Posts in sports injuries
How Painful Should My Physical Therapy Feel After A Hamstring Strain?

One of the most common questions we receive in our Boulder Physical Therapy practice involves how much pain should be felt with exercise. This is a complicated answer dependent on many factors including but not limited to the nature of the injury. In general, the field of sports medicine is moving away from a purely R.I.C.E. (rest, ice, compression, elevation) approach to injury recovery and has found a progressive, optimal loading approach may be better suited to less severe muscle injury. In fact, within acute muscle strains, exercise has been shown to accelerate a patient’s recovery compared to rest. General guidelines exist on the acceptance of a mild to moderate pain (1-4/10) which stops at the conclusion of exercise in these muscle strains, but a new research study examined the differences between this approach and a pain avoidance approach.

Hickey and colleagues in the Journal of Orthopedic and Sports Physical Therapy randomized 43 men with acute hamstring strains to one of two Physical Therapy groups (2019). Both groups underwent the same bi-weekly progressive rehabilitation program (bridging, hip extension, hamstring sliders, and nordic hamstring curls) but one group was instructed to remain pain free (0/10) while the other was allowed to complete these exercises with mild pain (<4/10). Authors completed a subjective and clinical examination at the start and conclusion of the study period (2 months) and also followed each athlete up to 6 months after their return to play. Authors reported no difference in time to return to play between the two groups, but the athletes allowed to exercise with mild pain demonstrated improved strength and hamstring muscle healing (measured by ultrasound) compared to the pain free group. Authors reported “the conventional practice of pain avoidance during hamstring strain rehabilitation may not be necessary” and instead advocated for an approach consistent with progressive, optimal loading.

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Strengthening Cuts Hamstring Injury Rates In Half

Hamstring injuries are common and can occur in any sport with any athlete. The three muscles of the hamstring are put through rapid lengthening and shortening contractions making them susceptible to strains or minor tears. Due to the common occurrence of these injuries, it is important to target proper strength and conditioning regimes to decrease the risk of injury to this muscle.

A recent article by the British Journal of Sports Medicine investigated the available research on the effectiveness of hamstring strengthening utilizing the Nordic Hamstring Exercise and its’ impact on injury rates (van Dyk. 2019). The review included over 8,459 athletes and found when the athlete's strengthening program included the Nordic Hamstring Exercises, the risk of injury to the hamstring decreases by 51%. As mentioned by a previous blog, the Nordic Hamstring Exercise recruits the hamstring more evenly with a eccentric contraction (contraction of muscles while lengthening) consistent with the demands of sport.

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PRP Effects On Tendon Injury Attributed To Post Injection Physical Therapy

Patellar tendinopathy is one of the more common sports medicine conditions seen in our Boulder Physical Therapy clinic. This condition causes increased pain along the front of the knee just beneath the knee cap and leads to pain with jumping, running, and squatting activities. Current medical evidence has described an absence of inflammatory cells and instead we find an increase in cells responsible for tendon repair. These immature cells are initially laid down in a disorganized pattern and require progressive, optimal loading through exercise to reach a mature, healthy state. In addition to exercise some physicians have advocated for PRP injections into the injured tendon in an effort to accelerate the healing process, but well constructed research trials have not been conducted and this treatment is still considered experimental. A recent research trial examined the effectiveness of PRP for patellar tendinopathy.

A well done randomized controlled trial in the American Journal of Sports Medicine examined the effectiveness of PRP vs. placebo (saline) in patients with patellar tendinopathy (> 6 months of symptoms) (Scott et al. 2019). Patients were randomized to one of three injection groups under ultrasound guidance leukocyte rich PRP, leukocyte poor PRP, and saline. Each group then received 6 weeks (3 times per week) of supervised Physical Therapy including heavy slow strength training (concentric and eccentric loading). Patients were folllowed up at 6,12,36, and 52 weeks. Authors found an improvement in all three groups but no difference in pain, function, or recovery between the three groups. If PRP added to the recovery we should have seen a superior effect of PRP and PT vs. saline and PT, but because all groups were similar we can attribute this change in function to the Physical Therapy strengthening program. This evidence supports our current view on the limited benefits of injections for tendon pain. Patients are encouraged to use a Physical Therapy exercise program consisting of progress, loading exercises to accelerate their recovery from tendon injury.

The Importance Of An Offseason In Adolescent Baseball Players

Early sport specialization where our youth athletes focus on a single sport year round has become more popular over the last decade. The 10,000 hours reference (original study in violinists not athletes) reinforced this concept despite the adverse events of early sports specialization include burnout, depression/anxiety, lower athletic performance, and sports injuries. Research into high level professional athletes indicates the vast majority of these athletes did not specialize in an individual sport until their late teens (post high school). Playing a variety of sports or playing sports on a seasonal vs. year round allows for recovery and correction of repetitive sport specific movements like throwing. A recent study highlights the importance of the offseason in youth baseball athletes.

Otoshi and colleagues in the Journal of Shoulder and Elbow Surgery enrolled close to 700 elementary school baseball players who underwent a medical history, physical examination, and ultrasound investigation of their elbow joint (2019). Authors reported an inverse relationship between elbow pathology found on ultrasound and the duration of the athletes’ off season. Athletes who played either a longer season or multiple seasons per year were found to have the greatest prevalence of elbow pathology. Conversely, an athlete’s risk of pain and pathology on ultrasound was significantly lower if their off season last longer than 1-2 months. As expected, authors found off season recovery was significantly associated with the presence of elbow pathology.

Previous History of Hamstring Injury Associated With Reduced Sprint Performance

Hamstring injuries are one of the most common injuries in both individual and team sports. In sports such as soccer and football these injuries involve a traumatic pull of the muscle while sprinting or accelerating. After the initial healing phase athletes must rehabilitate the injury with Physical Therapy exercises to regain optimal muscle function and reduce their risk for future injury. Hamstring injuries often become recurrent if strength is not normalized along the hip, knee, and ankle muscles along the back of the leg. A new article highlights how these injuries also limit performance in sprinting trials.


Roksund and colleagues studied professional soccer players and collected data on previous hamstring injuries, as well as, each athlete’s strength, flexibility, aerobic capacity, and sprint performance (Front Physiol. 2017). Of the 75 athletes included in the study, 16% sustained a hamstring strain over the previous 2 years. The previously injured athletes demonstrated a significant loss of velocity during a 40 meter sprint test, as well as, a drop in performance over repeated sprints compared to their healthy peers. Interestingly, measures of flexibility, strength, aerobic capacity, and maximum power was not significantly different between groups. Injured athletes are encouraged to work with their local Physical Therapist to accelerate their recovery from muscle strains and eventual return to sport.

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When will my knee tendinitis get better?

Knee tendinopathy, either in the quadriceps or patellar tendon, is a common source of knee pain among jumping athletes, but can occur in non jumping athletes or the general population as well. This overuse injury is caused by repetitive sub maximal loading of the knee through a bending range of motion. If the loading is faster and/or greater than the tendon’s capacity to tolerate this tensile loading pattern, tendinopathy can occur leading to pain and decreased knee function. Our current understanding of these tendon injuries has moved from passive care (rest, anti inflammatories) to an active Physical Therapy approach focused on optimal loading of the tendon to promote remodeling and healing of the injured tissues. A new article sheds light on when patients can expect to recover from their knee tendinopathy.

van Ark and colleagues randomized 29 volleyball and basketball players with patellar tendinopathy to a 4 week full range of motion or isometric exercise program (Am J Phys Med Rehab. 2018). Patients were assessed for symptoms and function, as well as, each player underwent a baseline and 4 week ultrasound scan of the injured tendon. Interestingly, although players reported decreased pain and improved function after the exercise program, no structural changes were detected in the injured tendon. This study is consistent with the research on achilles tendinopathy which demonstrated improved clinical symptoms after 8-12 weeks of Physical Therapy treatment, but continued healing of the injured tendon up to 12 months after the onset of symptoms.

Physical Therapy exercises are the gold standard treatment for tendinopathy but should be continued after resolution of symptoms for optimal recovery of the tendon.

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