Hamstring Injuries and Rehab

Page Contents

A hamstring injury is a strain, tear or pain at the back of the thigh or below the buttocks.
A common injury in sports and can occur in different grades.
The 3 grades of hamstring injury are:
  • grade 1 – a mild muscle strain or pull
  • grade 2 – a partial muscle tear
  • grade 3 – a complete muscle tear

The recovery time of a hamstring strain or tear will depend on how severe the injury is, depending on its grade and the individual. A grade 1 may take a few days to a week to heal, whereas grade 2 and 3 anywhere from a few weeks to a few months to recover from a muscle tear.

Hamstring muscles have their origin, where their tendons attach to bone.

The ischial tuberosity of the hip (often called the sitting bones) and the linea aspera of the femur.

The hamstring tendons flank the space behind the knee. The most medial muscle, the semimembranosus, inserts on the medial condyle of the tibia bone.

The semitendinosus inserts on the superior part of the medial tibia. The most lateral hamstring, the biceps femoris, inserts on the lateral side of the fibula. They are innervated by the sciatic nerve.

A hamstring injury can occur when any of the tendons or muscles are over stretched beyond their limit or range.

Occurring during sharp, explosive movements, such as jumping, sprinting or power lifting. Injuries can also occur over time or during slower movements that overstretch your hamstring.

Sports people who have recurring hamstring issues, have more than likely had previous hamstring problems.

Symptoms of hamstring injuries after examination usually reveal spasms, tightness, and tenderness.

The more severe injuries, may incur swelling with black and blue or bruised appearance that will follow. In some cases, a palpable defect (detectable by touching) will be present in the muscle. Tears and strains most often occur at the middle of the back of the thigh where the muscle joins its tendon or at the origin of the hamstring at the base of the buttocks (at the ischium).

Grade 1 – usually cause sudden pain and tenderness the back of your thigh. It may be painful to move your leg, but the strength of the muscle shouldn’t be affected.

Grade 2 – are usually more painful and tender. There may be some swelling and bruising at the back of your thigh and loss of strength.

Grade 3 – is usually very painful, tender, swollen and bruised. There may have been a “popping” sensation at the time of the injury and you’ll be unable to use the affected leg.

During the first 48 hours, you should care for your injury using the principals of RICE:

  • Rest – keep your leg as still as you possibly can and avoid movement.
  • Ice – apply cold packs (Physicool) to your hamstring for up to 20 minutes every 2 to 3 hours during the day. Don’t apply ice directly to your skin.
  • Compression – compress or bandage (Physicool) the thigh to limit any swelling and movement that could cause further damage.
  • Elevation – keep your leg raised and supported on a pillow as much as possible, to help reduce any swelling.

Some will recommend regular painkillers and anti inflammation tablets.  But we recommend a drug free approach using Painpro

Painpro™ modes

Early stages injury treatment

Mode 1 Pain relief – low and high frequency TENS; adjust intensity for a preferred comfortable intensity.

Recovery

Mode 12 cell repair – PainPro™ also incorporates Microcurrent Technology.  Microcurrent has been the subject of multiple scientific research projects and is now regarded to be at the cutting edge of electrotherapy treatment.  By applying current at a specific intensity and frequency, the body can be “tricked” into significantly boosting Adenosine TriPhosphate (ATP) levels.  The process behind this is complex, but the outcome is simple:  Increased ATP levels means you can heal much quicker.  Studies have seen ATP levels boosted by over 400% – and healing times accelerated by up to 200%

Exercise & rehab stage

Mode 10 Muscle/ strength build – By using Electrical Muscle Stimulation (EMS)which has been routinely used in elite level sport for many years and is widely recognised (and medically proven) to significantly improve recovery from training or injury, enhance strength gains and promote muscular development.

When can i stretch or exercise after a hamstring injury?

Once the hamstring is pain free you can get back to gentle activity and stretching. Try not to do strenuous exercise too quickly this could make your injury worse, but avoiding exercise for too long can cause your hamstring muscles to shrink and scar tissue to form around the tear.

To avoid this, you should start some gentle stretches to get the length back into the hamstrings.

This should be followed by a programme of gentle exercise, such as walking and cycling or swimming, and hamstring strengthening exercises.

hamstring stretch

Check out our latest videos on our JDB Health youtube channel.

First of all start by strengthening the two opposing muscle groups, hamstrings and the quadriceps.

The hamstring is responsible for hip extension and knee flexion, while the quadriceps is responsible for the opposite actions of hip flexion and knee extension. Both of these muscle groups also stabilize the knee joint, especially during sporting activities.

Hamstrings are the smaller of the two muscle groups, generally being the more weaker with the quads being more dominant, therefore should spend more time on hamstring strength work to prevent injuries, as hamstrings will be more at risk to injury.

Good strength programmes should concentrate specifically on strengthening the hamstring muscles, improving the flexibility of your quadriceps muscles, and strengthening your core.

  • Romanian Dead-lift (RDL) – hamstring
  • Dead-bug – core exercise
  • stretching the quads

Having tight hamstrings can limit your mobility. Releasing them will increase your range of motion without causing you to lose strength.

Using a foam roller can sometimes not be as precise as a rigger ball, you can target smaller areas and pin any tight spots in the muscle.  Unlike other muscles where the individual heads are closer together, the hamstrings run farther apart along the femur. This is where the trigger ball is useful, it can get in between each hamstring head, where as the foam roller will miss this.

Hamstrings are arguably the most important muscle group in athletes

Most people think hamstrings only serve one function: knee flexion. Hamstrings having multiple functions such as; hip extension, which is vital for explosiveness, sprinting, jumping, and even low-back health.

Dead Lift

Have your feet flat on the floor, bend at the knees and grab the bar with hands shoulder-width apart.

  • Stand close enough to bar so your mid-foot under the barbell
  • Bend over and grab the bar with arms shoulder-width apart
  • Bend your knees until your shins touch the bar
  • Lift your chest up and straighten your lower back
  • Now stand up holding the bar maintaining good form.

Assisted Nordic hamstring curls

  • Have someone help by securing your ankles firmly while you engage your core.
  • Deep breath then as slow as possible begin to lower yourself to the ground maintaining a neutral spine and a straight body as possible, maintaining a engaged core..
  • Avoid flexing your spine.
  • Once you fail or reach the ground, press yourself up to the starting position and repeat.

Single Leg Deadlift

  1. Start by firmly placing your foot into the ground to maintain a stabilized position.
  2. Now slowly hinge at your hips, forcing the backwards, while also hinging your knee until you have a flat back. ( with No rounding of the back)
    Your moving leg should be straight out behind you,as straight as possible to keep your spine aligned. The higher your back leg goes, the lower your chest goes, being careful to never let your chest drop lower than your hips.
  3. As you start to hinge back and sit in to the single deadlift position, feel for the weight that is placed right outside your stabilizing foot.
  4. Now pick up the weight, make sure your shoulder is pulled back so your lat engages properly during the entire movement.
  5. Hinge your hip forward while bringing the weight with you. Lock out your stabilizing leg and squeeze your glute.

Why Painpro™ -TENS, EMS & Microcurrent are a cut above the rest?

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Why PainPro?

We’ve come to the conclusion that TENS is a viable and, some may say, even preferential treatment for pain relief. But of the myriad of devices of varying cost out there why should you choose PainPro? What’s so special about the PainPro that makes it the unit of choice for people considering TENS? To understand this, I’m so happy to say that we have to go into a little bit of Physics .

Why TENS

Historically, TENS had a reputation of being something that worked for a while then lose its effectiveness on the individual. To understand the reason for this it is important to understand the waveform of the applied current.

Waveform is the description that is used to illustrate what the electric current leaving the unit looks like:

The old style TENS machines used square waves as a basic repeated pattern. Whilst they provided pain relief their onset of action was very abrupt making the experience somewhat uncomfortable due to the fall time being virtually zero ie from resting to full intensity is virtually an instant process as is the return journey. This would cause sudden jerky movements that would not be conducive to normal behavior or relaxation during treatment.

As there is a basic repetition of the applied square wave after a while its effectiveness decreases. This is termed ‘accommodation’ and is a natural phenomenon within the body in response to constant and predictable stimuli, ticking clock, dripping tap, etc.

The modern machines have a sinusoidal wave that gradually reaches the maximum selective intensity before returning back to zero/starting position or resting phase. Whilst this is much gentler than the square waves, again the body can accommodate for these rendering them less effective over time.

Factors to consider when selecting a TENS machine

There are typically four TENS modes used in clinical practice:

Conventional TENS

Most common – High frequency/Low intensity TENS

Skin deep travel of waves → stimulation of afferent nerves → disruption of ascending pain pathways

Analgesic effect is of rapid onset but relatively short duration duration of action – typically lasting only a few hours post treatment.

Acupuncture – like TENS

Low frequency/High intensity/Long duration

Initiates and maintains a muscle contraction (effect is on the muscles so waves travel deeper and act to stimulate muscle afferent nerves: pain relief is primarily through the release of endogenous opioids via descending pain pathways)

Analgesic effect – slower onset of action but lasts longer than with Conventional TENS

Burst Train or Wave TENS

(Blended Sensory & Motor Level Stimulation)

A mixture of conventional & Acupuncture like TENS

Comprises the application of ‘Pulse Trains’ or bursts of pulses

The frequency of the trains is 1-4Hz and the internal frequency of the Trains is around 100HZ. Is often preferred due to a more comfortable patient experience.

Analgesic effect is generally maintained for several hours post application/treatment

Brief/Intense TENS

(Sometimes referred to as Noxious level stimulation)

Generally viewed as last resort or for painful procedures eg, skin debridement, suture removal etc.

Application is at high frequency (100-150Hz), long pulse duration and at highest tolerable intensity for short periods of time (≤15mins)

Modulated output is preferred:

This means the output varies as a mixture of two or more of the different TENS modes in a cyclic fashion to overcome ‘accommodation’ and provide more comfort to the patient.

The PainPro has a sophisticated modulated output of TENS and the whole unit not only concentrates on TENS and pain relief but, unlike other units it may be compared with, also has micro current technology delivered as a continually varied current to tap into and augment the body’s own healing capacity.

Thus the total treatment option or output of the PainPro is described as ‘Bioelectric Microcurrent Wave Technology’ to distinguish it from other units that don’t come close to the mark when it comes to offering the full range of treatments.

PainPro™painpro device
£16.00 £12.00

Use discount code JDB10 for 10% OFF at check out

Bioelectric theory of Pain

Background

Each tissue type in the body has its own signature electrical frequency. What happens when this signature frequency, or resting potential as is more commonly termed in the scientific community, is disrupted? And how does this manifest as pain and slow down the healing/recovery process?

To understand this we need to touch upon a little biochemistry!!!

All our cells are surrounded by a membrane (a lipid bi-layer) with proteins embedded in it. The membrane acts as an insulator and a diffusion barrier to the movement of ions.

Virtually all eukaryotic cells maintain a non zero trans-membrane potential by selectively regulating ions via ion pumps, e.g, Na+ K+ pump, the levels of specific ions both inside and outside of the cell. This creates a trans-membrane potential typically in the region of -40mV to -80mV (cell interior to exterior)

Why is this important? You may ask

The membrane potential has two basic functions –

  1. It allows the cell to function as a battery providing power to operate a variety of molecular devices embedded in the membrane
  2. Important in electrically excitable cells e.g, neurons and muscle cells for transmitting signals.

Under normal conditions the trans-membrane potential or resting potential is held at a relatively stable value which allows all the cell processes to function harmoniously.

Whenever there is tissue trauma or dysfunction:

  • There is a decrease in ATP and disruption of the sodium pump. (for those of you not familiar with ATP and its function we will come on to that in a short while)
  • The cells increase their electrical resistance and the injured area will have a higher electrical resistance than the surrounding tissue
  • This decreases electrical conductance throughout the injured area and decreases electrical capacitance which leads to impairment of function and inflammation
  • The cells become less able to receive nutritional input, water, minerals etc, and are unable to remove toxins.

All of these events are perceived by the individual as pain.

THIS IS NOT AN ENVIRONMENT THAT SUPPORTS HEALING!

Due to the damage, the loss of intracellular ions and the disruption of the sodium pump mechanism the damaged cells produce an electric current which is termed the ‘current of injury’ – almost like an SOS

WHAT CAN WE DO TO HELP?

We have TENS plus EMS in the PainPro to relieve pain centrally and locally

WHAT MORE CAN WE OFFER?

We now have in our new generation of PainPro microcurrent technology that mimics and augments the endogenous current flow allowing cells in the traumatized area to regain their capacitance.

  • REGAIN CAPACITANCE  → REDUCE
  • RESISTANCE → IMPROVED BIO ELECTRIC
  • FLOW → REESTABLISH HOMEOSTASIS → HEALING

ATP is replenished allowing membrane active transport to resume → Inflow of Nutrients & Outflow of toxins + waste (we’ll get to the role of ATP next)

Pre- clinical studies have shown that externally applied stimulation can:

  • Cause migration of epithelial cells and fibroblasts in to the wound site
  • Increase ATP concentrations in tissues
  • Increase protein and DNA synthesis
  • Promote healing of soft tissues or ulcers
  • Accelerate the healing of damaged neural tissue
  • Reduce oedema
  • Inhibit growth of various pathogens

History

Electric therapy is nothing new with the ancient Egyptians, Greeks and Romans using electric eels for headaches and neuralgia.

How does microcurrent treatment differ from TENS/EMS treatment?

The main treatment of TENS/EMS therapy is pain relief with concomitant small scale repair of tissues due to intermittent delivery of appropriate current frequency → direct pain relief.

Mircocurrent therapy is specially designed to tap in to the body’s own (SOS) frequency to normalize the environment, promote healing and hence remove the source of the pain → indirect pain relief/removal.

customer at runfit expo 2018

FOLLOW SAM WEDGBURY’S JOURNEY AND RECOVERY FROM HIS ACL INJURY ON INSTAGRAM

WHAT CAN YOU EXPECT IN A MICROCURRENT TREATMENT?

During treatment, electrodes are placed at strategic locations to direct currents to target tissues. Treatment microcurrents are very weak and typically sub sensory so do not stimulate sensory nerves hence the subject normally does not feel anything.

USES:

Microcurrent therapy has been used and recommended for:

Arthritis

Back pain

Diabetic ulcers

Fibromyalgia

Headaches

Herpes

Neck pain

Neuropathy

Sciatica

Shingles

Slow healing wounds

Sports injuries- ACL, MCL, breaks, fractures etc.

Tendon and ligament pain

Calf Injuries, Treatments and recovery

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diagram of calf muscle

The calf muscle is located on the back of the lower leg below the knee, its made up of two main muscles.

The gastrocnemius is the larger calf muscle. The gastrocnemius has two parts or “heads,” which together create its diamond shape.

The soleus is a smaller, flat muscle that lies underneath the gastrocnemius muscle.

The gastrocnemius and soleus muscles merge at the base of the calf muscle. Tough connective tissue at the bottom of the calf muscle merges with the Achilles tendon. The Achilles tendon inserts into the heel bone (calcaneus).

while walking, running, or jumping, the calf muscles pull the heel up to allow forward movement.

What causes pain in the calf muscle?

Often pain in the calf muscles are related to injuries such as;

  • calf strain
  • Plantaris muscle rupture
  • Medial gastrocnemius strain
  • Achilles tendonitis
  • Bakers cyst
  • Blood clot
  • Leg cramps

The severity of pain varies from person to person, typically a sharp, dull or aching pain, with more severe symptoms like swelling, weakness of the leg, fluid retention or redness,warmth or tenderness of the calf.

  • Grade 1 Calf Strain- Mild discomfort with minimal or no limit to activity.
  • Grade 2 Calf Strain-  Discomfort with activities such as walking, with possible swelling bruising and tenderness.
  • Grade 3 Calf Strain- Severe pain that can cause inability to walk with swelling and significant bruising.

Calf strain

Calf strains are very common and causes by overstretching or excess force through the lower leg.

How long does it take to a calf strain to heal?

Grade 1 can heal between 7- 10 days.

Grade 2 can be within about 4- 6 weeks.

Grade 3 usually within 3 months time scale.

What Treatment can i apply for a calf strain?

Always seek medical advice and assistance with in 48 hours.

Apply the principals of RICE

Rest- avoid activities to protect the muscle from ore damage.

Ice- use ice packs such as Physicool (as seen below) or frozen peas anything that can cool the affected area to reduce inflammation.

physicool wrapped on a calf muscle

Compression- to provide support and also reduce swelling.

Elevate-  place the affected area up higher than normal to decrease swelling. example- place leg up on a chair while siting.

Applying the RICE procedure will help with the healing process and help you on your way to recovery after suffering an injury, hopefully getting you back to activities and daily routines quicker.

What exercises can i do for a calf strain?

Some exercises to help with rehabilitation of the injured calf. Once the calf is pain free you can progress with gentle light stretches of the calf, start and ease your way into the stretch. You can push more into the stretch if no pain occurs.

Calf wall stretch.
  1. Stand facing a wall with your hands on the wall at about eye level. Put your affected leg about a step behind your other leg.
  2. Keeping your back leg straight and your back heel on the floor, bend your front knee and gently bring your hip and chest toward the wall until you feel a stretch in the calf of your back leg.
  3. Hold the stretch for at least 15 to 30 seconds.
  4. Repeat 2 to 4 times.
calf stretch 1
calf stretch 2
Ankle plantar flexion
  1. Sit with your affected leg straight and supported on the floor. Your other leg should be bent.
  2. Keeping your affected leg straight, gently flex your foot downward so your toes are pointed away from your body. Then slowly relax your foot to the starting position.
  3. Repeat 8 to 12 times.

Calf raise
  1. Stand behind a chair or counter with both feet flat on the floor.
  2. Using the chair or counter as a support, rise up onto your toes and hold for 5 seconds.
  3. Then slowly lower yourself down without holding onto the support.

Using a Trigger ball on my calf.

Lie on the floor while placing the rigger ball or peanut under the bulk of the calf muscle, then slowly roll up and down using your arms to desired areas (mainly the tight areas) rotating the leg either side to hit every area.

You can stop, hold an apply more pressure in tighter areas to trigger and release the muscle.

Ben Tollitt using Painpro™ helps him stay ahead of schedule by 5 weeks.

The ACL is a ligament situated deep inside the knee. Its helps to provide stability, but it also acts as the knee’s brain. It’s full of sensors, so when the knee is running,sprinting, turning and twisting, it provides the brain with all this information about the speed it’s moving at and keeps it nice and stable and in the correct position. If you damage it, your knee will become wobbly and unstable.

Stage 1, pre-operation:

  • Control swelling
  • Restore full mobility of the knee.
  • Maintain strength of the quadriceps and hamstring muscles. Using contraction device (such as painpro)
  • Regain normal walking patterns, no limping

Home treatment:

  • Apply the PRICE principles of rest, ice compression and elevation.
  • Wear a hinged knee brace to protect the knee from further injury.
  • Perform patella mobilizations.
  • Knee mobility exercises including heel slides, knee flexion and prone knee hangs.
  • Ankle mobility exercises.
  • Quadriceps and hamstring isometric exercises (static contractions with pain pro muscle building setting).
  • Hip strengthening exercises including bridging and adduction.

Stage 2, post op (week 0-4):

  • Control swelling.
  • Improve bending of the knee up to 90 degrees.
  • Improve straightening of the knee to full.
  • Continue quads and hamstrings contractions with pain pro on muscle building setting
  • Walk partial weight bearing in crutches. Get rid of crutches after 2 weeks

Home Treatment:

  • Apply principles of P.R.I.C.E.
  • Wear a Knee Brace to protect the knee from further injury – your surgeon will advise on how much movement the brace should allow.
  • Continue to perform patella mobilisations.

Exercises:

  • ¼ squats.
  • Bridging.
  • Step ups.
  • Static bike – high seat with NO resistance, in pain free range of movement.
  • Hamstring curls – only if patella tendon graft is used, not Hamstring graft.
  • Calf Raises.

General body weight exercises and movements with limited strain.

Stage 3, post op (week 5-12):

  • Control swelling.
  • Improve bending of the knee up to 120 degrees.
  • Maintain full straightening of the knee.
  • Improve quads and hamstrings strength.
  • Continue walking with a “normal” pattern, increase proprioception and balance.
  • Remove Brace at 6 weeks.

Home Treatment:

  • Continue to apply cold therapy post exercises.
  • Continue to perform patella mobilisations.

Exercises:

  • ½ squats.
  • Lunges.
  • Leg Press.
  • Step downs.
  • Static bike – high seat with NO resistance, in pain free range of movement.
  • Sit to stand.
  • Single leg balance exercises.

Build up the exercises during this stage from body weight to exercises with resistance and weight like normal gym work just not full on yet.

Stage 4, post op (week 13-20):

  • Continue to control swelling.
  • Regain full movement of the knee.
  • Continue to improve quads and hamstrings strength.
  • Continue to work on balance and proprioception.
  • Start jogging and progress speed straight line only.

Home Treatment:

  • Continue to apply cold therapy post exercises.
  • Continue to perform patella mobilisations.

Exercises:

Exercises that are typically introduced at this stage, in addition to the previous stage’s exercises are:

  • Hopping single leg.
  • Double leg jumps.
  • Static bike.
  • Jogging – start slowly and ensure there is no limp before going quicker.
  • Increase running speed slowly and progressively over a period of weeks but only in straight lines no twisting or turning.

Gym work should now be resisted weights work and from this point build up the amount of weight can be lifted

Stage 5, post op (week 21-24):

  • Introduce twisting, turning and cutting movements.
  • Introduce ball work (if required).
  • Continue to improve balance around the knee.
  • Achieve at least 90% strength in the quads and hamstrings in comparison to the other uninjured leg.
  • Improving confidence.

Home Treatment:

  • Continue to apply cold therapy post exercises.
  • Continue to perform patella mobilisations.

Exercises:

  • Box Jumps
  • Start to gradually introduce twisting and turning movements.
  • Start to introduce striking a ball (if required).
  • Start to perform functional sports specific drills.

Along side this continue gym work

Stage 6, post op (week 25+):

Return to sport

Improvements I made and stages I bettered during rehab:

Ben Tollitt used Painpro™ to help with rehab from his acl injury 5 weeks early

Page Contents

How Painpro™ helped Ben Tollitt with his ACL rehab

Ben is a talented professional football at Tranmere  Rovers. Ben suffered an horrific set back with a grade 3 Acl injury. This is how he combined his rehab and Painpro™ to help speed up his healing and progression.

ben tollitt

It helped me with many of the systems it had to offer. The muscle building setting helped massively as I was performing muscle contractions with the device rather than on my own so it gave me extra help in getting muscle strength back quicker and better than it was before. When I could then do gym weights I used this setting whilst performing workouts for extra help.

With the recovery cell repair settings they helped massively by placing the pads on affected areas like knee, quads, hamstring, etc it allowed me to recover quicker on back to back days of work and also on days off so that I healed quicker but was also able to perform in the gym during my rehab to a higher standard more often.

The ACL is a ligament situated deep inside the knee. Its helps to provide stability, but it also acts as the knee’s brain. It’s full of sensors, so when the knee is running,sprinting, turning and twisting, it provides the brain with all this information about the speed it’s moving at and keeps it nice and stable and in the correct position. If you damage it, your knee will become wobbly and unstable.

ACL injuries are very common in footballers due to all the twisting and turning at sharp speeds. When we think about footballers’ movements – they sprint, jump, land, twist, and turn compared to a runner who just run in a straight line, so their ACL isn’t as integral to their movement and performance as a footballer. Pitches are harder and firmer which doesn’t help, the speed of the game has increased and players are playing more games. All these factors all play their part in ACL injuries in footballers.acl injury in football

From injury to return to play

Stage 1, pre-operation:

  • Control swelling
  • Restore full mobility of the knee.
  • Maintain strength of the quadriceps and hamstring muscles. Using contraction device (such as painpro)
  • Regain normal walking patterns, no limping

Home treatment:

  • Apply the PRICE principles of rest, ice compression and elevation.
  • Wear a hinged knee brace to protect the knee from further injury.
  • Perform patella mobilizations.
  • Knee mobility exercises including heel slides, knee flexion and prone knee hangs.
  • Ankle mobility exercises.
  • Quadriceps and hamstring isometric exercises (static contractions with pain pro muscle building setting).
  • Hip strengthening exercises including bridging and adduction.

Stage 2, post op (week 0-4):

  • Control swelling.
  • Improve bending of the knee up to 90 degrees.
  • Improve straightening of the knee to full.
  • Continue quads and hamstrings contractions with pain pro on muscle building setting
  • Walk partial weight bearing in crutches. Get rid of crutches after 2 weeks

Home Treatment:

  • Apply principles of P.R.I.C.E.
  • Wear a Knee Brace to protect the knee from further injury – your surgeon will advise on how much movement the brace should allow.
  • Continue to perform patella mobilisations.

Exercises:

  • ¼ squats.
  • Bridging.
  • Step ups.
  • Static bike – high seat with NO resistance, in pain free range of movement.
  • Hamstring curls – only if patella tendon graft is used, not Hamstring graft.
  • Calf Raises.

General body weight exercises and movements with limited strain.

Stage 3, post op (week 5-12):

  • Control swelling.
  • Improve bending of the knee up to 120 degrees.
  • Maintain full straightening of the knee.
  • Improve quads and hamstrings strength.
  • Continue walking with a “normal” pattern, increase proprioception and balance.
  • Remove Brace at 6 weeks.

Home Treatment:

  • Continue to apply cold therapy post exercises.
  • Continue to perform patella mobilisations.

Exercises:

  • ½ squats.
  • Lunges.
  • Leg Press.
  • Step downs.
  • Static bike – high seat with NO resistance, in pain free range of movement.
  • Sit to stand.
  • Single leg balance exercises.

Build up the exercises during this stage from body weight to exercises with resistance and weight like normal gym work just not full on yet.

Stage 4, post op (week 13-20):

  • Continue to control swelling.
  • Regain full movement of the knee.
  • Continue to improve quads and hamstrings strength.
  • Continue to work on balance and proprioception.
  • Start jogging and progress speed straight line only.

Home Treatment:

  • Continue to apply cold therapy post exercises.
  • Continue to perform patella mobilisations.

Exercises:

Exercises that are typically introduced at this stage, in addition to the previous stage’s exercises are:

  • Hopping single leg.
  • Double leg jumps.
  • Static bike.
  • Jogging – start slowly and ensure there is no limp before going quicker.
  • Increase running speed slowly and progressively over a period of weeks but only in straight lines no twisting or turning.

Gym work should now be resisted weights work and from this point build up the amount of weight can be lifted

Stage 5, post op (week 21-24):

  • Introduce twisting, turning and cutting movements.
  • Introduce ball work (if required).
  • Continue to improve balance around the knee.
  • Achieve at least 90% strength in the quads and hamstrings in comparison to the other uninjured leg.
  • Improving confidence.

Home Treatment:

  • Continue to apply cold therapy post exercises.
  • Continue to perform patella mobilisations.

Exercises:

  • Box Jumps
  • Start to gradually introduce twisting and turning movements.
  • Start to introduce striking a ball (if required).
  • Start to perform functional sports specific drills.

Along side this continue gym work

Stage 6, post op (week 25+):

Return to sport

Improvements Ben Tollitt made and stages he bettered during rehab compared to a normal ACL rehab period.

Stage 1.

Ben was able to;

bike

Do weights in the gym

No pain

No swelling

Full quads muscle strength

Stage 2:

More than 90 degrees knee bend

Fully straight leg

Walking after 5 days

Better than normal quad strength

Doing single leg volleys standing on operated leg

Brace removed week 1 not week 6

Stage 3:

At week 6 (instead of week 13) was told I could jog)

Full knee bend not just 120 degrees

Full muscle strength back with good amount of hyper extension

Stage 4:

Twisting and turning week 16 not week 21

Full sprinting

Performing football ‘Hoff circuits’ week 16

Joining in with non contact pre season training week 17 not week 21

Stage 5:

Ben returned to full training with the team rather than returning and building up his training minutes over  a period of training session.

Ben’s rehab was 5/6 weeks ahead of schedule  schedule.

Ben Training during his rehab from ACL



Ben using Painpro™ to help maitain muscle mass

Which PainPro™ Mode to use for your legs.

Mode 1: Chronic Pain Relief – for long term chronic pain.

painpro used on legMode 2: Acupuncture – for relieving acute pain.

Both modes can be used to help reduce pain whether that be living with pain acute or chronic. Also perfect for post surgery for pain and to help reduce pain while trying to get your range of movement back to normal.

Mode 4: Circulation Enhancement – for better blood flow.

Can be used to reduce inflammation due to injury or a chronic condition like arthritis. Can also help people with circulation issues.

Mode 3: Muscle Tapping – deep massage for pain relief

Mode 5: Muscle Massage – for targeted pain relief

Mode 6: Regeneration – joint pain and muscle cramp.

Mode 7: Relaxation – for ultimate muscle recovery

Mode 9: Deep Tissue Relief – stimulation and restoration

All these modes are different variations of massage from relaxation to deep tissue massage. Can help fatigue and cramp flushing out toxins and lactic acid using regeneration mode.

Mode 8: Foot Massage – short, deep pulses.

Foot massage can help flush lactic acid out of the lower limbs, ideal for runners and sports people to have a perfect recovery.

Mode 10: Muscle Stimulation – enhance muscle performance.

Muscle build can help maintain muscle while incapacitated due to injury, surgery or chronic conditions. Making recovery from injury a lot quicker, helping maintain muscle mass and strength.

Mode 12: Cell Repair via Microcurrent – enhanced recovery and repair.

Microcurrent Therapy, you can further enhance your recovery by boosting your ATP levels, accelerating muscle fiber regeneration

A mechanistic approach to pain management: Applying the biopsychosocial model to physical therapy

“Physicians and patients usually harbor a concept of pain that involves a linkage between body damage and the pain reported by the patient. This is an inadequate concept that leads both physicians and their patients into unnecessary difficulties in the management of chronic pain.” Loeser, 1982 [1]

We recently read the classic article by Loeser written over 30 years ago, in which he proposed the biopsychosocial model.[1] It is amazing how many of the statements in the article, such as the quote above, still reflect current practice and patient experience. We recently wrote a perspective in Physical Therapy[2] that expands the biopsychosocial model to include a motor component in order to translate this theoretical model to physical therapy practice. Our goal was to provide a conceptual framework within which physical therapists could consider a mechanism-based approach to individualize care for a patient with pain, rather than focus predominantly on a diagnosis or perceived “body damage.”

Before describing the different types of “pain mechanisms,” we first need to qualify our use of this term. We are operationally defining a ‘pain mechanism’ as an aspect that can begin, maintain, and/or modulate pain, including influencing relationships between other aspects of pain. In addition, several of these modulating ‘pain mechanisms’ can occur in a cyclical manner, both in response to pain and influencing pain. Given that pain is a complex experience, people in pain often have multiple mechanisms occurring simultaneously that can increase or decrease the experience of pain. Individuals with a common diagnosis, such as knee osteoarthritis, who share common symptoms, have a unique combination of mechanisms and subset of factors contributing to their pain.

There are three primary biological pain mechanisms (nociceptive, nociplastic, neuropathic) that can contribute to pain, as previously described by Phillips and Clauw.[3] As currently defined by the International Association for the Study of Pain (IASP),[4] these three terms, respectively, refer to pain arising from nociceptor activation, adaptations to nociceptive pathways in the central nervous system, and direct damage to the nociceptive system. While nociceptor and/or nociceptive pathway activation alone are not sufficient to cause pain, they can be triggering events that need to be addressed in pain management. These three biological pain mechanisms can be influenced by, as well as directly influence, psychosocial and motor mechanisms (See Figure 1). This means that psychological factors such as depression could have a negative impact on pain, or psychological factors such as a high level of self-efficacy could have a positive impact on pain.[5] Similarly the motor system can negatively (e.g. muscle cramp) or positively (e.g. endorphin release with running) impact pain. Because physical therapists specialize in the evaluation and treatment of the motor system, our profession has the potential to drastically improve our understanding of how this particular mechanism interacts with other pain mechanisms.

Figure 1. Schematic representation of 3 biological pain mechanisms occurring within the context of the movement system and psychosocial mechanisms.

The first step of a mechanism-based approach is to evaluate the potential involvement of each pain mechanism. This allows for prioritizing specific treatments based on the mechanisms reasoned to be involved rather than a general diagnosis. In a recently completed study on people with chronic Achilles tendon pain, 68% (15/23) had high fear of movement, yet only 17% (4/23) of age-, sex- and BMI-matched pain-free controls had high fear of movement (https://clinicaltrials.gov/ct2/show/NCT03316378). Of note fear of movement was common in those with chronic Achilles pain yet not ubiquitous; there were still over 30% that did not have high fear of movement. Thus rather than recommending interventions targeting fear of movement for all people with chronic Achilles tendon pain, we suggest screening for this potential mechanism and targeting treatment accordingly. Further, this example illustrates that patients may present with only certain components of a pain mechanism. In this same study, we found that only 4% had high pain catastrophizing. In other words, just because a patient reports elevated levels of one type of psychosocial factor, it does not mean that they will report others (e.g. pain catastrophizing, depression, anxiety). In addition, patients often present with multiple pain mechanisms (e.g. heightened psychosocial factors and nociceptor activation). Therefore, a thorough evaluation examines each potential pain mechanism rather than targeting a single pain mechanism, and recognizes that there may be multiple factors within a single mechanism: i.e. fear of movement vs. pain catastrophizing. Unfortunately, we are limited to indirect assessments, including patient history, questionnaires and potentially quantitative sensory testing (QST), to determine the involvement of the 3 biological pain mechanisms in humans. Increasingly QST has been used to infer the presence of centrally-mediated mechanisms, but we are far from having fully validated tools to discern with certainty the relative roles of nociceptive, nociplastic, and neuropathic mechanisms.

After identifying contributing pain mechanisms, the second step of the mechanism-based approach is to provide treatment(s) targeting these mechanisms. Our recent article describes the basic and clinical science supporting known mechanisms that underlie a few common physical therapy treatments, including exercise, education, TENS, massage, and manipulation (Figure 2A).[2] These selected treatments were chosen because their underlying mechanisms have been well studied, the mechanisms underlying many other physical therapy treatments are still unclear.

Figure 2. This diagram illustrates sites of action, based on currently available mechanistic data, for A) common physical therapy treatments and B) common pharmacological treatments on the five pain mechanisms

It is worth noting that a mechanism-based approach has long been used by pharmacologists to maximize the therapeutic benefit of pain relieving medications (Figure 2B). As an example in patients with peripheral neuropathic pain, oxcarbazepine, a sodium channel blocker that reduces nociceptor activity, had a larger effect in the “irritable nociceptor” group than the “nonirritable nociceptor” group (Number Needed to Treat=4 vs. 13).[6] In comparing the lists of treatments for each mechanism in figure 2A to figure 2B, many of the physical therapy treatments target multiple pain mechanisms while pharmaceutical agents target a single mechanism. Both a clinical strength and research challenge for physical therapy pain management is that exercise can affect all five mechanisms. There are a multitude of clinical trials comparing 2 different exercise interventions in the same population and having equivocal results (see table of systematic reviews on exercise-induced analgesia).[7] These findings are potentially due to the generalized effect of exercise on pain. While research on pain mechanisms continues to grow, it is yet to be seen if physical therapy can augment the effect of exercise by providing treatments to specifically target an individual’s pain mechanisms.

About Ruth Chimenti

Ruth Chimenti, DPT, PhD is a postdoctoral scholar in the Department of Physical Therapy and Rehabilitation Science at the University of Iowa. Her current line of research is creating a bridge between the fields of pain science and orthopaedic biomechanics. Dr. Chimenti has experience working with groups of clinicians and scientists to make practice recommendations for physical therapists (e.g. author on 2018 Achilles tendinopathy clinical practice guidelines). Her work is currently supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health under the Career Development Award K99AR071517.

About Laura Frey Law

Frey Law~Laura

Laura Frey Law, MPT, MS, PhD is an Associate Professor in the Department of Physical Therapy & Rehabilitation Science, Carver College of Medicine, at the University of Iowa. She received her PhD in Rehabilitation Science in 2004, and has a background in biomedical engineering (BSE and MS) and clinical physical therapy (MPT) with 5 years experience in sports medicine PT. Her research interests include musculoskeletal pain and fatigue with over 40 manuscripts in this area.  She has been funded by the National Institutes of Health as well as by various Foundations; has served on National and International Pain Association Boards; and is an Associate Editor for the Journal of Applied Biomechanics.

About Kathleen Sluka

Kathleen A. Sluka, PT, PhD, FAPTA is a professor in the Department of Physical Therapy and Rehabilitation Science at the University of Iowa. She is also an advocate for improved guidelines and standards for pain education, and has served on the numerous task forces by the IASP including those to  develop physical therapy pain curriculum guidelines and those to define pain terminology. She has authored ‘Pain Mechanisms and Management for the Physical Therapist,’ an evidence-based textbook on basic science mechanisms, physical therapy treatments, interdisciplinary care, and pain syndromes published by the IASP Press. Dr. Sluka’s translational research laboratory focuses on the neurobiology of musculoskeletal pain as well as the mechanisms and effectiveness of non-pharmacological pain treatments commonly used by physical therapists. She has published over 200 peer-reviewed manuscripts and has received numerous awards including the Marian Williams Award for Research in Physical Therapy and the Catherine Worthingham Fellow Award from the American Physical Therapy Association, and the Kerr Basic Science Research Award from the American Pain Society.

References

[1] Loeser JD. Concepts of Pain. New York: Raven Press; 1982.

[2] Chimenti RL, Frey-Law LA, Sluka KA. A Mechanism-Based Approach to Physical Therapist Management of Pain. Phys. Ther. May 1 2018;98(5):302-314.

[3] Phillips K, Clauw DJ. Central pain mechanisms in chronic pain states–maybe it is all in their head. Best Pract. Res. Clin. Rheumatol. Apr 2011;25(2):141-154.

[4] International Association for the Study of Pain (IASP) Terminology. Dec 2017; https://www.iasp-pain.org/Education/Content.aspx?ItemNumber=1698.

[5] Edwards RR, Dworkin RH, Sullivan MD, Turk DC, Wasan AD. The Role of Psychosocial Processes in the Development and Maintenance of Chronic Pain. J. Pain. Sep 2016;17(9 Suppl):T70-92.

[6] Demant DT, Lund K, Finnerup NB, et al. Pain relief with lidocaine 5% patch in localized peripheral neuropathic pain in relation to pain phenotype: a randomised, double-blind, and placebo-controlled, phenotype panel study. Pain. Nov 2015;156(11):2234-2244.

[7] Sluka KA. Mechanisms and Management of Pain for the Physical Therapist. Second edition ed. Seattle, WA: IASP Press; 2016.

Science cranks

“Therapy babble” is an irritating combination of jargon, bafflegab, pseudoscience, and abused science that sounds impressive but means little, and it’s particularly common in alternative health care. Science cranks are a significant sub-species of therapy babbler. They have a lot of admirably sincere enthusiasm about science, which sets them apart from most other therapy babblers, who are merely paying lip service to science. The crank is truly keen on science, but just isn’t any good at it — downright terrible, actually.

Just like conspiracy theorists seem a bit brain-glitchy, like they might have a mild form of mental illness (because they probably do), so too science cranks exhibit some suspiciously consistent types of reasoning problems, which might be more about malfunctions than mere mistakes. They suffer from crippling confusion about the relevance and weight of ideas. To them, whatever they aim their attention at is significant, nothing that seems similar is a coincidence, and the scientific method is basically just identifying superficial connections and blowing them way out of proportion. Speculation is always good enough.

After languishing in my drafts file for about eight years, I finally added this train of thought about science crankery to PainScience.com, a small new section of:

Exhibit A: “I’M PURE SCIENCE”

Over the years, I have received many pain-cure pitches from delusional cranks who believe that they have a lock on a cure for “all” or “most” chronic pain. Some of them, rather than being pissed at me for my anti-quackery activism, are so delusional that think I’ll be impressed by their theory. They might hope that they can woo me (pun intended), and many are obviously hoping to recruit me to become an evangelist for their nonsense. Some are more condescending, and probably don’t think I’m likely to see the light, but it can’t hurt to try, right? They all remind me of kooky inventors who are convinced that they have a perpetual motion machine.

The following is surely the apotheosis of this phenomenon. This is a transcribed voice mail, presented it to you here for your amusement and amazement, in the form of a free verse poem. The emphasis is mostly mine for dramatic effect, but not entirely — he was definitely hitting some of these words as hard as the capitals imply. Behold the dazzling ego!

found you on the net by accident
I would love to have a discussion with you about TRUE pain healing science
which is non-medical
which apparently you have no been made aware of
I am an expert in it, I’ve written a book on it, I’ve done the work
I’ve healed migraines, dozens, actually hundreds of them
in less than 20 minutes!
very, very, very easy to do WHEN you understand the TRUE science
not the medical science, which is nonsense
but true quantum science, quantum physics, biophysics, epigenetics!
that kind of thing, you know
I’d love to have a talk with you to help you understand how REAL science is helping people to heal pain
not just cope with it
and I am the expert on it
and I do this work around the world
I’m not a flake, I’m not some kind of weirdo
I’M PURE SCIENCE
and I’d love to share this with you
and maybe I’ll enlighten you a bit on how things really work on this planet
when you look at the ADVANCED science

What a truly classic example of a “science crank”! This was added to:

[Go to this post on PainScience.com]

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“Why would he mislead people like that?”

I once explained to a reader that a claim made by a popular massage therapist author was completely bogus, and she earnestly asked, “Why would he mislead people like that?” She was actually puzzled! Apparently it had never occurred to her that any health care professional might be a crank, or self-serving, or even just too optimistic. It’s hard for me to relate to such innocence. The world is overflowing with misinformation, particularly about health. Indeed, most of it is problematic in some way, even though much of it is produced with good intentions.

That little anecdote is now the new intro to an old article:

[Go to the link featured in this post]

[Go to this post on PainScience.com]

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Biased towards pain: the role of expectancy in impaired selective learning in fibromyalgia patients

Body in Mind

Associative learning is the process by which people and animals learn that two events or stimuli occur together. One of the evolutionary advantages of associative learning is to identify predictors of adverse situations or consequences (i.e., those that produce harm), so that we can anticipate and avoid them. For example, a person suffering from back […]

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The post Biased towards pain: the role of expectancy in impaired selective learning in fibromyalgia patients appeared first on JDB Health.