Em Stuart Injuries Clinic

Graduate Sports Therapist Bsc Hons

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Hamstrings – Part 7 of the grumbly muscle blog…Guardian angels, or a bit too overprotective?

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Hamstrings – Part 7 of the grumbly muscle blog…Guardian angels, or a bit too overprotective?

What are they and how many have we got?

We’ve all heard of them, but many don’t know how many we have. The answer is 3… semimembranosus and semitendinosus (the two inside the knee) and biceps femoris (the outside hamstring).

Sometimes, adductor magnus helps out as a hamstring when things just aren’t in balance, so it’s sometimes known as the fourth hamstring, but it’s an adductor first and foremost.

I love hamstrings, they fascinate me, I wrote my dissertation on them, but I promise to try and keep this blog brief and to the point.

Anatomy

All three muscles originate on the same place, the ischial tuberosity (the sit-bones of the pelvis) with the biceps (meaning two heads – long and short head) femoris short head come from the lateral lip of the linea aspera (outside, top of the femur).

Biceps femoris inserts onto the head of fibula (the bone on the outside of your leg) on the outside of the knee.

Semitendinosus inserts onto the at the pes anserine tendon (meaning goose foot, because three tendons join together, which looks like a goose foot) on the medial shaft of the tibia.

Semimembranosus inserts onto the back of the medial condyle (posh word for the knobbly bit).

So, what do they do?

Well unually, they cross two joints, the hip, and the knee, so they have an impressive CV of jobs both as a group and individually.

As a team they flex (bend) the knee and extend the hip along with glute max, that’s how we get up from a seated position.  

They protect the ACL (anterior cruciate ligament) by helping to control forward movement of the tibia during sprinting and kicking.

They work synergistically with the quad muscles. When the quads contract, they extend and vice versa and tilt the pelvis posteriorly.

If you’re a runner, you’ll know a lot about hamstrings. During running, the hamstring tendons also store elastic energy in one part of the gait cycle to be used in another part of the gate cycle: known as the stretch-shortening-cycle.

Individually we have;

Biceps femoris – also assists to laterally rotates the hip (turn it out).

Semitendinosus & Semimembranosus – also medially rotate the flexed knee and medially rotate the hip (turn it in).

Why are they an issue?

In sports, particularly sports involving running at speed; track & field, rugby and football, hamstring strains are a very persistent problem but in general, for non-athletes as well, they are quite grumbly creatures.

If there is instability or injury at the hip or the knee, I tend to find that the hamstrings ‘go on guard’ and tighten protectively.

When people have an anteriorly tilted pelvis, because of their attachment to it, the hamstrings are put on a stretch, becoming tight and grumbly.

We can get hamstring tendinopathy, more commonly where they insert (known as proximal or insertional tendinopathy) at the ischial tuberosity where you get a lovely (not) localised deep pain, or, less commonly, where they attach around the knee (distal tendinopathy). There are a multitude of causes for tendinopathy, excessive sitting can be one of them.

They are also very neural muscles; Proximal Hamstring Tendinopathy-related Sciatic Nerve Entrapment (PHTrSNE) is where scar tissue can build up between the sciatic nerve and the tendon of semimembranosus where it originates from the pelvis.  

Semitendinosus, semimembranosus, and long head of biceps are all innervated from tibial branch of the sciatic nerve however, biceps femoris short head is innervated instead by the peroneal portion of the sciatic nerve. The hamstrings can refer sharp shooting neural pain very similar to sciatica.

What can we do about it?

  • Stretch them properly. When I was a long-distance runner, I thought I was stretching my hamstrings off correctly, only to realise later that I was performing a neural stretch.
  • Foam roll them, this is self-myofascial release but personally, I find this too painful, so it’s not for everyone.
  • Massage is a good tool to relax them, firm but not too deep.
  • One thing I do find good results with is a PNF (peripheral neurological facilitation) stretch. If I’m ever on a rugby pitch and a player say’s their hamstrings are tight, this is a quick fix to get them through the match, it improves range of motion substantially, and doesn’t aggravate the nerves.
  • Another technique I use is kinesio tape, from knee to the sit-bones, to off-load them.
  • Finally, strengthen them! Eccentric exercise (lengthening under tension) is particularly good for tendinopathies and returning from injury stronger.

Rotator Cuffs – Part 6 of the grumbly muscle blog…they hug us and depress us…well, kind of…

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Rotator Cuffs – Part 6 of the grumbly muscle blog…they hug us and depress us…well, kind of…

What are rotator cuffs and what do they do?

Well, we have 4 of them on each scapula (shoulder blade). As you can imagine, four muscles, four slightly different jobs, but as a team they dynamically stabilise the head of humerus; basically they hug the head into the socket but also keep the head depressed (sitting lower) in the socket which actually gives us a better range of motion at the shoulder so as we raise our arms, allowing the head of the humerus to glide down and roll up and prevent obstruction to these movements.

They are necessary for virtually every movement of the shoulder joint. The scapula fossa (the socket, if you will) is really shallow so these muscles have a lot of work on their hands…We have.

Supraspinatus – does the first 20-30° of shoulder abduction (takes the arm away from the body).

Infraspinatus and Teres minor – both adduct the shoulder (brings the arm inwards) but also laterally rotates the shoulder.

Subscapularis – this one medially rotates the shoulder.

 

Anatomy

Supraspinatus – Comes from the supraspinous fossa above the spine of scapula and inserts onto the greater tubercle of the humerus.

Infraspinatus – Infraspinous fossa of the scapula and, inserts onto the greater tubercle of the humerus.

Teres Minor – Upper two thirds of the lateral border of the scapula and also inserts into the greater tubercle of the humerus.

Subscapularis – Comes from underneath the scapula (subscapular fossa) and inserts onto the lesser tubercle of the humerus.

 

Why do they hurt?

The subscapularis can become impinged (caught between two bones; the acromion process and the humerus), sub acromial pain syndrome (SAPS) is often linked to this but can include tendinopathy and bursitis. And there are often tears, particularly of infraspinatus and teres minor, the two lateral rotators.

As we age the properties of the tendon (this is the white bit of the muscle that attaches to the bone) degenerate (sorry folks, but age is a risk factor), and we can observe not only microscopic tears to the tendons and muscles and, as mentioned, tears to the muscle. Tendons can also suffer tendinopathies. I often find while I massage the rotator cuffs that they are quite tender to the touch on most people.

 

What can we do about it?

In the clinic I test for impingement using a few different tests; Empty Can test, Painful Arc (pain between 60-120 degrees is common), Hawkins Kennedy – pain in outer range can indicate impingement. Hornblower’s sign is indicative of an infraspinatus or teres minor tear. Overhead athletes are at a greater risk of rotator cuff tears.

I often prescribe strengthening of infraspinatus and teres minor as they are the main lateral rotators of the shoulder and often the weakest of the rotator cuffs when tested. However, they’re really up against it, some of the medial rotators are BIG muscles; Pectoralis major (pecs), Latissimus Dorsi (lats) and subscapularis. If you ask me its an unfair balance.  In the gym, people commonly train the pecs and the lats but don’t give due consideration to the rotator cuffs.  We need to stretch off the muscles at the front, which will improve our posture a little and strengthen the muscles that attach to and come from the shoulder blade.

Piriformis – Part 5 of the grumbly muscle series…literally a pain in the arse!

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Piriformis – Part 5 of the grumbly muscle series…literally a pain in the arse!

What’s a piriformis and what does it do?

The piriformis is the more superficial of the deep external rotators of the hip.

  • It keeps the femur turned out when we stand.
  • During flexion (walking), it keeps the femur abducted.
  • Helps tilt the pelvis laterally.
  • Helps tilt the pelvis posteriorly.

Anatomy

It originates from the anterior of the sacrum (S2-S4) inserting into the superior aspect of the greater trochanter (the big knobbly bit on the outside) of the femur.

Why does it hurt?

The sciatic nerve runs VERY close to the piriformis muscle. In some rare cases, the sciatic nerve growth THROUGH the piriformis.

Pressure can be exerted on the sciatic nerve if the piriformis and the other external hip muscles are tight. This can cause pain that radiates down the legs – piriformis syndrome. This rather painful. More women have this than men, and it’s believed to be because women have wider hips – known as a quadriceps angle or Q-Angle.

What can we do about it?

Release – In the clinic, I often get my elbow into the gluteal fold while rotating the femur internally and externally… (it’s nicer than it sounds).

At home, I like to sit on a hockey ball while doing the below stretch.

Upper Traps – Part 4 of the grumbly muscle series…quite literally a pain in the neck!

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Upper Traps – Part 4 of the grumbly muscle series…quite literally a pain in the neck!

Anatomy

The trapezius muscle is divided up into upper middle and lower fibres, but today we’ll concentrate on the upper fibres because that’s where we experience the most pain…

The trapezius as a whole originates right up in the skull at the occipital protuberance, ligamentum nuchae and then attach to the spinous process (the sticky out bit of bone you can feel through the skin) of C7 (cervical spine – bottom of the neck) to T12 (thoracic spine, right at the bottom) ….see the picture.

The traps then insert into the clavicle, acromion, and spine of scapula (basically, the outside of the shoulders).

What do the upper traps do exactly?

Well, out of the three portions they do the bulk of the work.

  • Both sides working together will extend the neck (hold the head up).
  • One side working alone flexes the neck on the same side (ear to shoulder).
  • It will rotate the neck and head to the opposite side.
  • It elevates ↑ the scapula (shoulder blade).
  • And finally, it upwardly rotates the scapula.

Why do they hurt?

Acute and persistent neck pain can occur because of tight upper traps which can include an occipital headache (at the base of the skull) and very tender upper trapa – Trapezius myalgia…interestingly, women suffer more, possibly due to prolonged postures at work (which can decrease blood flow to the muscle), coupled with high mental loads. Poor posture (a forward head carriage) overloads the traps which also weakens them.

Weak rotator cuffs – The upper traps, as many other muscles do, can overcompensate for these weakened muscles.

Tension – We all carry tension and stress, most notably in our upper traps. When I treat people, I often feel trigger points (tight and tender areas of muscle which can refer pain elsewhere). Stress can also lead to areas of heightened sensitization in a muscle.  

What can we do about it?

Massage and stretching will ease muscular pain, but neither will cure it. Strengthening and altering your posture regularly are the best way to truly reduce pain. Movement is medicine! – Exercise reduces pain by creating local changes within the muscle.

How? – A shrug, particularly an overhead shrug with straight elbows (this stops levator scapula from working overtime) or a monkey shrug (dumbbell in hand, hands on hips so shoulders abducted to 30 degrees). Lateral raises (which also work the deltoids and rotator cuffs) in an abducted position.

Tensor Fascia Latae – Part 3 of the grumbly muscle series

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Tensor Fasciae Latae (TFL) part 3 of the grumbly muscle series…
 
TFL is an interesting and multifaceted muscle in my opinion.
 
Anatomy
TFL sits on the side of the hip bone (Iliac crest) just up from and behind the sticky out bits that you can feel at the front (ASIS). Along with fibres from Gluteus maximus, it then inserts into the IT (iliotibial) band which is a thick piece of fascia that runs down the outside of the thigh, interacts with the retinaculum (fascia) of the kneecap (Patella) and finally ends its journey inserting onto the head of fibula (the bone which sits on the outside of the tibia) and Gerdy’s tubercle on the tibia. It’s about 15cm long before it inserts into the IT band.
 
What does the TFL do?
• Medially rotates the hip joint.
• It assists in flexing the hip joint.
• And it (weakly) abducts the hip joint (takes the leg away from the body at the hip joint).
• With its ‘IT band’ hat on, it assists with lateral rotation of the femur.
• While we’re walking it tilts the hip on the side that’s weight bearing so the non-weight bearing foot can swing through without hitting the ground.
 
Why then does this muscle cause a lot of problems?
When the main hip stabiliser and hip abductor, gluteus medius, fatigues, TFL (possibly due to its proximity with gluteus medius?) takes over to stabilise the hip during single stance (while we walk and run) though it has enough jobs to begin with.
Because it’s often engaged a lot more than it’s intended to be, it becomes tight, and when it gets tight, it shortens and pulls the IT band…bearing in mind the IT band attaches to the fascia on the outside of the kneecap, it can pull the kneecap off its runner if circumstances allow. Think of a sliding wardrobe door, that isn’t sliding on its runner properly, causing patellofemoral (anterior knee) pain.
 
I recall quite well when I was marathon training and the pain from this muscle was outstanding. I also found that it is possible, and highly beneficial, to release this muscle off…😊
 
What can we do to reduce pain?
I advocate putting a tennis ball (or something harder) at hip height and leaning into it for 30 seconds. You’ll know when you’re on the right spot! If you’re strengthening gluteus medius you must do this beforehand otherwise, you’ll aggravate TFL further and won’t activate Gluteus medius.
 
 
 
 

Levator Scapula – Part 2 of the grumbly muscle series…

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Levator Scapula – Part 2 of the grumbly muscle series…

What does it do?

It does what it says on the tin…

  • It elevates the scapula (shoulder blade).
  • Downwardly rotates the scapula in the scapulothoracic joint.
  • Helps you side flex your head (ear to shoulder) AND allows you to rotate your head to the same side.

 

Anatomy

The muscles originate from the transverse processes if C2, C2, C3 & C4 (the upper part of the C-Spine). It then inserts onto the medial border of the scapula around the superior angle (the top inside bit).

Why does it hurt?

Bear in mind that the scapula is an extremely movable bone, held in place predominantly by muscles.

A forward head position (many of us have this) makes these muscles contract to try and counteract the action. If left unchecked, the muscles become tight or taught in order to jeep the neck extended, and this could lead to chronic headaches.  Think of it like standing on a surfboard on water and trying to pick to the sail with its rope…not easy is it?

What I also see during assessments, is that if there is a range of movement deficit in the shoulder (glenohumeral joint), the levator scapula will sometimes cheat and hike the shoulder upwards to achieve the range of motion, adding to its stress and discomfort.

How can we stop it hurting?

Well, working on posture and any pre-existing muscle neck or shoulder dysfunction is a start but that doesn’t provide immediate pain relief.

In the meantime, we can help ourselves: Soft tissue release that you can do yourself by using a tennis ball (on a rope is helpful) to pinpoint the site of pain, rotating your head to the opposite side, gently pulling your head forward with your opposite hand and dropping your chin forward towards the other knee– you’re putting the muscle on a stretch, hold for 10-20 seconds.

In the clinic I find good results when I use deep tissue massage and myofascial cups over the area and educating my clients as to what will make the muscle sore and how stretch it off when it aches.

 

 

Quadratus Lumborum (QL) Part 1 of the grumbly muscle series.

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Quadratus Lumborum (QL) Part 1 of the grumbly muscle series.

In my clinic, I see particular muscles that are often sore and painful on clients and I like to explain what the muscles are designed to do and why the muscle is causing pain…

Anatomy

The Quadratus Lumborum (QL) muscles run up from the posterior hip bone (ilium) or sometimes the iliolumbar ligament and insert onto transverse processes of L4 to L1 and the bottom 12th rib.

What do they do?

  • They help us flex to the side and when both sides work together, they help us to bend (extend) the lumbar spine backwards.
  • They are a deep abdominal and diaphragm stabiliser and assists with inhalation.
  • They also work with Gluteus medius (a hip muscle) to stabilise the hip while we’re walking and running.

Why then does this muscle cause a lot of pain?

As discussed above, it works with Gluteus medius to stabilise the hip, but if Gluteus medius fatigues too easily then the QL’s can be left taking the brunt of the load in terms of hip stabilising and become very tight and prone to spasming from decreased blood flow and adhesions in the fascia of the muscle. This tends to occur because we’re often seated too much. The car, our desks, sitting all evening on the sofa etc…

When clients come in complaining of lower back pain, one of the first test I do is to look at what happens to their hip when they stand on a single leg. If the hip hikes abruptly then I know that QL is overworking. Often, when I palpate the muscle, its painfully tender.

Good news!

It responds very well to soft tissue treatments and releases and it calms down well when hip stability is restored with targeted rehabilitation.

Shin splints (MTSS)

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Medial tibial stress syndrome (MTSS) is probably a more accurate description. 

How does it present?

It is categorised as diffuse pain along the posterior medial border of the tibia.  Warming up eases it slightly but mostly it presents after training and even the following morning.

What is it?

It is a stress injury to the bone. Particularly, traction on the medial boarder of the tibia from Soleus, Tibialis posterior, Flexor halucis longus and Flexor digitorum longus (deep posterior calf muscles) pulling on the periosteum (outer layer) of the bone due to different factors. It used to be argued that it was an inflammatory condition, but this has been largely moved away from in more recent years. 

If the pain is more focal, rather than localised, it may have led to a stress fracture, so its worth taking it seriously. 

What factors?

The foot has high arch (pes cavus) or low arch (pes planus) and excessive pronation of the ankle joint, both factors which affect shock absorption. The soleus muscle contracts to prevent pronation, couple that with repetitive impacts of running and you’ve got a lot of traction on the medial boarder where those muscles insert.

The muscles fail to provide adequate shock absorption due to fatiguing too easily. Yep, it’s a thing.

A change in running shoe, or indeed the wrong running shoe for your gait.

A change in surface.

Increasing your distance too quickly.

Being female…being female means certain injuries are more common, but I’ll get into that another time.

People carrying more weight – Higher body mass index.

Training errors.

Hip weakness and instability.

What can be done about it?

Ease off on the distance you are training and see if that helps – in an ideal world you should not increase your distance by more than 10% per week.

Swim or cycle temporarily – these are non-weight bearing activities that will maintain your CV fitness while you address your injury. 

Cross train – one mistake I made as a runner was, I ran, and nothing else. Cardio is great but I didn’t have the sufficient muscle strength to guard against this or any other injury. 

Avoid putting heat on the area – this will increase the local blood flow but also exacerbate the symptoms. Ice is a good pain killer.

Orthotics – once the underlying factor has been identified, orthotics may help, if its related to the foot, but caution should be used when introducing orthotics, and their use should be built up gradually. 

Identify the underlying factor in this injury. It could be poor foot and ankle mechanics causing this issue or it could be the hip complex impacting further down the kinetic chain. **Shameless plug** This is where your local sports therapist comes in handy. They can run a series of functional test and look at the gait mechanics of the foot to identify the underlying issue and then come up with a plan to address it and get you back to running strong.

 

Achilles Tendinopathy

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Formally known as Achilles tendinitis, ‘itis’ meaning inflammation, but in recent years we have realised that tendons aren’t get inflamed, they suffer overuse, and a decreased tolerance to exercise, so we now call it a tendinopathy.

Are there different types of Achilles tendinopathy?

You can experience mid tendon and insertional Achilles tendinopathy (see image). Tendinopathy has three stages, a continuum, if you will.  The stages are.

           Reactive Tendinopathy

                          ↓  ↑

           Tendon disrepair

                          ↓  ↑

           Tendon degeneration.

Because tendinopathy is a continuum, it is possible to improve a tendon with proper care.

What is it and how does it present?

Characterised by pain at the back of the heel particularly in the morning and generally the day after a run/exercise. You may be able to see a thickening of the tendon in comparison to the other Achilles. 

What can happen if left untreated?

An Achilles tendon rupture can occur when the tendon is in the degeneration phase. 

What factors?

  • Achilles tendinopathy is more common age 30+
  • Its more common in men
  • More common if you’re overweight
  • Have tight or weak calf muscles
  • If you have diabetes
  • Poor endurance of calf muscles
  • Poor stability of hips
  • Stiff joints in foot
  • Poorly supporting footwear
  • Increase mileage too fast

 

What can be done about it?

  • Ice (natural pain killer)
  • Painkillers i.e. paracetamol*
  • Reduce exercise load temporarily
  • Stretching calf muscles
  • Maintaining ankle joint mobility
  • Strengthening hip complex
  • Alfredson Eccentric exercises – specific tendon loading.
  • Consider maintain fitness by changing to cycling swimming or aqua jogging
  • Leave 48 hrs. in between runs

Plantar Fasciitis (Plantar Fasciopathy)

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Plantar fasciitis can be a very painful and debilitating condition of the foot, I have had it a few times now. It affects the plantar fascia, which is the fascia on the sole of the foot and pain is experienced where it attaches to the heel, particularly on the inside of the foot.

The term ‘itis’ suggests inflammation, but clinicians’ agree that it is a degeneration, rather than inflammation, of the fascia and therefore it’s a ‘fasciopathy’ most likely due to age-related collagen disrepair. Ultrasound investigations often find the fascia has thickened compared to the non-affected side.  

This condition is multifactorial in nature; therefore, its treatment can be as well.

 

Why is the plantar fascia important?                       

Not only is it a ‘dynamic shock absorber’ when our foot meets the ground when walking or running, it also acts as a spring when the big toe is extended (see picture) becoming a ridged lever making foot propulsion possible. This is called the ‘Windlass mechanism’ of the foot and if this mechanism is impaired, it can cause problems, especially to the plantar fascia.

 

Risk factors

  • Tight Achilles tendon and calves.
  • Reduced ankle mobility (dorsi-flexion) and excessive pronation at the sub-talar ankle joint.
  • Reduction in the extension of the big toe joint.
  • Runners, particularly those who run excessively, suddenly increase their distances, change their footwear or indeed use poorly cushioned footwear inappropriate for their running gait.
  • Jobs that involve a lot of standing, particularly on hard surfaces.
  • Being female – We girls have a greater ‘Quadriceps angle’ due to a naturally wider pelvis, this predisposes to greater forces running through the inside of the knee, which causes compensatory internal rotation from the tibia (shin bone), altering the force through the Achilles tendon and ultimately restricting ankle mobility.
  • Reduced strength of the hip abductors (weak Gluteus Medius).  
  • Being overweight.
  • High or low arches of the foot.
  • An age range of between 40 and 60 years.

 

Symptoms

  • Gradual onset of pain along the heel.
  • Soreness on rising in the morning, many people commonly experienced classic ‘first-step’ pain upon waking with relief after a bit of activity. This is because, during sleep, the Achilles tendon and plantar fascia tighten with the foot in a plantar-flexed position.
  • The pain is aggravated by daytime activity and will ache in the evening especially after an active day. 
  • Pain is eased by rest and rubbing of the foot arch.

 

Other conditions to rule out.

  • An acute tear of the plantar fascia.
  • Neural pathologies such as Tarsal Tunnel Syndrome, neuroma of the medial calcaneal nerve or lateral plantar nerve entrapment.
  • A bruise to the heel fat pad (this separates the heel bone from the plantar fascia).
  • A stress fracture of the calcaneus (heel bone).
  • Bone spurs on the heel.

 

How do we treat it? 

A thorough examination and assessment of the foot, ankle and hip (yes, the hip can play a part in foot problems!) will allow for identification of any weaknesses or biomechanical problems.

When I see clients with this condition, I would typically target the stiff calf muscles with deep tissue massage and subsequent passive stretching, address restricted ankle mobility (there are a few ways we can achieve this), I like to dry-cup the sole of the foot (I absolutely love this being done to my own feet) and I would lastly kinesio tape the foot and calf (see picture) to offload the muscles and provide some immediate pain relief while the bigger causative factors are identified and addressed.     

I always give my clients homework, which generally involves strengthening the weak muscles we have identified and to maintain mobility of the ankle which may be achieved by foam rolling the calves at home.