[Physio Discussed] Making sense of hamstring injuries with Adam Johnson and Scott Hulm

What differential diagnoses should always be on your radar in the context of hamstring strains? And which subjective and objective signs really matter? And which ones don't? And how should hamstring strains be classified to guide rehab and return to play decisions? Today on Physio Disgust we're unpacking hamstring injuries with two world-class clinicians working at the very top of professional sport and applied research. Scott Holm is a highly skilled sports physiotherapist with a strong interest in injury prevention, rehab and athletic performance. He has completed a master of high performance sport and is currently undertaking PhD research focused on hamstring strain injuries and high speed running biomechanics. Scott is a senior AFL rehabilitation physiotherapist at the Western Bulldogs, where he plays a pivotal role in optimizing athlete recovery and return to performance. Adam Johnson is a physiotherapist currently working full-time at the Everton Football Club in England. He has over 14 years of full-time experience in professional football, including roles at Brighton and Hove Albion and Stoke City. Adam has been heavily involved in short to medium-term rehabilitation of muscle and ligament injuries and has published multiple peer-reviewed research articles. You're going to absolutely love today's episode. It's filled with plenty of clinical jams. I'm Sarah Yule and this is Physiodeskust. Well welcome Adam and welcome Scott to the podcast today. Thank you very much. Thank you very much. It's great to have you both talking all things hamstring injury and hamstring strains. So I think it's right that we start at the very beginning and just going to clinical practice. So I'm curious in your clinical practice, how do you both go about diagnosing a hamstring injury or a hamstring strain? Perhaps Adam will start with you. Obviously within the elite's sports setting, there's generally quite a lot of pressure to make that diagnosis quite early. We would be lucky enough that we would see a lot of the mechanisms and be able to go and refer back to them. We would generally get that kind of early picture of a mechanism of injury, whether it's an acceleration, a maximal sprint, has any curve. Anything involved, those sort of things, again, generally be able to get the video footage so be able to review it. And then on the bed, really, it's about getting those early signs. Is there any loss of range, any loss of strength? And then again, I think you look at the literature and a lot of it would suggest it's probably quite relatively easy to pick up. If someone's got a hamstring strain where the difficulty comes is trying to figure out how big and significant that injury is and exactly what structures are involved. So I think again, with the pressures that are involved, we would generally look to utilize MRI imaging relatively quickly within our practice to support what we're seeing in our objective findings and give confidence in that diagnosis and then be able to give a prognosis off that. So a lot of our decisions will be, as I said, relatively acute. We'll see that person quite early on when they're still probably quite symptomatic and then lead them down that path of utilizing the correct imaging processes. Just in terms of obviously mechanism of injury is very relevant and you've got the luxury of video playback. How much wider you putting on mechanism of injury and immediate symptoms versus what you might find objectively? Yeah, I think again, if we were always going to have warning signs, if we say it's a game and someone's gone from a maximum sprint and they go down and they're unable to continue, it's going to be one of our kind of key signs that would lead us there. Again, where it becomes maybe challenging is those cases who present you in the treatment room with those kind of low level symptoms that have maybe progressed over a couple of days. And again, I think there's some recent stuff come out from the guys at British Athletics to suggest that they're the real warning signs. And are they structural injuries? Are they recurrent? Are they structural injuries? And what can we do about that? So I think again, reading that paper in the last couple of weeks has really resonated with me in terms of just because someone's functional and maybe assesses well and objectivity looks okay, really listening to that subjective that they're giving you to understand and pick up that clinical picture as early as possible to try and see what might contribute further down the line. So trying to take everything in subjectively as well as objectively to give you that picture and really flag up those lower level injuries if you can before they progress to anything more significant. Yeah, great. So you're getting the whole picture and Scott, what are your thoughts? Adam summed up pretty well. I think definitely in our late sporting world it is fortunate to have the video footage. And I think someone's linking that in turnally in terms of location of injury seems to be a really crucial piece of the puzzle. I think now we're starting to have a better understanding of probably the structural locations and some of these tricky sites. So definitely sort of add to the clinical assessment is those palpatory locations, particularly for instance, if I'm seeing a particularly high grade sprinting mechanism with sort of internal tubular rotation. And we're seeing that distal side as the side of injury and palpatory soreness out already got a pretty high degree of concern for sort of that distal upon your osus and these T junction type injuries and alternatively those high, so long lengthy centric sort of actions, maybe with a level of hip abduction, the high grade proximal semi-mem sort of a bolshin injury. So like just trying to place those mechanistic elements with some of the clinical features particularly in terms of location. I think is something that certainly jumps out at me, which then certainly helps guide our imaging process from there to exactly identify sort of the level of injury from a severity point of view, the tissue involved in terms of are we looking at a free tendon type injury either from an abulsion or a rupture point of view or we're starting to look at some of these aponniotic injuries intramuscular or these distal upon your osus involving the T junction. So just trying to place those together, but I think Adam's point around sort of these acute on chronic type injuries we don't tend to often categorize them in that manner, but certainly in our fields, I think where the training demands can be so high and match congestion at times depending certainly on the sporting pursuit, trying to navigate where our athletes may be starting to show signs of I guess overload or fatigue or at a subbacelial level of failure and then as a result, a chemoey look to identify those low grade type injuries and there's a great scope of these that diagnosing is obviously our primary sort of rowing these acute instances, but yeah, can we strategise our way to prevent some of the more high severe, the high grade, so you know, particularly severe type injuries. I was going to dive into that classification component a little later on, but how do you go about classifying those handstring strains in your practice and what are your thoughts in terms of as clinicians, how specific do you think we should get prior to sending for MRIs imaging? I've probably biased in this space with my interest in around the aponniotic sort of involvement in sort of my practice, obviously similar Adam, where you we utilize MRI pretty readily and as a result that sort of certainly helps to guide us along the bay make so the British Athletics classification system and certainly that helps to start to build out what sort of tissue type, we're certainly the level of the lesion is occurring in as I was sort of alluding to, I think our understanding around probably exploring that in a little bit more detail is probably necessary now in sort of our practice we tend to use a little bit more dynamic ultrasound approach, particularly maybe at that distal aponniotic site, MRI tends to undersell maybe the severity of those injuries and we've certainly had instances where MRI would suggest a lower level injury where we were concerned about the, so the level of that severity based on some of the findings from their MRI, we went to the dynamic ultrasound, we went to a surgical approach and alpha scopically what was sort of, from a surgical perspective that the severity was certainly more extensive, so we know that there's still limitations to some of these things to try to build out the whole picture, but I tend to blend a, a, a bay make approach with certainly some of the, the work that's done, certainly from bus aloner and Carl's portray and, and certainly his work through the use of sort of alternative imaging approaches to try and classify to the level and type of maybe tenderness or aponniotic injury. Just to agree with that as well, the similar, similar thing and we would utilize over the years has been much more understanding of of what that means, not just within the kind of medical space, but our players would be very conscious and aware of what those gradings are, that they kind of have an understanding of that, which is a positive and a negative, it helps with explaining that'll be the first question they ask when the report comes back, well what grade is it, is it a C because they know that that means significantly longer rehab time and anything, it might not hear those kind of three, four C's and they understand and the implications of that around time loss. Then the negative is that's a really big band to just put people in. Not all three Cs are gonna be the same. Scott's kind of touched on the location of it has a massive implication. And also again, around some of Scott's work, even just the direction of the tears, it longitude and all transverse, there's so many different bits that are going into it that I think we're trying to understand more on. Again, within this elite sport setting, you're always trying to minimise time loss and trim as much time as you can, but with that comes knowing the ones that you also aren't push and you have to respect and respect that those tissue healing times. So I think that's definitely useful and I think we would look to utilize dynamic ultrasound. I think the issues are that it's a lot more user dependent in kind of open to misinterpretation or missing things, whereas that MRI is a little bit more consistent now that the BAMIC classification's being used so consistently for so long, we have a little bit more confidence in that I think it's kind of stuff and plays in a group, we understand what that means. So it'd be very similar to what Scott said just to build on those points a little bit. Yeah, I just want to jump in. I just think Adam's point there and the player involvement and even educating other staff around that as soon as the tendon or the epondrosis involved, everyone is completely aware within the four wars of the organisation to try and educate on, yeah, not all tendon assinuries are the same and not all are going to have to miss the extensive times. And the bias at that obviously, the we have to navigate as clinicians, I think is certainly something to be cognizant of and no doubt we'll talk to some of the clinical and features and criterion based approaches where it is a real blending of these skill set and knowledge base because just to suggest that we have this level of injury particularly maybe like a tendon or sight indicates this level of time miss is probably underselling sort of the interpretation around trying to pull a multitude of clinical as we've alluded to, subjective features there and all that imaging data altogether at least put a brain work around when we're returning to staff to apply. And no doubt this is probably a larger question here but Adam you also spoke before about the decision process of who you might push versus who you might take a more conservative approach and Scott, as you've mentioned, not all tendon injuries are created equal. What's your decision process in terms of who you do push and who you don't and then how do you navigate that conversation with the players or with the patients? It's a real challenge and had some recent conversations around these not just with hamstrings but it might be ankles or whatever and it's about understanding the player and their demands and I think if your conversation around a 35-year-old centre back in football who has been around the game understands their demands, understands how to manage themselves and won't be exposed to huge volumes of high-speed running will very rarely hit sprint distance, maybe in a tactical setup that you're in versus your 19-year-old star striker who is going to be achieving repeated maximum velocity outputs, high sprint distance and that utilising that as their game. Those decisions have to look very different and what your level of acceptance of risk is has to be very different and again all those things like timings in the season, what are you looking at if this is someone who is in pre-season and has the whole season ahead of them, the chances are you're going to be a little bit more cautious around that to try and minimise the risk of re-injury and have them fully fit throughout the whole season versus someone who again is looking end of season, cut final, etc. All those scenarios that we talk about are the things that come into play. That's where some of the subjective comes in around players, appetite or grief, as such, or appetite for being aggressive around again previous experiences, this will look very different for someone who has had two, three hamstring injuries in the last 18 months versus someone that is again off way through their career 26-27, never had this before and again you think you okay that this might be due to external factors and if we can manage those a little bit better we can manage them through versus someone who has got a chronic injury history and you're not going to need time to really address that and make those changes and get them in the best place to minimise re-injury risk. So I think that's a lot of the conversations that we would be having with the management, with the player, with us as a medical department is okay what's contributed to this and what do we think is a successful outcome for this player and again, as Scott's not as touched on not just looking at it as this is a 3C or a 2B it'll be six weeks or 12 weeks, it's okay who's the player in front of us? What's led them to this and again have they had neural symptoms and the lead up to it has the been factors that we need to work on has the been issues with submersal soreness before or is this just a one-off incident that we understand why we think that's come about? Adams was brilliant in terms of the athlete in front of you and obviously the injury history and the demands of the game and the demands of that particular player is absolutely first and foremost how do we look to get this athlete back to those peak demands and obviously that looks a little different for everyone but I certainly I do still come back to just some of the pieces around okay what type of legion are we dealing with I still think that plays a role here and there's certainly aspects of tissue healing and a respective elements in terms of the type of lesion that would influence when I would might push and pull and that certainly that would look very different for very different types of lesions and again locations may play a role with that and then that's then starting to drive what are some of the other features that this athlete's shown me before in terms of that might be muscle architecture some of their clinical strength outputs where have they been particularly poor where are they strong what else have we been able to explore with them we might even have a little bit more about from a morphology point of view what they look like does that play into some of their risk profile but just to add to get Adams overall pointers it's all about building this risk profile and then providing key stakeholders this is sort of the cumulative effect of all these pieces and this is what we are proposing and then as a result like particularly as a medical and high performance team we make decisions based on that and go to work in the rehab space once an easy way to improve your assessment and treatment skills introducing practicals where you can watch video recordings showing exactly how top experts assess and treat a range of conditions it's the fastest way to develop your practical skills and enhance your clinical reasoning treat to your patients likely experts do with practicals by physio network click the link in the show notes to try it for free today I think you've both summarised that marvelously and it sounds like as it never usually is yes or no and a straightforward answer but drives home the importance of understanding that full patient profile and making a patient-led decision based on the evidence that you have in front of you let's zoom in a little bit more on what you're actually seeing and hearing in the room and at some point Scott I'd love to hear your thoughts on how you actually explain the physiology in terms of those tendon injuries versus the muscle injuries because as we know the the education that we give to the patient can often reinforce the adherence to the treatment as well well actually I might ask that question now to be honest there's nothing better than a great so I Graham and visual representation for athletes so generally that's where I tend to lead a lot of those questions in terms of we'll often utilize the MRI and then I'll tend to illustrate that in terms of a more sort of muscle tendon schematic and trying to explain to our fleet where the lesion or injury is then provide some context around you know for instance if it is that t-junction side I'll illustrate why we suspect particularly if we're seeing a splitting type lesion where we see an extension of kind of the t-junction like protrusion along the epimacial border that might be something that we would suggest is a little bit more concerning and therefore explain why we might take a little bit longer in the early stages before for instance these athletes know a lot about their training to me as why I might take them into sort of some longer length either testing or training positions early why I might protect some of that m2-ulink kind of again just using that visual representation and kind of connecting that with things that they know around a set exercise or testing procedures that we would often do and as a result the athlete is completely aware of so yeah connecting those types of things really as simply as possible yeah fantastic thank you do you have anything to add there Adam again just building on that I totally agree I think they were imagery around it works really nicely so again just those kind of different examples around if someone's got a big intramuscular tendon injury and there's some loss of tension in that tendon. and just that ability to explain and demonstrate that to the patient, the player to show, okay, let's compare this side to the injured side and we can see that loss of tension, that waviness and that understanding that, okay, that tendon isn't going to be able to provide the scaffolding and the elasticity that you need it to provide and this is what we're trying to work towards and utilizing those re-imaging areas throughout the process to show how that's progressing and continue to try and gain that ongoing buy into the rehabilitation to be able to show, okay, this is this is where it started, this is what you had originally, this is how we're progressing through and this is how you're adapting to to the work and the loading that we're giving you in hopefully a positive way, again to give confidence that, okay, I've seen that before and I can see how that's progressing and I can see how that's going to allow me to function again within my return to sport and again as you go into those criteria-based approach through to ISP running sprint distance, max-lustic exposures, trying to provide them the confidence from the real obvious imagery and understanding of what they've involved to guide them through that process so I definitely think imagery is a really good way, obviously one of the skills is to try and be able to explain it to everybody, you have to be able to explain the same injury to the medical team, to the manager, to the player, to the agent, all those different stakeholders within the process but images and diagrams help with that to kind of level the pain field to everyone's seeing and understanding, hopefully the same information. Yeah, absolutely, understanding the how and the why and then set the expectations. I'm curious before we move on to the next question, do either of you have any regular analogies that you use or usual descriptions you roll off? My athletes would just say that I always bring out my three-dimensional computational models, I think I have these sort of fancy biceps fam and long hair and short hair, I'm showing them and I'm sure they're more sick of seeing them than anything but that's generally more than a good analogy but yeah I'm just a elected champion and give them a bit of a demonstration. Yeah, great, what about you, Adam? I think a lot of mine will be around like the, what are the demands of it? So again, like really driving home, what that tender is going to have to do for example, is it nice and elastic? Is it compliant with what we need it to do, trying to break down? So using those kind of keywords rather than nothing else and then leading that through into the rehab exercises and going, okay, we're doing this because we want to change the elasticity of this structure or because we want to provide load to this certain area and just trying to keep using keywords so they see the point of everything that they're doing and not going to maybe in depth with everything the exercise but today is a day focused around this or this morning we're going to really focus around ex kind of keyword and try to utilize that and give themes to everything that we're doing so it'd be more those kind of rehab based themes throughout the process that hopefully they they would see and not get bored with but I kind of understand constantly what we're trying to achieve and see they can continue to see and progression throughout the process. Adam, the elastic band model I think is like a such a nice one for athletes to grasp from a tender's point is it often news that in terms of snipping the therapy and into ways to demonstrate like how the lesion might be presenting again the longer tune all kind of split along the intramuscular tenders such a nice example of why if you keep loading that structure it's just going to keep peeling apart so hence why again when you lay that onto the rehab themes of why you're doing XYZ I think yeah that's such a such a nice way of I think for athletes to really grasp that and my argument is that they're probably largely these are all connective tissue lesions I think the idea of that low this isolated muscle injury is probably a little of an outdated model you effectively are you are going to fail at some point of sort of that connected continuum so explaining to athletes that elastic band theory is is probably preferable yeah in terms of trying to explain too much more outside of that. That's great it's the ultimate challenge for us as clinicians isn't it it's making the how do we make the complex simple without losing the integrity of what we actually need to say and I know that often that comes with both of you probably explaining the same thing in a thousand different ways and having a feel of what lands and what doesn't land and so refining it over time so it's out never ending journey so let's dive in a little bit more going to the subjective side you've already mentioned mechanism of injury. What other things might you listen to in the patient's story that will influence what you then go on to measure objectively or what might influence your prognosis I know that's a large question but Adam might go to you first. Yeah so I think one of the one of the key things again within the literature and it's a really difficult one is that kind of link between maybe some low back pain or neural sort of symptoms and I think again where the research not is lacking but where it's very difficult to research this sort of area is to expectively understand that is difficult to kind of get a big sporting cohort where as an air assessing slump test every day or at least weekly to try and understand what is that a risk factor because we know that it's something that's there host injury we see it whether that's whether bleeding or scarring host injury around the nerve has that led to it before is there something further up that chain or along that chain orally that's contributed to it so that's definitely something that I would always be asking in trying to understand from a subjective point of view have you felt anything in the lead up to this because we're likely to see as I say positive slumps or straight leg raises with hip internal rotation afterwards we're likely to see some of those neural signs after is that a symptom of the injury that they've sustained or is that a predisposing factor that we need to consider within our rehabilitation and and try to redress that again in those patients we might see with recurrent injuries this is definitely something that I'm looking to consider and what can we do to try and probably dampen down that and a neural sensitivity that's were maybe seen as part of the rehab process against that that's a really key subjective questioning line that I would always go down because I think you don't want to just assume that that's come about because of the injury and then you're addressing all the other structural things respecting all the the kind of healing processes and the timelines that come with that but actually the the main thing that was there right to it you haven't addressed and then you're always heightening that risk of a re-injury further down the line so yeah for me that that kind of neural component or how that to that's referred or low back pain and what's going on at a disc level within the lumbar spine what kind of structural components are there that might increase the risk of re-injury or reduce the risk of a successful rehabilitation process so yeah definitely that for me yeah for me it's a nice thing to have some of Matt Wallens great work sort of in an injury prevention spice which is really around touch points and respecting this idea of niggles the thing is with elite sporters they've all got niggles so this idea of having these constant dialogue with your athletes and touch points and that might look like you know wellness or monitoring in different organisations that might be how our conversations align after training after games after the whole range of different aspects I guess of the sort of a weekly business but yeah how do all these touch points feeding to to the how the athlete is responding to said training load and game loads that's a really big piece and because as out of alluded to within the literature it's a really challenging space but then that sort of feeds out into the kind of the sequelae so is there a lumbar component is there complaints around anterior hip tightness abdominal glor is there a groin history how that affecting some of their swing phase mechanics is there a recent ankle niggle that's feeding up the chain from a stance base aspect of the mechanics and part of some of their extensor kind of mechanism so it's trying to like put all these pieces together and feed in obviously we're leading all the theories here to hamstring based injuries but that sort of obviously that has a fallout effect in lots of different spaces but as Adam also alluded to is like those with a past history those things flashing the back of your mind when these things pop up from a monitoring conversation a sort of touch point point of view obviously yeah some athletes are more resilient and others that have had that sort of past history may be more susceptible so really listening out but then looking to explore from a secondary kind of injury prevention perspective and then it look when necessary intervening and modifying so that's kind of I would suggest our primary kind of approach in that kind of subjective space yeah so I suppose going down that rabbit hole of differential diagnosis before we move on to objective assessments you've spoken about clearing the joints above being the lumber spine and considering the kinematics from the ankle what do you find other most common differential diagnoses when someone does present with hamstring pain and are there perhaps one or two clues that really help you separate true hamstring strain from other pathologies. Yeah, no, I think it probably touches on some of the things that we've discussed and that's where it's really difficult around as and when to use imaging and I think there will be 100% players that we see who, again, maybe aren't even reporting things or reporting low-level symptoms that will have some element of injury to an extent if you were to image them. Again, athletes are very good at coping. They find strategies to cope with things and whether that be their demands in training, they find ways to not cheat, but adapt and get through sessions and be able to self-manage. So I think that's where it is very difficult to really, truly, differentiate diagnosed between some of its structural, something it's not structural. And again, I think it's more about the pattern of it. We know that the big high grade ones might think we're not going to miss them, they're going to have those bigger mechanisms, classic patterns, but it's more the subtle ones that I think are the real challenge for us in terms of differentially diagnosing the grade zeroes and the grade ones and those sorts of things. So I definitely think that's where it's the real challenge. I think more than thinking, okay, I'm going to miss a hamstring injury. It's more what level of the injury and what exactly is involved within that. Completely agree, Adam. I think that kind of the idea of the grade half grade one, that that's the most challenging area because a lot of these athletes we know will present with some hamstring tightness or soreness that won't go on to have a more significant injury, will continue to apply, train and effectively survive and then we'll have others. That niggle is really something that is probably suggesting us some sort of subcellular, like failure point that we're just not able to either discern from our clinical markers, from our clinical testing point of view, our subjective components and particularly in my right imaging in that space as well. So yeah, it's a really complex sort of area. And it keeps coming back to the testing element. It's just not precise enough in many of those cases. So it's a really hard space. But just the only other thing I have is that this idea of the neural, like the differential element is clearly that we've touched on that. But the proxhamie tendon components, I speak to a lot of maybe clinicians with, especially within clinics and working at different sort of local clubs that that can present in a variety of different ways as well. So just being cognizant, I guess, of that a mask variety and obviously as these niggling posterior thigh pain obviously there's that it's clearly going to have that proximal component. But yeah, having an understanding how that may inform you or your ongoing management of that athlete as well. It's certainly just something to consider in these cases. Absolutely. And then presumably you're considering the language used and do you notice consistency in terms of the descriptors people use burning versus lancinating versus ache dull, those sorts of things for your tendon opathy versus your hamstring strains versus your lumbar referrals. The hamstring strain ones, as Adam alluded through the big ones show themselves pretty clearly. They're kind of hard to miss as they like gray ones, but they will present with often the player will describe either which is this is the horrible one, but they always say they've got doms. They've got doms immediately after training sessions, which is unlikely in terms of how that actually would work out. Tightness is often the descriptors will tend to see if we are seeing lancinating, burning these types of descriptors, well already I'm starting to suggest that maybe there's another sort of aspect to what is driving these symptoms which might lead me along with as it's some of the as it said, the slum, the passive strait like rays and some of our sort of other neural dynamic sort of testing approaches to try and clear some of those features. Yeah, but the what the big ones are pretty clear cut, I think they're sort of hard to miss. Absolutely. Moving on to then the objective component, objectively do you have any tests that are your non-negotiables? Looking at from my point of view would be looking to understand strength because I think like say they're they're good at being able to adapt and show different different ways. So I think always trying to quantify, objectify those strength markers again within our setting we're going to be very fortunate to have a lot of historical data. So we're going to be able to compare that and really understand is that they're norm and I think if you have someone walking into a clinic that's going to be difficult to do, you don't know their norms, you don't know whether they're able to produce it and again, it's got such under the different ranges and the different lengths, the different contraction types, but one of the other big tests for me is it kind of non-negotiable if someone can't perform that kind of asklings, H test that real quick rapid, active straight leg raise essentially. I find that as a really good marker because it's an objective marker, but also very subjective. It's trying to see how comfortable that player isn't they can't cheat that. They can maybe find different certain positions in a strength test to bias a slightly more medially if they want to stay away from that that kind of lateral hamstring and just find slight little ways, but if you set up the asking H test properly with the straps and everything like that and you're looking to get them warm that test rapidly, they should show a lack of comfort or a lack of willingness around that. So again, if someone's come in as we've talked about, they've got stoms, like symptoms that are reporting subjectively and we just quickly want to test that if they're unable to perform that objective test because of a lack of kind of subjective willingness to do it, that would be a real red flag for me think, okay, if they can't perform this bed based test, then I'm not comfortable with them then going out and looking to perform something maximally in a functional setting because they're showing a lack of willingness in an isolated environment and probably not really comfortable them carrying that then out onto the pit. My only add-ons is that I tend to lean on a lot of the aspital work and particularly Rod Wiley's paper around some of the clinical exam stuff and mainly focusing on the combination of palpatry soreness, that MH-fake discrepancy particularly in length there. I think that's a key feature. I think when I'm seeing a subjective reporting opposed to your thigh pain acutely palpatry soreness and then a loss of MH-fake then combine with a series of sort of bridge testing and that might may or may include these really outer range based testing which again we can measure from a strength point view from a load cell or a donor momentary point of view combining those pieces together I think you can elucidate kind of the location of that failure point if you are going to find it and that I'm sort of interested in the ones that clear those sort of period, those sort of testing that testing battery and they're kind of like still presenting pretty well that's when you do a list that I think something that's more demanding from your velocity point of view as you alluded to and then you're going to feel a little bit more comfortable about testing the monfield based off that as well because I think that's obviously going to be part of the process as well to make sure that you feel really confident but if they're not clearing a lot of those other basic tests I'm starting to have a pretty high degree of concern people ask me a little bit about this with the ponjurosis involvement I think when you are seeing a pretty notable failure point some of those ponjurotic injuries particularly the longitudinal split summons can present quite well strength wise but they tend to still be quite poor from a length perspective so I think if I'm seeing a big deficit there I especially as I had coupled with maybe video footage mechanistic I understand like when you're starting to put together all the pieces yeah in isolation it gets really strange especially if the athlete's like well I haven't I can't recall an incident in that case so yeah it's again not so clear cut but it's that that's sort of I think a pretty yeah a rigorous approach that would look to capture more than you miss it would be boring if it was too straightforward wouldn't it absolutely once an easy way to improve your assessment and treatment skills introducing practicals where you can watch video recordings showing exactly how top experts assess and treat a range of conditions it's the fastest way to develop your practical skills and enhance your clinical reasoning treat to your patients likely experts do with practicals by physio network click the link in the show notes to try it for free today the last point here is I'd love to talk about what I'm sure everyone's also wanting to know which is around rehab so I'm curious what are both of your processes in terms of early to mid and late stage rehab understanding that as we've already spoken about the diagnosis obviously will dictate and change the prognosis but are there any consistencies across your rehab protocols for me it's I'm kind of quite a criteria driven and a therapist really so there'd be a lot of consistency through the different stages again almost showing why we're looking to achieve things but I think in that early phase again as as has been touched on a lot of the early ones are trying to get them asymptomatic because again I think we have an understanding that longer there they are symptomatic on things like pain on walking loss of range on that MHF8 palpable test tenderness the longer that is there. Ultimately the longer we're expecting them to miss. So that's gonna be a big, kind of form the early part of the criteria is we can't progress into anything meaningful loading wise and how that looks in terms of rehab until we've got these early signs and symptoms under control. So setting a number on them and kind of going, okay, we need to get that powerful tenderness down to two or less out of 10 and make sure that's not reactive as well, kind of monitoring that day to day, making sure we've not had kind of an acute or a date delayed reaction to the loading that we've got. So kind of using that in the early phases and again looking to progress through those criteria from a strength based marker and looking to progress, seeing how they go and going, okay, we might be able to look to get you outside jogging, low-level jogging early doors when you're at 70%, 75% of your opposite side or your BC and screening markers because we understand that we're not actually gonna be using the muscle that much at lower level jogging speeds. Within that we wanna encourage kind of functional patterns getting the muscle being fired in the way again, I think there's so much really good work coming out at the moment to show how individualized everything is and the way that people react to so individual, all our exercises are gonna have completely, the same exercise is gonna have a completely different outcome in all the different athletes we work with. And ultimately the sooner we can get them functional and running or moving in the way that they move will get that muscle firing in the way that they need it to fire. So trying to get that kind of rehab process as functional as possible as early as possible but as safely as possible is what I would look to do and then use those gym-based, bed-based criteria as such on things like H-Test to give us confidence to progress through with the function and then probably last point with me on this is around the again going back to the imaging that's why I'm balanced between again, some of the stuff that's coming out to me guys in Barcelona and Carlos around like re-imaging classification and our healing stages and try use those to again give us confidence or understanding looking at a demon within there has that changed and A, we're hoping that that demons going away and regressing as we're progressing through the rehab but ultimately using that and going okay there's been an increase in a demon through this stage. We just need to back off at this point and use that as a criteria to understand is the muscle and distress again or are we providing too much load too early and using those kind of healing classifications to guide us through but it is a challenge because that's bringing in so much information to the rehab and trying not to let just one thing guide you and again trying to make that bigger picture of okay subjectively we're getting this information objectively from the imaging we're getting this objectively and the gym we're getting this objectively outside we're getting this information and where does that put them out throughout those different phases and stages to progress through. - Yeah completely agree with everything Adam mentioned there. I really like the idea of thinking about it almost like an imaging kind of like approach like that. There's got a clinical kind of testing approach, a strength testing approach like maybe a morphology like architecture kind of approach like all those are feeding in across kind of those periods of the rehab atoms alludes to like you have that kind of protective earlier phase. Clearly you're the clinical and markers inform that in terms of as lujzu like when are you recovering from certain elements of arbitrary soreness are able to clear it might be a simple trunflexion tears can you pain free bike you know pain free walk pain free run and you're clearing those and in my mind it's in the back of I guess my mind I'm thinking what is the tissue doing in those early stages where are we sitting from a tissue healing perspective again imaging can help inform and support either am I writing my decision making there you know is that sort of going to inform when I may use a bit more of a strain based approach and I kind of probably sit more that side like when am I going to explore more strain on the tissues that have failed so can I protect them early can I progressively load them and I'll use again imaging to help support that but also obviously a range of exercise election to again either protects progressively restore and then times exceed and try and like achieve adaptation at these tissue sites and you're trying to do that across the phase of the rehab and trying to align all those pieces is the real fun and out of it is like when do I intervene in terms of an audio based approach which I think we hope to put some workout pretty shortly to try and illustrate some of the demands that the M to you is under going in some of these to not hide degree of trunk tip flexion tasks as well as what does that look like when we're looking at some of our more knee dominant based approaches and kind of what the M to you strain looking like that was the muscle forces that they're undergoing in these spaces and how does that kind of look to inform when we intervene and then we come in all the way back to the stars kind of like the peak demands element like when are we laying on our acceleration demands we know from a strain rate point of view that can be really demanding so maybe some of the constant sort of speed running in terms of velocity is probably where we tend to start we then try and explore that a little bit later and that's obviously going to replicate a lot of sporty pursuits not just European or ramble football and other rules so trying to just overlay all those pieces of the puzzle I guess the only things that I tend to lean on with that is a lot of the muscle morphology elements and then utilizing some different technologies spring block analysis been really big in this space that really helps to inform the type of athlete I'm working with in terms of maybe where they have preferential adaptation so that might actually look to shift my approach from what they've actually been doing to where I think they need to trend and layering on some of the muscle architecture stuff so looking at some fastball length for national changes is my also exercise having the effect that I think it is that's the other piece of the puzzle because there's some great protocols and there is great guidelines out there like it's there for everyone to see a new lives but the challenge is that individual piece that Adam mentioned is did this athlete actually adapt in the manner that I suspected they would and then that kind of puts all the way back around to the imaging approach and am I seeing that adaptation at that tenderness leisure Adam's put around the ademot a demoness like recovery but then we've also seen some great work from them showing that from the guys from Carlis and that this was Barcelona imaging team that that tendon and the appendrosis will actually have some significant adaptation there but identified at least some key time points now we know that probably differs for the type of lesion and the type of athlete but that does give us an idea of what is that a more mature based lesion so therefore I can explore a little bit more from an intensity point of view that that might look like maximal glossy sprinting all the type of task that we're completing the gym so you can hear this is the exciting piece of the job and the pieces that we still yeah where it really is the art form we clearly using science to inform us really dramatically but when we're working with the athlete in front of us you've got to make a decision on that intervention and and so I think trying to utilize strategies to at least try and to yeah review your work here you constantly doing little pre-test post-test sort of analyses on a variety of these different levels that I've mentioned so I think that's yeah kind of my approach to it I feel like to summarize both of your approaches to this magical combination of beginning with the end in mind understanding the athlete understanding the sport the physiology the muscle morphology knowing your asterisk signs and the why to drive your rehab pathway hopefully I haven't missed anything there yeah the beginning with the end in mind is such a is it such a great way to place and I think of the peak demands Elmer tend to use that terminology more and more now I think they're old so used to be worst case scenario which seems like a little negative but that idea of yeah preparing your athlete but all the aspects that they need to do and that can include it many factors but absolutely well Scott and Adam thank you both so much for sharing your insights on all things hamstring today I think there's a ton in there for clinicians to reflect on from sharpening up our diagnoses to differential thinking right through to the rehab and what that looks like as the research morphs as well so thank you very much both for your time thanks very much for having us it's been great chat to you both thanks Sarah's beat yeah so great conversation always happy to chat hamstrings