Patient Education: Hamstring Strains - Rehab Exercises That Work

Hamstring strain.jpeg

Hamstring strains affect not only elite athletes, but sometimes we see them in the weekend warrior population as well...

Sprinting, going for that loose ball...they even affect ballet dancers with excessive eccentric stretching.

So how can we best treat those with Hamstring Strains?  

With what's proven to work: eccentric strengthening along with a progressive agility and trunk strengthening program...

Here's a Patient Education article you can share that offers your patient's easy-to-understand info about their injury, plus a few exercise videos they can get started on...

continue reading...

Mentoring Minutes: Knee Osteoarthritis

Knee Joint Contact Mechanics during Downhill Gait and its Relationship with Varus/Valgus Motion and Muscle Strength in Patients with Knee Osteoarthritis

Shawn Farrokhi, PT, Ph.D., DPT,1 Carrie A. Voycheck, Ph.D.,2 Jonathan A. Gustafson, B.S.,3 G. Kelley Fitzgerald, PT, Ph.D.,4 and  Scott Tashman, Ph.D.5

- The objective of this exploratory study was to evaluate tibiofemoral joint contact point excursions and velocities during downhill gait and assess the relationship between tibiofemoral joint contact mechanics with frontal-plane knee joint motion and lower extremity muscle weakness in patients with knee osteoarthritis (OA).

- patients with knee OA demonstrated significantly increased frontal-plane varus motion excursions (p<0.01) and greater quadriceps and hip abductor muscle weakness

Clin Biomech (Bristol, Avon). 2011 Aug; 26(7): 741–748. 

Published online 2011 Apr 21. doi:  10.1016/j.clinbiomech.2011.03.006

Effects of Progressive Resistance Strength Training on Knee Biomechanics During Single Leg Step-up in Persons with Mild Knee Osteoarthritis

Kevin James McQuade, PhD and  Anamaria Siriani de Oliveira, PhD

- Subjects participated in an individually supervised training program 3 times a week for eight weeks consisting of progressive resistive exercises for knee extensors and knee flexors. Pre and post training outcome assessments included: 1. Net internal knee joint moments, 2. Electromyography of primary knee extensors and flexors, and 3. Self-report measures of knee pain and function. The distribution of lower extremity joint moments as a percent of the total support moment was also investigated.

- Pain, symptoms, activities of daily life, quality of life, stiffness, and function scores showed significant improvement following strength training. Knee internal valgus and hip internal rotation moments showed increasing but non-statistically significant changes post-training. There were no significant differences in muscle co-contraction activation of the Quadriceps and Hamstrings.

BMC Musculoskelet Disord. 2013; 14: 266. Published online 2013 Sep 12. doi:  10.1186/1471-2474-14-266

Efficacy of strength and aerobic exercise on patient-reported outcomes and structural changes in patients with knee osteoarthritis: study protocol for a randomized controlled trial

Britt Elin Øiestad,1 Nina Østerås,2 Richard Frobell,3 Margreth Grotle,4 Helga Brøgger,5 and May Arna Risberg1,6

- strength training: 2-3x aweek, 12 weeks; 3 sets of 8-10 reps, 30 -60 sec rest breaks; 5 min warm up on bike

- first 2 weeks, focused on neuromuscular exercise with low intensity

- Quadriceps and hamstrings, hip abductors and extensors, and calf muscles.

- load increased when able to do 2 more reps

-Aerobic: main aim of the aerobic exercise is to improve cartilage quality, in addition to the general health effects physical activity gives. Both overloading and underloading may cause cartilage degradation, but moderate loading has been shown to be beneficial for joint health because of mechanosensitive chondroprotective pathways. Based on the moderate loading benefits, ergometer cycling for 45 minutes 2–3 times a week, including 10 minutes warm up, 30 minutes on moderate loading (75% of max heart rate) and 5 minutes cool down will be required. For instance, a patient with a maximal heart rate of 160 and rest heart rate of 60 will be required to cycle at a heart rate of about 135 using the formula for heart rate reserve (160-rest heart rate of 60 × 0.75 + rest heart rate of 60).


J Orthop Res. 2013 Jul;31(7):1020-5. doi: 10.1002/jor.22340. Epub  2013 Mar 12.

Six-week gait retraining program reduces knee adduction moment, reduces pain, and improves function for individuals with medial compartment knee osteoarthritis.

Shull PB1, Silder AShultz RDragoo JLBesier TFDelp SLCutkosky MR.

- 6-week gait retraining program on the knee adduction moment (KAM) and knee pain and function. subjects with medial compartment knee osteoarthritis and self-reported knee pain –

- WOMAC scores and a 10-point visual-analog pain scale score were measured at baseline, post-training (end of 6 weeks), and 1 month after training ended.

- Gait retraining reduced the first peak KAM by 20% post-training as a result of a 7° decrease in foot progression angle (i.e., increased internal foot rotation), compared to baseline

- WOMAC pain and function scores were improved at post-training by 29% and 32%, pain scale scores improved by two . Changes in WOMAC pain and function were approximately 75% larger than the expected placebo effect. Changes in KAM, foot progression angle, WOMAC pain and function, and visual-analog pain score were retained 1 month after the end of the 6-week training.


J Biomech. 2013 Jan 4;46(1):122-8. doi: 10.1016/j.jbiomech.2012.10.019. Epub 2012 Nov 10.

Toe-in gait reduces the first peak knee adduction moment in patients with medial compartment knee osteoarthritis.

Shull PB1, Shultz RSilder ADragoo JLBesier TFCutkosky MRDelp SL.

- The first peak of the knee adduction moment has been linked to the presence, severity, and progression of medial compartment kneeosteoarthritis. The objective of this study was to evaluate toe-in gait (decreased foot progression angle from baseline through internal foot rotation) as a means to reduce the first peak of the knee adduction moment in subjects with medial compartment knee osteoarthritis. Additionally, we examined whether the first peak in the knee adduction moment would cause a concomitant increase in the peak external knee flexion moment, which can eliminate reductions in the medial compartment force that result from lowering the knee adduction moment. We tested the following hypotheses: (a) toe-in gait reduces the first peak of the knee adduction moment, and (b) toe-in gait does not increase the peak external knee flexion moment. Twelve patients with medial compartment knee osteoarthritis first performed baseline walking trials and then toe-in gait trials at their self-selected speed on an instrumented treadmill in a motion capture laboratory. Subjects altered their foot progression angle from baseline to toe-in gait by an average of 5° (p<0.01), which reduced the first peak of the knee adduction moment by an average of 13% (p<0.01). Toe-in gait did not increase the peak external knee flexion moment (p=0.85). The reduced knee adduction moment was accompanied by a medially-shifted knee joint center and a laterally-shifted center of pressure during early stance. These results suggest that toe-in gait may be a promising non-surgical treatment for patients with medial compartment knee osteoarthritis.

J Orthop Sports Phys Ther. 2010 Jun;40(6):A1-A35. doi: 10.2519/jospt.2010.0304.

Knee pain and mobility impairments: meniscal and articular cartilage lesions.

Logerstedt DSSnyder-Mackler LRitter RCAxe MJOrthopedic Section of the American Physical Therapy Association.

J Man Manip Ther. 2010 Mar;18(1):29-36. doi: 10.1179/106698110X12595770849560.

The effect of tibio-femoral traction mobilization on passive knee flexion motion impairment and pain: a case series.

Maher S1, Creighton DKondratek MKrauss JQu X.

- The purpose of this case series was to explore the effects of tibio-femoral (TF) manual traction on pain and passive range of motion (PROM) in individuals with unilateral motion impairment and pain in knee flexion. Thirteen participants volunteered for the study. All participants received 6 minutes of TF traction mobilization applied at end-range passive knee flexion. PROM measurements were taken before the intervention and after 2, 4, and 6 minutes of TF joint traction. Pain was measured using a visual analog scale with the TF jointat rest, at end-range passive knee flexion, during the application of joint traction, and immediately post-treatment. There were significant differences in PROM after 2 and 4 minutes of traction, with no significance noted after 4 minutes. A significant change in knee flexion of 25.9°, which exceeded the MDC(95,) was found when comparing PROM measurements pre- to final intervention. While pain did not change significantly over time, pain levels did change significantly during each treatment session. Pain significantly increased when the participant's knee was passively flexed to end range; it was reduced, although not significantly, during traction mobilization; and it significantly decreased following traction. This case series supports TF joint traction as a means of stretching shortened articular and periarticular tissues without increasing reported levels of pain during or after treatment. In addition, this is the first study documenting the temporal aspects of treatment effectiveness in motion restoration.


Product Updates: The Gait app now includes Case Studies

One of the best ways to bridge the gap from the text book to the clinic is to work through case studies!  Instructors and students have been asking for ways to put their analysis skills to the test.

As a professor, I believe these types of exercises are critical for developing your reasoning and your analytical skills, which is why we built "Case studies" into the Gait app as a new way to elevate your thinking.

This is a glimpse into what we will be releasing for the other apps like Clinical Pattern Recognition: Orthopaedics and Cardiopulmonary Rehabilitation!

So.... Put your thinking caps on and enjoy the new "Case studies" feature that is now available in the Gait app!

case studies
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Challenge your reasoning and analytical skills! Get the first-hand experience of PhysioU, sign up for a 2-week free trial today!

Hamstring Strains: What to Expect and How to Get Back Out There


Did you know that hamstring strains are a common lower extremity injury that occur at all level of sports?  

However, the top sports prone to this injury are track and field, football, and rugby. Curious as to why these sports specifically? Well all 3 of them require high sprinting demands. Hamstring injuries tends to happen during the terminal swing phase of running gait, here the hamstring is not only under large stress but it is also at its most stretched position. So a combination of loading and stretching all at once sometimes leads to muscle tearing.  

Do your patients know that PT can aide in recovery and return to sport?

In this week's article, we will go over hamstring injury grades, risk factors, and how to go about the process of helping your patients heal from this injury and work towards getting back to sport! 


Continue Reading ...

Mentoring Minutes: Meniscal Tears of the Knee


EFORT Open Rev. 2017 May 11;2(5):195-203. doi: 10.1302/2058-5241.2.160056. eCollection 2017 May. The knee meniscus: management of traumatic tears and degenerative lesions.
Beaufils P1, Becker R2, Kopf S3, Matthieu O4, Pujol N1.

- Robust scientific publications indicate the value of meniscal repair or non-removal in traumatic tears and non-operative treatment rather than meniscectomy in degenerative meniscal lesions

- In traumatic tears, the first-line choice is repair or non-removal. Longitudinal vertical tears are a proper indication for repair, especially in the red-white or red-red zones. Success rate is high and cartilage preservation has been proven.

- Degenerative meniscal lesions are very common findings which can be considered as an early stage of osteoarthritis in middle-aged patients. Recent randomized studies found that arthroscopic partial meniscectomy (APM) has no superiority over non-operative treatment.

- So non-operative treatment should be first line of choice, 3 months is considered acceptable threshold (meniscus consensus project).

Arthroscopy. 2016 Sep;32(9):1855-1865.e4. doi: 10.1016/j.arthro.2016.05.036. Epub 2016 Jul 27. Arthroscopic Partial Meniscectomy or Conservative Treatment for Nonobstructive Meniscal Tears: A Systematic Review and Meta-analysis of Randomized Controlled Trials.
van de Graaf VA1, Wolterbeek N2, Mutsaerts EL3, Scholtes VA3, Saris DB4, de Gast A5, Poolman RW3.

- To conduct a meta-analysis of randomized controlled trials comparing the outcome of arthroscopic partial meniscectomy (APM) with conservative treatment in adults with nonobstructive meniscal tears and to recommend a treatment of choice.

- We included 6 randomized controlled trials, with a total of 773 patients, of whom 378 were randomized to APM and 395 were randomized to the control treatment. After pooling the data of 5 studies, we found small significant differences in favor of the APM group for physical function at 2 to 3 months and at 6 months  We found no significant differences after 12 and 24 months.

Knee Surg Sports Traumatol Arthrosc. 2017 Feb;25(2):335-346. doi: 10.1007/s00167-016-4407-4. Epub 2017 Feb 16. Surgical management of degenerative meniscus lesions: the 2016 ESSKA meniscus consensus.
Beaufils P1, Becker R2, Kopf S3, Englund M4, Verdonk R5, Ollivier M1, Seil R6,7.

- A degenerative meniscus lesion is a slowly developing process typically involving a horizontal cleavage in a middle-aged or older person. When the knee is symptomatic, arthroscopic partial meniscectomy has been practiced for a long time with many case series reporting improved patient outcomes. Since 2002, several randomized clinical trials demonstrated no additional benefit of arthroscopic partial meniscectomy compared to non-operative treatment, sham surgery or sham arthroscopic partial meniscectomy.

- used patients > 35 without acute significant trauma… 84 surgeons,22 countries.

- main finding was that arthroscopic partial meniscectomy should not be proposed as a first line of treatment for degenerative meniscus lesions. Arthroscopic partial meniscectomy should only be considered after a proper standardized clinical and radiological evaluation and when the response to non-operative management has not been satisfactory. Magnetic resonance imaging of the knee is typically not indicated in the first-line work-up, but knee radiography should be used as an imaging tool to support a diagnosis of osteoarthritis or to detect certain rare pathologies, such as tumors or fractures of the knee.

BMJ. 2016 Jul 20;354:i3740. doi: 10.1136/bmj.i3740. Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up.
Kise NJ1, Risberg MA2, Stensrud S3, Ranstam J4, Engebretsen L5, Roos EM6.

- No clinically relevant difference was found between the two groups in change in KOOS4 at two years (0.9 points, 95% confidence interval -4.3 to 6.1; P=0.72). At three months, muscle strength had improved in the exercise group (P≤0.004). No serious adverse events occurred in either group during the two year follow-up. 19% of the participants allocated to exercise therapy crossed over to surgery during the two year follow-up, with no additional benefit.

Open Orthop J. 2016 Dec 30;10:797-804. doi: 10.2174/1874325001610010797. eCollection 2016. The Role of Arthroscopic Partial Meniscectomy in the Management of Degenerative MeniscusTears: A Review of the Recent Literature.
Azam M1, Shenoy R2.

- majority of randomized control trials suggest that arthroscopic partial meniscectomy is not superior to conservative measures such as exercise programs. Furthermore, one randomized control trial found that arthroscopic partial meniscectomy was not even superior to sham surgery.

Int Orthop. 2015 Apr;39(4):769-75. doi: 10.1007/s00264-014-2539-z. Epub 2014 Oct 10. Arthroscopic partial meniscectomy is superior to physical rehabilitation in the management of symptomatic unstable meniscal tears.
El Ghazaly SA1, Rahman AAYusry AHFathalla MM.

- Stable peripheral tears may heal, while degenerative tears do well with physical therapy. However, the exact role of physical therapy in treating symptomatic unstable meniscal tears is not known

- Seventy patients with unstable meniscal tear met the inclusion criteria. Clinical examination, McMurray test and magnetic resonance imaging were done. Age ranged from 18-67 years (average 39.87). Mild osteoarthritis was seen in 20 cases. Physical therapy thrice a week for eight weeks was offered (quadriceps stimulation and neuromuscular strengthening exercises). After physical therapy, patients still complaining or unsatisfied were offered arthroscopic partial menisectomy (APM). Outcomes were evaluated using the VAS pain score and the Lysholm knee score.

- Mean VAS before interventions was 7.4, significantly improved to 5.16 after rehabilitation and to 1.9 after APM (p = 0.001). Mean Lysholm score before rehabilitation was 65.1 and improved to 69.6 after rehabilitation, the difference was non-significant. However, Lysholm score difference before and after APM showed a highly significant difference

- Pain and swelling improved after physical therapy. However, patients were not satisfied as limited range of knee motion persisted. APM was superior to physical therapy in treating symptomatic unstable meniscal tears, with high patient satisfaction and restored knee function.

Hudson R1, Richmond A1, Sanchez B1, Stevenson V1, Baker RT1, May J1, Nasypany A1, Reordan D2.

- purpose of this case series was to examine the effect of the Mulligan Concept (MC) "Squeeze" technique in physically active participants who presented with clinical symptoms of meniscal tears

- The MC "Squeeze" technique was applied in five cases of clinically diagnosed meniscal tears in a physically active population. The Numeric Pain Rating Scale (NRS), the Patient Specific Functional Scale (PSFS), the Disability in the Physically Active (DPA) Scale, and the Knee injury and Osteoarthritis Outcomes Score (KOOS) were administered to assess participant pain level and function.

- Signifcant improvements on pain, functional and disability scale.

- The MC "Squeeze" technique produced statistically and clinically significant changes across all outcome measures in all five participants.

J Orthop Sports Phys Ther. 2015 Jan;45(1):18-24, B1. doi: 10.2519/jospt.2015.5215. Validity of the Thessaly test in evaluating meniscal tears compared with arthroscopy: a diagnostic accuracy study.
Goossens P1, Keijsers Evan Geenen RJZijta Avan den Broek MVerhagen APScholten-Peeters GG.

- To evaluate the diagnostic accuracy of the Thessaly test compared with an arthroscopic examination in patients with suspected meniscal tears.

- The Thessaly test alone and the combination of the Thessaly and McMurray tests were considered as index tests, and arthroscopy was used as the reference test. - -

- Experienced physical therapists performed the Thessaly test at 20° of flexion and the McMurray test for both knees. The physical therapist was blinded to patient information, the affected knee, and the results from possible earlier diagnostic imaging. An orthopaedic surgeon blinded to the clinical test results from the physical therapist performed the arthroscopic examination.

- A total of 593 patients were included, of whom 493 (83%) had a meniscal tear, as determined by the arthroscopic examination.

- The Thessaly test had a sensitivity of 64% specificity of 53%, positive predictive value of 87%, negative predictive value of 23%, and positive and negative likelihood ratios of 1.37, and 0.68

- The combination of positive Thessaly and McMurray tests showed a sensitivity of 53% and specificity of 62%.

- The results of the Thessaly test alone or combined with the McMurray test do not seem useful to determine the presence or absence of meniscal tears.

Health Technol Assess. 2015 Aug;19(62):1-62. doi: 10.3310/hta19620. Diagnostic accuracy of the Thessaly test, standardised clinical history and other clinical examination tests (Apley's, McMurray's and joint line tenderness) for meniscal tears in comparison with magnetic resonance imaging diagnosis.
Blyth M1, Anthony I1, Francq B2, Brooksbank K1, Downie P3, Powell A1, Jones B1, MacLean A1, McConnachie A2, Norrie J4.

- To determine the diagnostic accuracy of the Thessaly test and to determine if the Thessaly test (alone or in combination with other physical tests) can obviate the need for further investigation by MRI or arthroscopy for patients with a suspected meniscal tear.

- Two cohorts of patients were recruited: patients with knee pathology (n = 292) and a control cohort with no knee pathology (n = 75).

- Participants were assessed by both a primary care clinician and a musculoskeletal clinician. Both clinicians performed the Thessaly test, McMurray's test, Apley's test, joint line tenderness test and took a standardised clinical history from the patient.

- The Thessaly test had a sensitivity of 0.66, a specificity of 0.39 and a diagnostic accuracy of 54% when utilised by primary care clinicians. This compared with a sensitivity of 0.62, a specificity of 0.55 and diagnostic accuracy of 59% when used by musculoskeletal clinicians. The diagnostics accuracy of the other tests when used by primary care clinicians was 54% for McMurray's test, 53% for Apley's test, 54% for the joint line tenderness test and 55% for clinical history. For primary care clinicians, age and past history of osteoarthritis were both significant predictors of MRI diagnosis of meniscal tears. For musculoskeletal clinicians age and a positive diagnosis of meniscal tears on clinical history taking were significant predictors of MRI diagnosis. No physical tests were significant predictors of MRI diagnosis in our multivariate models. The specificity of MRI diagnosis was tested in subgroup of patients who went on to have a knee arthroscopy and was found to be low 0.53 (95% confidence interval 0.28 to 0.77)], although the sensitivity was 1.0.