force on the hamstring insertion from sitting.
What Causes Proximal Hamstring Tendinopathy?
The role of the hamstring tendon is to transfer the force of the hamstring muscle group to the pelvis. The hamstrings are prone to tendinopathy. They contribute to the decelerating of the straightening knee during activities such as sprinting and hill-climbing (Petersen et al., 2005).
When you apply an exercise load to the proximal portion of the hamstring tendon, the tendon is responsible for transferring this load to the pelvis. The normal tendon strengthening process occurs when the tendon has to undertake this action repetitively, the tendon adapts to withstand the pressure. These healthy tendon changes keep your body continuing to participate in your chosen activity at the performance level required for as long as possible. Usually, the tendon is capable of intrinsic repair, meaning that the consequences of loading are minimal and recover in preparation for the next bout of exercise (usually 24 hours).
However, if you continually apply an excessive load to the tendon, these changes occurring in the tendon can exceed the rate of repair. This repetitive tendon overload results in tendon pain and dysfunction. In some cases, the inability to repair is a multitude of factors that can result in the repair not to occur and to start to reduce the tendon’s ability to adapt, in some cases this can even result in failed healing. All of this leads to the formation of tendinopathy (Kannus 1997, Sharma and Maffulli 2005, Warden 2007).
Proximal Hamstring Tendinopathy Risk Factors
Several factors can contribute to the development of proximal hamstring tendinopathy. Your physiotherapist is the best person to discuss these factors. Tendinopathy physiotherapists are skilled to identify all the contributing factors concerning your tendinopathy.
In some cases, proximal hamstring tendinopathy may occur following an acute hamstring tear. However, in most cases, tendinopathy is an overuse injury. There are several intrinsic (within the athlete) and extrinsic (external to the athlete) factors which may increase the likelihood of developing an injury.
Intrinsic Risk Factors:
- Previous injury – loss of muscle strength and flexibility may predispose an athlete to injury.
- Gluteal muscle dysfunction – reduced gluteal muscle strength can increase the hamstring strength requirements during activity.
- Anterior pelvic tilt – an athlete in anterior tilt may increase compressive forces across the ischial tuberosity.
- Female gender.
- Core weakness – Core muscle strength is required to ensure that you maintain pelvic alignment during activity, loss of pelvic control may result in increased loads through the hamstring tendon at the pelvis.
- Stiffness of the hip – loss of active hip motion may increase the requirement of the hamstrings and pelvis in dynamic movement.
- Training Load Changes – A sudden change in load, most commonly an increase in capacity can be associated with PHT; alternately a period of unloading (e.g. a holiday, off-season) and a sudden boost to your regular load, may be enough.
- Training errors – inadequate rest between training sessions, poor technique
- Inadequate equipment – old or worn footwear
- Insufficient warming up and recovery methods.
- Fatigue – Injury risk can significantly increase when the body is fatigued.
Your physiotherapist will address any of these factors that may be influential. If you have any specific concerns that you would like them to investigate, please ask your physiotherapist.
Tendinopathy is a continuum of pathological processes, and your treatment plan requires correct identification of the current phase of injury and the application of appropriate exercise in the rehabilitation of your injury. Inappropriate loading may delay your recovery and your return to sport.
Identification of the phase helps to identify an entry point for your rehabilitation and how much you can perform in your recovery and balancing your activity levels in your rehabilitation plan.
It is imperative to have your tendinopathy professionally assessed to identify your injury phase. Identifying your tendinopathy phase is also vital to direct your most effective treatment since specific modalities or exercises should only be applied or undertaken in distinct tendon healing phases.
How is Proximal Hamstring Tendinopathy Diagnosed?
Proximal hamstring tendinopathy is one of many causes of lower buttock pain. The correct diagnosis is vital to your treatment plan and recovery!
Your physiotherapist or a sports doctor can confirm the diagnosis clinically. Your diagnosis involves a combination of your history of injury and pain provocation tests. Diagnostic imaging is optional in your diagnosis. Imaging such as MRI is often used to exclude other conditions that can mimic pain similar to proximal hamstring tendinopathy.
In some cases, an MRI ensures that your injury is proximal hamstring tendinopathy and not a complete rupture of the tendon. MRI can also be used to visualise any bone marrow oedema at the ischial tuberosity in conjunction with your injury.
Proximal Hamstring Tendinopathy Treatment
Your physiotherapist is highly skilled in the management of proximal hamstring tendinopathy. They will also oversee your subsequent safe return to sport. Among other tests, your physiotherapist will use your pain provocation tests, strength measures, and functional activities as a useful tool to monitor your pain, function and when to progress exercises or return to sport.
They’ll also be happy to discuss your injury rehabilitation with your coach.
How Do You Treat Proximal Hamstring Tendinopathy?
Proximal hamstring tendinopathy treatment has progressed significantly in recent years. Based on this, it is now more important than ever to be assessed and treated by a tendinopathy physiotherapist. They will be up-to-date in the latest proximal hamstring tendinopathy research findings and treatment strategies.
There is increasing importance in exercise in the management of tendinopathy. Isometric exercise, or exercise that the joint angle and muscle length do not change during use have proven effects at pain relief for athletes suffering from tendinopathy.
Tendinopathy treatment is progressed based on your tendon’s ability to withstand your exercises load. For most athletes, the traffic light system defines how much training is too much clearly.
Red will indicate that you need to reduce your exercise load. Amber suggests that you can exercise at current loads. Green indicates that you can safely increase your exercise loads.
Your physiotherapist will explain how to interpret your symptoms and plan your exercise loads based upon their assessment and your symptoms.
Managing Your Activity Load is the Priority!
Appropriate exercise load management is vital to the successful treatment of proximal hamstring tendinopathy. Mild load increases will stimulate new tendon growth, whereas overload leads to tendinopathy deterioration. Getting the balance right is critical.
Reduce the load to a level that allows the tendon to recover. In severe cases, this may mean total rest from your sport or modifying training depending on the severity of tendinopathy. Discuss your activity load with your physiotherapist, who will plan and adjust your program accordingly, based upon your pain provocation tests, traffic light response to activity and other symptoms.
When managing load, you should be guided by how the tendon responds not just immediately but also 24 hours later. Tendons are known to have a latent response to loading. This latency means they can take 24 hours or more to react. It is essential to modify your activity to remain pain-free during and for following 24 to 48 hours.
Proximal Hamstring Tendinopathy Prognosis
If you identify your hamstring tendon injury in the early stages, then load management and reduction will allow the tendon time to adapt and quickly recover. The reactive stage can be relatively short. Pain may settle in 5 to 10 days, but the tendon will still be sensitive to high loads, and training needs progression gradually to prevent relapse. It mustn’t progress into late-stage two or stage 3 tendinopathy. These tendinopathies require additional time and rehabilitation.
Brukner and Khan (2002) suggested that a likely return to sport is in the order of 12 weeks. However, everyone is very different!
Some practitioners suggest that the prognosis with guided treatment can be summed up by the tendinopathy phase:
- Phase I: days
- Phase II: weeks
- Phase III: months
- Phase IV: years
Exercises to Avoid with Proximal Hamstring Tendinopathy
Avoid exercises that provoke your pain such as running up hills or stairs, bending forward with a straight knee (e.g., hockey) until advised otherwise by your physiotherapist.
Massage, Foam Rollers & Stretches
Massage or foam roller of your gluteals, quadriceps, ITB, and hamstrings, may assist in cases of hamstring tendinopathy. You can perform these in positions that do not hyperflex your hip with a straight knee. Ask your physiotherapist for specific advice.
Eccentric exercises were for many years the “go-to” exercises for tendinopathy rehabilitation. While important, premature or overloaded eccentric exercises can delay your recovery. Your physiotherapist will guide you when appropriate. Your strengthening should not aggravate your hamstring tendinopathy. They may start you with isometrics that avoid tendon compression and progress from there towards a basic and then advance eccentric exercise program.
Adjacent Joints & Lower Limb Biomechanics
Researchers have identified several lower limb biomechanical issues may predispose you to hamstring tendinopathy. Your physiotherapist will assess things such as your ankle dorsiflexion, gluteal control, hip/knee bend ratio and running and landing technique. They’ll advise you if you require some treatment to address any deficiencies.
Novel therapies such as the injection of sclerosing agents, platelet-derived growth factor (PDGF), and autologous blood into diseased tendons have shown promising results, but more clinical trials are needed. Your physiotherapist is happy to discuss these options with you when they consider them an appropriate treatment option.
Remember, all tendinopathies are different. Please seek the advice of your physiotherapist to determine the best rehabilitation appropriate to your tendinopathy.
- Corked Thigh
- Thigh Strain
- Hamstring Strain
- ITB Syndrome
- Muscle Strain (Muscle Pain)
- DOMS - Delayed Onset Muscle Soreness
Other Knee-Related Conditions
FAQs for Hamstring Tendinopathy
Sports Injury Management
You probably already know that a sports injury can not only affect your performance, but also your lifestyle. The latest research continues to change sports injury management considerably. Our challenge is to keep up to date with the latest research and put them to work for you.
How we treated you last year could vary greatly to how we treat you this year. The good news is that you can benefit significantly from our knowledge.
What Should You Do When You Suffer a Sports Injury?
Rest from painful exercise or a movement is essential in the early injury stage. "No pain. No gain." does not apply in most cases. The rule of thumb is - don't do anything that reproduces your pain for the initial two or three days. After that, you need to get it moving or other problems will develop.
Ice or Heat?
We normally recommend avoiding heat (and heat rubs) in the first 48 hours of injury. The heat encourages bleeding, which could be detrimental if used too early. In traumatic injuries, such as ligament sprains, muscle tears or bruising, ice should help reduce your pain and swelling.
Once the "heat" has come out of your injury, heat packs can be used. We recommend 20 minute applications a few times a day to increase the blood flow and hasten your healing rate. Heat will also help your muscles relax and ease your pain. If you're not sure what to do, please call us to specifically discuss your situation.
Should You Use a Compressive Bandage?
Yes. A compressive bandage will help to control swelling and bleeding in the first few days. In most cases, the bandage will also help to support the injury as the new scar tissue is laid down. This should help to reduce your pain. Some injuries will benefit from more rigid support such as a brace or strapping tape. Please ask us if you are uncertain what to do next.
Gravity will encourage swelling to settle at the lowest point. Elevation of an injury in the first few days is very helpful, especially for ankle or hand injuries. Think where your injury is and where your heart is. Try to rest your injury above your heart.
What Medication Should You Use?
Your Doctor or Pharmacist may recommend pain killers or an anti-inflammatory drug. It is best to seek their professional advice as certain drugs can interfere with other health conditions, especially asthmatics.
When Should You Commence Physio?
In most cases, "the early bird gets the worm". Researchers have found that intervention of physiotherapy treatment within a few days has many benefits. These include:
- Relieving your pain quicker via joint mobility techniques, massage and electrotherapy
- Improving your scar tissue using techniques to guide the direction it forms
- Getting you back to sport or work quicker through faster healing rates
- Loosening or strengthening of your injured region with individually prescribed exercises
- Improving your performance when you do return to sport - we'll detect and help you to correct any biomechanical faults that may be affecting your technique or predisposing you to injury
What If You Do Nothing?
Research tells us that injuries left untreated take longer to heal and have lingering pain. They are also more likely to recur and leave you with either joint stiffness or muscle weakness. It's important to remember that symptoms lasting longer than three months become habitual and are much harder to solve. The sooner you get on top of your symptoms the better your outcome.
What About Arthritis?
Previously injured joints can prematurely become arthritic through neglect. Generally there are four main reasons why you develop arthritis:
- Previous injury that was inappropriately treated (eg old joint or ligament sprains)
- Poor joint positioning (biomechanical faults)
- Stiff joints (lack of movement diminishes joint nutrition)
- Loose joints (excessive sloppiness causes joint damage through poor control)
What About Your Return to Sport?
Your physiotherapist will guide you safely back to the level of sport at which you wish to participate. If you need guidance, simply ask us.
What If You Need Surgery or X-rays?
Not only will your physio diagnose your sports injury and give you the "peace of mind" associated, they'll also refer you elsewhere if that's what's best for you. Think about it. you could be suffering needlessly from a sports injury. Please use our advice to guide you out of pain quicker . and for a lot longer.
If you have any questions regarding your sports injury (or any other condition), please contact your physiotherapist to discuss. You'll find our friendly staff happy to point you in the right direction.
Acute Sports Injury Clinic
The acute sports injury consultation fee is significantly lower than a routine assessment and treatment consultation. In most cases, your private health will cover the full cost of your full acute injury physio assessment fee.
How to Best Care for Your Sports Injury?
There is never an excellent time for an injury. But we do know that most sports injuries occur over the weekend! That's why at PhysioWorks, we have established an Acute Sports Injury Clinic at a selection of our clinics on a Monday and Tuesday.
Why Use an Acute Sports Injury Clinic?
Your Acute Sports Injury Assessment Consultation allows us to provide you with:
- A quick and accurate diagnosis. One of our Sports Physiotherapist's or an experienced sports injury-focused Physiotherapist will confidently guide your new injury management.
- Early acute sports injury care, professional advice and education. What to do this week?
- Fast referral for X-rays, ultrasound or MRI scans to confirm your diagnosis.
- Prompt referral to Sports Physicians, GPs or Surgeons with whom we work if required.
- Immediate supply of walking boots, braces and rental crutches if needed.
- Low-cost professional service.
Who is a Sports Physiotherapist?
Sports Physiotherapy is the specialised branch of physiotherapy which deals with injuries and issues related to spokespeople. Practitioners with additional formal training within Australia are Sports & Exercise Physiotherapists.
What is Sports Physiotherapy?
Sports injuries do differ from common everyday injuries. Athletes usually require high-level performance and demand placed upon their body, which stresses their muscles, joints and bones to the limit. Sports physiotherapists help athletes recover from sporting injuries, and provide education and resources to prevent problems.
Each sports physiotherapist usually has sport-specific knowledge that addresses acute, chronic and overuse injuries. Their services are generally available to sportsmen and women of all ages engaged in sports at any level of competition.
Members of Sports Physiotherapy Australia (SPA) have experience and knowledge of the latest evidence-based practice, skilled assessment and diagnosis of sports injuries, and use effective 'hands-on' management techniques and exercise protocols to assist recovery and prevent future damage. SPA members have access to the most recent advances in sports physiotherapy. You'll be pleased to know that most of PhysioWorks physiotherapists and massage therapists have a particular interest in sports injury management.
What is Physiotherapy Treatment?
Physiotherapists help people affected by illness, injury or disability through exercise, manual joint therapy, soft tissue techniques education and advice. Physiotherapists maintain physical health, help patients to manage pain and prevent disease for people of all ages. Physiotherapists help to encourage pain-relief, injury recovery, enabling people to stay playing a sport, working or performing activities of daily living while assisting them to remain functionally independent.
There is a multitude of different physiotherapy treatment approaches.
Acute & Sub-Acute Injury Management
Hands-On Physiotherapy Techniques
Your physiotherapist's training includes hands-on physiotherapy techniques such as:
- Joint Mobilisation (gentle joint gliding techniques)
- Joint Manipulation
- Physiotherapy Instrument Mobilisation (PIM)
- Minimal Energy Techniques (METs)
- Soft Tissue Techniques
Your physiotherapist has skilled training. Physiotherapy techniques have expanded over the past few decades. They have researched, upskilled and educated themselves in a spectrum of allied health skills. These skills include techniques shared with other healthcare practitioners. Professions include exercise physiologists, remedial massage therapists, osteopaths, acupuncturists, kinesiologists, chiropractors and occupational therapists, just to name a few.
Your physiotherapist is a highly skilled professional who utilises strapping and taping techniques to prevent and assist injuries or pain relief and function.
Alternatively, your physiotherapist may recommend a supportive brace.
Acupuncture and Dry Needling
Many physiotherapists have acquired additional training in the field of acupuncture and dry needling to assist pain relief and muscle function.
Physiotherapists have been trained in the use of exercise therapy to strengthen your muscles and improve your function. Physiotherapy exercises use evidence-based protocols where possible as an effective way that you can solve or prevent pain and injury. Your physiotherapist is highly-skilled in the prescription of the "best exercises" for you and the most appropriate "exercise dose" for you depending on your rehabilitation status. Your physiotherapist will incorporate essential components of pilates, yoga and exercise physiology to provide you with the best result. They may even use Real-Time Ultrasound Physiotherapy so that you can watch your muscles contract on a screen as you correctly retrain them.
- Muscle Stretching
- Core Exercises
- Strengthening Exercises
- Balance Exercises
- Proprioception Exercises
- Real-Time Ultrasound Physiotherapy
- Swiss Ball Exercises
Biomechanical assessment, observation and diagnostic skills are paramount to the best treatment. Your physiotherapist is a highly skilled health professional. They possess superb diagnostic skills to detect and ultimately avoid musculoskeletal and sports injuries. Poor technique or posture is one of the most common sources of a repeat injury.
Aquatic water exercises are an effective method to provide low bodyweight exercises.
Sports physio requires an extra level of knowledge and physiotherapy skill to assist injury recovery, prevent injury and improve performance. For the best advice, consult a Sports Physiotherapist.
Women's Health Physiotherapy is a particular interest group of therapies.
Not only can your physiotherapist assist you in sport, but they can also help you at work. Ergonomics looks at the best postures and workstation set up for your body at work or home. Whether it be lifting technique improvement, education programs or workstation setups, your physiotherapist can help you.
Plus Much More
Your physiotherapist is a highly skilled body mechanic. A physiotherapist has particular interests in certain injuries or specific conditions. For advice regarding your individual problem, please contact your PhysioWorks team.
Post Running Muscle Soreness:
Is it an Injury or just DOMS?Have you ever finished a big run and felt sore right after it? What about two days afterwards? Do you ignore it or have it checked out? The most common causes of post-run pain are either a legitimate muscle injury or delayed onset muscle soreness (DOMS).
Tips to Determine if it is a Muscle Injury or is it DOMS?Differentiating between a muscular injury and DOMs is essential to ensure you are not overlooking a potentially sport-limiting injury and you are getting the injury managed appropriately. Early identification is key!
What is DOMS?Delayed Onset Muscle Soreness or DOMs for short, is an exercise-related muscle condition that arises after intense, unaccustomed, physical exercise. The condition gets its ‘delayed’ name as symptoms are not usually felt until 24 to 72 hours after the exercise, normally peaking at the 48-hour mark after exercise. Research has demonstrated that DOMS is associated with tearing of myofibrils often at multitudinous junctions - best described as microtrauma. This process is followed by inflammation and a shift in intramuscular fluid and electrolytes. This process in combination with other local factors at the cellular and increased intramuscular pressure promote are what causes the soreness and stiffness experienced in DOMS. Tenderness is typically felt at the end of the muscle (at the tendon) where it attaches down along the affected limb and then as the condition progress. This can be felt throughout the muscle belly itself. The swelling, inflammation, tenderness and pain that arises can manifest as decreased joint range of motion, decreased strength and a decreased ability to absorb shock while exercising. This alteration is muscle function can last up to 10 days!
Muscle InjuriesAcute muscle injuries are quite different in how they present compared to DOMS. Typically, pain and stiffness is felt immediately in the affected tissue or shortly after. A ‘pop’, twinge, feeling of being kicked - without anyone actually kicking you - or an immediate collapse to the ground. As expected, the amount of damage to the tissue with a muscle injury exceeds that of DOMS. Any general movement of the muscle will reproduce your symptoms and if the injury is severe enough - bruising can begin to develop with some associated swelling. At the time of injury, following the RICE protocol (Relative Rest, Ice, Compression, and Elevation) is your best go-to treatment. You should also avoid HARM factors. No heat should be applied to the affected area. You should also avoid alcohol consumption, running or other painful movements. Initially, it is a good idea to avoid massage until a professional has assessed the injury. All the HARM factors have the potential to increase bleeding, which may exacerbate your injury. Research suggests no anti-inflammatory drugs following a muscle strain is the best way to go. If you are seeking pain relief, it is best you consult your regular GP or a pharmacist for pain relief options that don't slow down your healing rates. More info: How to Treat an Acute Soft Tissue Injury
Benefits of DOMS?Thankfully yes! The body adapts to the physical exercise that was undertaken once the DOMS resolves. So when you go and perform the same exercise again, the chance of DOMS onset decreases! However, adaptation to the causative exercise occurs rapidly after DOMS resolves. This adaptation with repeated exercise is called the “repeated-bout effect.” More info: Delayed Onset Muscle Soreness (DOMS).
How to Tell the Difference?Your physiotherapist will be your best option for an efficient and accurate diagnosis between the two conditions, however, there are some simple factors to help piece together your injury when it comes to deciding whether or not to consult help. DOMS is more unpleasant when commencing a movement but eases as the muscle is warmed up, whereas a muscle injury will reproduce pain with any movement of the injured muscle. The most definitive factor is taking a detailed history of the injury. If pain was experienced during the event or immediately after, you are most likely looking at a muscle injury. If the pain is worst the day after and gets worse over the following days, you are most likely dealing with DOMS.
What to Do if You Have DOMS or a Muscle Injury?If you suspect you have a muscle injury, it is best to consult your physiotherapist earlier rather than later. A thorough assessment is required to ascertain what exactly it is you have injured and start rehabilitation immediately to help minimise your time out of the sport! If you suspect you have DOMS, you need to avoid therapeutic interventions that increase muscle pain (e.g. excessive stretching, deep tissue massage) and vigorous physical activity should be postponed until resolution of pain and restoration of function due to:
- Decreased shock absorption
- Decreased coordination of muscle sequencing motion
- Compensatory recruitment of uninjured muscle groups
- Increased relative work intensity of the affected muscles at the same workload
- Altered strength balance of agonist and antagonist groups
- Inaccurate perception of functional deficits
- tendon insertion (where the tendon attaches to the bone)
- mid-tendon (non-insertional tendinopathy)
- musculotendinous junction (where the tendon attaches to the muscle)
What is a Tendon Injury?Tendons are the tough fibres that connect muscle to bone. Most tendon injuries occur near joints, such as the shoulder, elbow, knee, and ankle. A tendon injury may seem to occur suddenly, but usually, it is the result of repetitive tendon overloading. As mentioned earlier, health care professionals may use different terms to describe a tendon injury. You may hear: Tendinitis (or Tendonitis): This means "inflammation of the tendon". Mild inflammation is actually a normal tendon healing response to exercise or activity loading, but it can become excessive, where the rate of injury exceeds your healing capacity.
Tendinopathy PhasesThe inability of your tendon to adapt to the load quickly enough causes the tendon to progress through four phases of tendon injury. While it is healthy for normal tissue adaptation during phase one, further progression can lead to tendon cell death and subsequent tendon rupture.
1. Reactive Tendinopathy
- Normal tissue adaptation phase
- Prognosis: Excellent.
- Normal Recovery!
2. Tendon Dysrepair
- Injury rate > Repair rate
- Prognosis: Good.
- The tendon tissue is attempting to heal.
- It is vital that you prevent deterioration and progression to permanent cell death (phase 3).
3. Degenerative Tendinopathy
- Cell death occurs
- Prognosis: Poor!
- Tendon cells are dying!
4. Tendon Tear or Rupture
- Catastrophic tissue breakdown
- Loss of function.
- Prognosis: very poor.
- Surgery is often the only option.
What is Your Tendinopathy Phase?It is very important to have your tendinopathy professionally assessed to identify it’s current injury phase. Identifying your tendinopathy phase is also vital to direct your most effective treatment since certain treatment modalities or exercises should only be applied or undertaken in specific tendon healing phases.
Systemic Risk FactorsThe evidence is growing that it is more than just the tendon and overload that causes tendinopathy. Diabetics, post-menopausal women and men with high central adiposity (body fat) seem to be predisposed to tendinopathies and will need to carefully watch their training loads.
What are the Symptoms of Tendinopathy?Tendinopathy usually causes pain, stiffness, and loss of strength in the affected area.
- The pain may get worse when you use the tendon.
- You may have more pain and stiffness during the night or when you get up in the morning.
- The area may be tender, red, warm, or swollen if there is inflammation.
- You may notice a crunchy sound or feeling when you use the tendon.
How is a Tendon Injury Diagnosed?To diagnose a tendon injury, your physiotherapist or doctor will ask questions about your past health, your symptoms and recent exercise regime. They'll undertake a thorough physical examination to confirm the diagnosis. They will then discuss your condition and devise an individualised treatment plan. They may refer you for specific diagnostic tests, such as an ultrasound scan or MRI.
Tendinopathy TreatmentTendinopathies can normally be quickly and effectively rehabilitated. However, there is a percentage of tendinopathies that can take months to treat effectively. As mentioned earlier in this article, it is important to know what phase your tendinopathy currently is. You physiotherapist can assist not only your diagnosis but also guide your treatment to fast-track your recovery. Before you seek the advice of your physiotherapist or doctor, you can start treating an acute tendon injury at home. To achieve the best results, start these steps right away:
- Rest the painful area, and avoid any activity that makes the pain worse.
- Apply ice or cold packs for 20 minutes at a time, as often as 2 times an hour, for the first 72 hours. Keep using ice as long as it helps.
- Do gentle range-of-motion exercises and stretching to prevent stiffness.
When to Return to SportEvery tendinopathy is different, so please be guided by your physiotherapist assessment. It may take weeks or months for some tendon injury to heal and safely cope with a return to sporting loads. Be patient, and stick with the treatment exercises and load doses prescribed by your physiotherapist. If you start using the injured tendon too soon, it can lead to more damage, and set you back weeks!
Tendinopathy PreventionTo minimise reinjuring your tendon, you may require some long-term changes to your exercise activities. These should be discussed with your physiotherapist. Some factors that could influence your tendinopathy risk include:
- Altering your sport/activities or your technique
- Regular prevention exercises.
- Closely monitoring and record your exercise loads. Discuss your loading with your physiotherapist and coach. They will have some excellent tips.
- Always take time to warm up before and cool down / stretch after you exercise.
Tendinopathy PrognosisWhile most acute tendinopathies can resolve quickly, persisting tendon injuries may take many months to resolve. Long-term or repeat tendinopathies usually have multifactorial causes that will require a thorough assessment and individualised rehabilitation plan. Researchers have found that tendon injuries do respond differently to muscle injuries and can take months to solve or potentially render you vulnerable to tendon ruptures, which can require surgery. For specific advice regarding your tendinopathy, please seek the advice of your trusted healthcare professional with a special interest in tendinopathies.
What is Therapeutic Ultrasound?Therapeutic ultrasound is an electrotherapy modality which has been used by physiotherapists since the 1940s. Via an ultrasound probe through a transmission coupling gel in direct contact with your skin, ultrasound waves are applied. Therapeutic ultrasound may increase:
- healing rates
- tissue heating
- local blood flow
- tissue relaxation
- scar tissue breakdown.
How Could Ultrasound Help?Ultrasound increases local blood flow. This increase may help to reduce local swelling and promote soft tissue healing rates. A higher power density may soften scar tissue.
Specific Ultrasound UsesMastitis or blocked milk ducts successfully respond to therapeutic ultrasound. The effect is quite dramatic, with improvement within 24 to 72 hours. The most common conditions treated with ultrasound include soft tissue injuries such as muscle, ligament injuries or some tendinopathies. Phonophoresis uses ultrasound in a non-invasive way of administering medications to tissues below the skin. This method may assist patients who are uncomfortable with injections. With phonophoresis, the ultrasonic energy forces the drug through the skin.
What is an Ultrasound Dose?A typical ultrasound treatment will take from 3-10 minutes. Where scar tissue breakdown is the goal, this treatment time could be much longer. During the procedure, the head of the ultrasound probe is in constant motion. If kept in continuous motion, the patient should feel no discomfort at all. Some conditions treated with ultrasound include soft tissues injuries such as muscles or ligament injuries, tendinopathy, non-acute joint swelling and muscle spasm.
How Does an Ultrasound Work?A piezoelectric effect, caused by the vibration of crystals within the ultrasound head of the probe creates the sound waves. The ultrasound waves generated then pass through the skin cause a vibration of the local soft tissues. This repeated cavitation can cause a deep heating locally though usually no sensation of heat will be felt by the patient. In situations where a heating effect is not desirable, an athermal application occurs. Athermal doses are typical during acute fresh injury and the associated acute inflammation.
When Should Ultrasound be Avoided?Contraindications of ultrasound include:
- local malignancy,
- over metal implants,
- local acute infection,
- vascular abnormalities,
- active epiphyseal regions (growth plates) in children,
- over the spinal cord in the area of a laminectomy,
- over the eyes, skull, or testes
- and, directly on the abdomen of pregnant women. Treatment ultrasound differs from diagnostic ultrasound!
7 Ways to Prevent a Future Leg Injury?You may reduce the chance of leg injury by following these seven simple tips:
- Warm-up before you exercise.
- Warm down when you finish. Warm down usually includes some simple stretching exercises and plyometric drills.
- Wear well-fitting shoes, boots or braces that provide excellent joint support.
- Tape or brace your ankles/knees in high-risk sports such as football, basketball, volleyball and netball.
- Avoid activities on slippery, wet or uneven surfaces, or in areas with poor lighting.
- Strengthen your leg muscles and regularly use a wobble disc or balance board
- Maintain general functional fitness.
Common Youth Leg Injuries
Why are Children's Injuries Different to Adults?Adolescent injuries differ from adult injuries, mainly because the bones are still growing. The growth plates (physis) are cartilaginous (strong connective tissue) areas of the bones from which the bones elongate or enlarge. Repetitive stress or sudden large forces can cause injury to these areas.
Common Adolescent Leg InjuriesIn the adolescent leg, common injuries include:
Osgood-Schlatter's DiseasePain at the bump just below the knee cap (tibia tubercle). Overuse injuries commonly occur here. The tibia tubercle is the anchor point of your mighty quadriceps (thigh) muscles. It is because of excessive participation in running and jumping sports that the tendon pulls bone off and forms a painful lump that will remain forever. This type of injury responds to reduced activity and physiotherapy. More info: Osgood Schlatter's Disease
Sinding-Larsen-Johansson DiseasePain at the lower pole of the knee cap (patella). Overstraining causes Sinding-Larsen-Johansson disease. It is the because of excessive participation in running and jumping sports that the tendon pulls bone off the knee cap. This type of injury responds to reduced activity and physiotherapy. More info: Sinding Larsen Johansson Syndrome
Anterior Knee PainAnterior knee pain or patellofemoral syndrome frequently gets passed off as growing pains. Cause of this pain includes overuse, muscle imbalance, poor flexibility, poor alignment, or more commonly, a combination of these. Anterior knee pain is one of the most challenging adolescent knee injuries to sort out and treat. Accurate diagnosis and treatment with the assistance of a physiotherapist with a particular interest in this problem usually resolves the condition quickly. More info: Patellofemoral Pain Syndrome
Knee LigamentsThe cartilage between the leg bones have a better blood supply and are more elastic in adolescents than in adults. As adolescents near the end of bone growth, their injuries become more adult-like, hence more meniscal and ACL (anterior cruciate ligament) injuries are likely. MCL (medial collateral ligament) injuries result from a lateral blow to the knee. Pain felt on the inner side (medially) of the knee. MCL injuries respond well to protective bracing and conservative treatment. More info: Knee Ligament Injuries
ACL (anterior cruciate ligament) injuriesThis traumatic knee injury is significant. Non-contact injuries of the ACL are becoming more common than contact injuries of the ACL. Adolescent females are at high risk. Combination injuries with MCL or menisci are common. Surgical reconstruction is needed if the adolescent wishes to continue participating in "stop-and-start" sports. More info: ACL Injury
Meniscal injuriesYour meniscus is crescent-shaped cartilage between the thigh bone (femur) and lower leg bone (tibia). Meniscal injuries usually result from twisting. Swelling, catching, and locking of the knee are common. If physiotherapy treatment does not resolve these types of damages within six weeks, they may require arthroscopic surgery. More info: Meniscus Tear, Discoid Meniscus
Sever's DiseaseHeel pain is commonplace in the young adolescent due to the stresses of their Achilles tendon pulling upon its bony insertion point on the heel (calcaneum). It is a common overuse injury as a result of excessive volume of training and competition, particularly when loads are increased dramatically in a short period. Diminished flexibility and muscle-tendon strength mismatching may predispose you. Physiotherapy, reduced activity, taping and orthotics are some of the best ways to manage this debilitating condition for the active young athlete. More info: Sever's Disease
Ankle SprainAn ankle sprain is probably the most common injury seen in sports. Ankles sprains involve stretching of the ligaments and usually occur when the foot twists inward. Treatment includes active rest, ice, compression and physiotherapy rehabilitation. An ankle sprain usually improves in 2-6 weeks with the correct treatment. Your ankle physiotherapist should check even simple ankle sprains. A residually stiff ankle post-sprain can predispose you to several other lower limb issues More info: Sprained Ankle
Patellar InstabilityPatellar (kneecap) instability can range from partial dislocation (subluxation) to dislocation with a fracture. Partial dislocation treatment is conservative. Dislocation with or without fracture is a much more severe injury and usually will require surgery. More info: Patella Dislocation
Osteochondritis DissecansSeparation of a piece of bone from its bed in the knee joint is Osteochondritis Dissecans (OCD). This injury is usually due to one major macro event with repetitive macro trauma that prevents complete healing. This injury is potentially severe. Treatment varies from rest to surgery. An Orthopaedic Surgeon's opinion is vital. More info: Juvenile Osteochondritis Dissecans (JOCD)
Growth Plate FracturesA fracture through the growth plate can be a severe injury that can stop the bone from growing correctly. These fractures should be treated by an Orthopaedic Surgeon, as some will require surgery.
Image source: https://radiologyassistant.nl/pediatrics/hip/hip-pathology-in-childrenAn avulsion fracture occurs when a small segment of bone attached to a tendon or ligament gets pulled away from the main bone. The hip, elbow and ankle are the most common locations for lower limb avulsion fractures in the young sportsperson. Treatment of an avulsion fracture typically includes active rest, ice and protecting the affected area. This period of active rest is followed by controlled exercises that help restore range of motion, improve muscle strength and promote bone healing. Your physiotherapist should supervise your post-avulsion exercises. Most avulsion fractures heal very well. You may need to spend a few weeks on crutches if you have an avulsion fracture around your hip. An avulsion fracture to your foot or ankle may require a cast or walking boot. In rare cases, an excessive gap between the avulsed bone fragment and main bone may not rejoin naturally. Surgery may be necessary to reunite them. In children, avulsion fractures that involve the growth plates also might require surgery. All avulsion fractures should be reviewed and managed by your trusted physiotherapist or an Orthopaedic Surgeon. For more information regarding your youth sports injury, please consult your physiotherapist or doctor.
Common Youth Leg Injuries
Pelvis & Hip
- Osgood Schlatter's Disease
- Sinding Larsen Johannson Disease
- Patellofemoral Pain Syndrome
- Patella Dislocation
- Meniscus Tear
- Discoid Meniscus
- Juvenile Osteochondritis Dissecans