Hamstring Strains: 5 Important Exercises for Recovery

Hamstring strains occur at high rates in sports that require running and sprinting. One of every 3 injuries in soccer are hamstring strains.  Other sports with high injury rates include baseball, football, and track and field. These injuries can be very frustrating for athletes.  This is because of the long rehabilitation time. Return to sport may take several weeks or 2 to 3 months based on the severity of the injury. Also, nearly 1 in 3 hamstring injuries will recur and many of these happen within the first 2 weeks of returning to sport.  Thankfully, rehabilitation exercises can help get you back in the game and avoid re-injury.

Your hamstrings consist of three muscles: the semitendinosus, semimembranosus, and the biceps femoris. These 3 muscles start from a common tendon on your pelvis. The hamstrings cross your hip and knee joints attaching just below the back of your knee. Hamstring injuries commonly occur during high speed running.  This occurs as your leg is swinging from a bent to an extended position in preparation for landing. During this phase of running, hamstring muscle activity is extremely high to control the length of the muscle.

Hamstring Injury

The Most Effective Approach to Rehabilitating Hamstring Strains

There are 3 types of rehabilitation exercises which assist in recovery from hamstring strains. Agility exercises involve changes of direction simulating sport movements.  These exercises reduce re-injury rates.  Always initiate these exercises early after your injury. Trunk or core stabilization exercises are also effective at reducing your risk of re-injury.  Finally, exercises that lengthen your injured hamstring can speed up your return to play.

The remainder of this article highlights 5 rehabilitation exercises for hamstring strains.  Three of the exercises progressively lengthen your hamstrings.  These are the active hamstring stretch, the “diver”, and the “glider”.  Perform lengthening exercises slowly and through pain-free ranges at first. Aggressive stretching delays recovery. As you improve, gradually increase the speed and range of movement.

Trunk stabilization exercises target your spine, hip, and pelvic muscles.  To reduce your risk of re-injury, it is important to strengthen your hamstrings and all surrounding muscles. Keep in mind, your hamstring muscle group originates from your pelvis. The position of your pelvis during running can influence the length and activity of your hamstring muscles. Increasing the strength of your injured hamstring itself builds resilience and promotes a safe return to sport.

Active Hamstring Stretch

Lie on your back holding your thigh. Your opposite leg remains straight. With your upper thigh in a vertical position, slowly extend your knee.  At the point where a mild stretch is felt pause and hold. The stretch should not be painful. Gentle stretching of your hamstring is helpful for recovery. Aggressive stretching of your hamstring will delay your recovery. Hold this position for 3 to 5 seconds, and then lower your leg back down.  Perform 3 sets of 12 repetitions once per day.

Cook Hip Lift

Begin lying on your back with your hips bent and feet lined up with your shoulders.   Pull your knee of the uninjured leg up to your chest. It is helpful to place a small towel roll or ball in the crease of your hip. Lift your toes off the floor and perform a bridge from your other leg. Be sure to achieve the bridge position by extending through your hips, not your low back. Hold this position for 2 to 3 seconds then return to the starting position. Typically, 2 to 3 sets of 10 to 15 repetitions are performed on each side once per day.

Bridge Walk-Out

Begin lying on your back with your hips bent and the feet lined up with your shoulders.  Perform the bridge by lifting both hips from the floor.  Hold the bridge position and alternately walk your feet out away from your body.  It is important to maintain a level pelvis throughout the exercise.  After 2 to 3 steps walk your feet back to the starting position.   Lower your body back down in a slow and controlled manner between each repetition.  Typically, 3 sets of 6 to 8 repetitions are performed once per day.

Hamstring “Diver”

This exercise resembles a simulated dive. Stand on your injured leg with your knee slightly bent. Bend forward at the hip and simultaneously stretch your arms forward. Your back should remain flat.  Your opposite knee remains bent as your hip extends.  Perform this exercise very slowly in the beginning. As a progression, you can increase the speed and range of motion. Typically, 3 sets of 6 to 8 repetitions are performed every other day.

Hamstring “Glider”

Begin in a standing position with one hand holding on to a support. Your legs are slightly split. All your body weight is on the heel of your injured (front) leg with your knee slightly bent. The motion is started by gliding backward on your other leg (wearing only a sock).  As always, stop just before pain is felt. The movement back to the starting position is performed with the help of your arms, not using your injured leg. Begin slowly in a pain-free range of motion. Progression is achieved by increasing the gliding distance and performing the exercise faster. This exercise requires slightly more recovery between each session. Typically, this exercise is performed 3 times per week for 3 sets of 6 receptions.

Get Started Soon

Your rehabilitation after a hamstring injury should begin as soon as possible. Initiate pain-free agility and trunk stabilization exercises immediately.  Also perform lengthening exercise soon after your injury, but be gentle.  It is best to perform these under the supervised of a licensed physical therapist. The progression of an athlete’s rehabilitation program is based on specific criteria. Your physical therapist will continually assess your injury and progress your program.  Our goal is to get you back as quickly and safely as possible. Contact us today if you have had a hamstring strain or simply have questions about which treatments are right for you.

Knee Replacement: Pre Surgery Physical Therapy

In the United States, more than 600,000 people undergo total knee replacement surgery each year. This number is expected to rise to over 1 million by the year 2025.  Success rates for knee replacement surgery are high.  Almost 90% of people report less pain and improved function.  Post surgical rehabilitation is considered an integral part of the recovery process.

Rehabilitation following surgery can make or break your long-term outcome.  With proper physical therapy, you can expect to perform most activities of daily living within 6 weeks.   You can expect to begin driving within 3 to 6 weeks depending on which leg is operated on.  Most people take 6 months to a year to fully recover.   However, new research is suggesting pre surgical physical therapy can expedite your recovery.

Preoperative Exercise for Knee Replacement

In 2017, researchers in Spain investigated the effects of intensive strength training prior to knee replacement surgery.  One group of patients performed the exercise program and another group did not.   The exercise program was performed 3 days per week for 8 weeks and supervised by a physical therapist.  Outcome following surgery favored the group of patients who performed the exercise program.   Hospital stay was significantly shorter in those who performed preoperative exercise.  Pain levels were less in those who exercised.  Also, these patients recovered greater strength, range of motion, and function 3 months after surgery.

Prior to knee replacement surgery, you should focus on 3 goals.  The first goal is to restore as much knee range of motion as possible.  It is especially important to have a fully straight knee in order to walk with normally.  The second goal is to maximize strength of your quadriceps muscle.  This muscle is responsible for walking, climbing stairs, and getting you up from a chair.  Your quadriceps muscle becomes very weak immediately after surgery.  The third goal is to normalize your walking pattern.  The following 5 videos include exercises that we commonly prescribe prior to knee replacement surgery.

Quadriceps Isometrics

This exercise can minimize quadriceps muscle loss following your surgery.   It also helps restore full knee straightening.  Begin with your knee extended with a small towel roll placed under your heel.  Push the back of your knee down towards the floor while simultaneously tightening the front of your thigh.  Hold the contraction for 10 seconds and perform 10 repetitions.

Knee Extension Stretch

This exercise also helps restore full knee straightening.  Again, this is imperative to walk normally.  Begin with your knee extended with a small towel roll placed under your heel.  Place a long towel, belt, or stretch-out strap around your foot.  Gently pull your toes towards your shin while keeping your knee straight.  Hold the stretch for 10 seconds and perform 10 repetitions.

Heel Slides

The heel slide helps restore full knee bending.  This is important to sit comfortably and climb stairs.  Begin with your knee extended with a long towel, belt, or stretch-out strap around your foot.  Gently slide your heel towards your hip until a mild stretch is felt in your knee.  Hold the stretch for 10 seconds and perform 10 repetitions.   The more your knee bends prior to surgery, the easier it will be to regain range of motion after surgery.

Sit to Stand

This exercise involves an activity that older adults perform frequently in their daily lives.  The ability to transfer from a chair without the assistance of your hands has been linked to fall risk in older adults.  It can be easily performed in the physical therapy clinic, any community exercise studio, or in your home.  The exercise is progressed by lowering the height of the chair or by holding weighted objects such as a medicine ball or kettle bell.

Single Leg Balance

The ability to balance on one leg is important to walk normally and negotiate a step or curb.  Use the assistance of a chair or a counter if needed.  As you improve, progress away from using assistance.  Aim for at least 10 seconds on each side.  Start with 5 to 10 repetitions each day.

Pre Surgery Physical Therapy Before Knee Replacement: Closing Thoughts

Preoperative physical therapy reduces your pain and results in a faster recovery from total knee replacement surgery.  The preoperative exercise program should be individualized based on your needs and goals.  Meet with your physical therapist to determine the exercises that are best for you to perform prior to your surgery.  Call us if you have questions about getting started.

Patellofemoral Pain Syndrome:  How a Physical Therapist Can Help

Patellofemoral pain syndrome refers to pain in the front of the knee or around the kneecap (patella).  It is the most common form of knee pain.  Patellofemoral pain syndrome is sometimes referred to as runner’s knee.  However, anyone can get it.  It commonly affects runners, cyclists, and office workers or anyone else who sits for a long periods.  Patellofemoral pain syndrome is also very common in teens, particularly girls.

Pain often occurs when friction is created between the undersurface of the kneecap and the thigh bone (femur).  Tenderness can be found along the edges of the kneecap.  The ligaments and soft tissues surrounding the knee cap can also become sensitive.  Changes within the nervous system may lead to the area of pain spreading to other areas of the knee.

Pain is often experienced with the following activities:

  • Walking up or down stairs
  • Walking on uneven surfaces
  • Squatting or standing up from a chair
  • Pain that increases with activity and improves with rest
  • After sitting for long periods of time with the knee bent
  • A “crack” or “pop” when bending or straightening the knee

Tracking of the Kneecap

Knee cap tracking

Anatomy allows the kneecap to slide smoothly on the femur in a groove (situated along the thigh bone) during movement.   Excessive friction between the undersurface of the kneecap and the femur can occur when the knee cap moves slightly out of this groove.   This is similar to a train sliding slightly off its track.

The kneecap may fail to track properly in its groove when the quadriceps muscle on the inside front of the thigh is weak.   Weakness of the hip muscles may also cause the track (femur) to move underneath the train (kneecap).   Also, the kneecap is pulled in the direction of any tight muscles or ligaments.  Any of these factors can cause the kneecap to track or tilt to the side, which irritates the tissues around the kneecap.

Physical Therapy for Patellofemoral Pain Syndrome

Manual therapy performed by a licensed physical therapist alleviates pain from patellofemoral pain syndrome.  Joint mobilization involves stretching the ligaments which attach to the kneecap.  This improves mobility of the kneecap allowing it to remain situated in its normal groove.  Soft tissue techniques to the surrounding muscles also alleviate pain and improve mobility of the kneecap.  Common muscles treated include the hamstrings, quadriceps, and iliotibial band.

manual therapy

Strengthening exercise is the foundation of any rehabilitation program for patellofemoral pain syndrome.  Research indicates strengthening exercise for the quadriceps and hip muscles is the most effective intervention for this condition.  Initial exercises should be pain free.  Exercise is started in non-weight bearing or lying positions.  Examples include the clam shell or bridge.  Once a baseline level of strength has been established, standing or weight bearing exercises are performed.

Rehabilitation involves improving poor movement patterns.  In order to uncover the cause of pain or poor movement, whole movement patterns must be assessed and treated.  For individuals with pain in the front of their knee, isolated treatments to the knee rarely provide complete relief.  The brain stores patterns of movement and then signals muscles to execute what is believed to be the most efficient pattern. With repeated performance of compensatory movement patterns, the abnormal becomes the new normal.  These patterns can be reprogrammed and corrected with appropriate movement training by physical therapists.

Closing Thoughts

Exercise is the most effective treatment for people with patellofemoral pain syndrome.  Less than 5% of people with this problem will undergo surgery.  The long-term success of these surgeries is questionable at best.  Physical therapists prescribe individualized exercise programs which are unique to each person’s needs and goals.  Of course, the long-term success of any exercise program is dependent on consistency and discipline.

Knee Arthritis:  How Physical Therapy Can Help

Osteoarthritis is a condition where the protective cartilage of the joint surfaces breaks down.  The cartilage serves as a pad or cushion to the bone beneath it.  The knee, hip, and spine are the most joints where osteoarthritis develops.  In the knee, this can occur on the end of the thigh bone (femur), the lower leg bone (tibia), or both.   Arthritis can also be present underneath the knee cap.   When the cartilage wears away, the body responds by laying down additional bone.  This results in spurs and narrowing of the joint space.

knee arthritis

Knee arthritis is not always associated with pain.  Also, “severe” arthritis viewed on x-rays may result in only mild pain.  Likewise, mild arthritis may result in higher levels of pain.  The experience of pain is complex.  Joint inflammation, joint stiffness, muscle weakness, muscle tightness, and changes within the nervous system can all contribute to pain experienced from arthritis.

Symptoms of Knee Arthritis

Knee arthritis typically affects people over 50 years of age, although it can be present in younger people.  It is more common in females.   Common symptoms include stiffness early in the morning or when initiating walking after prolonged sitting.  Pain, stiffness, weakness, and cracking or popping sounds are hallmark signs.  The pain is generally worse with weight-bearing activities (e.g., walking, standing, or twisting).  Most people experience “flare-ups” of increased pain and stiffness interspersed with periods of little or no pain.

Physical Therapy for Knee Arthritis

Recent research shows several types of exercise are effective for improving pain and function in people with knee arthritis.  This includes aerobic exercise, strengthening exercise and stretching.

knee arthritis

Aerobic exercise for people with arthritis is backed bys solid research. Regular walking for 30 minutes five days per week is recommended.  Continuous walking is preferred but if a person is unable to perform one 30-minute walk, multiple shorter walks totaling 30 minutes can be employed.  Physical therapists help patients begin and progress an individualized walking program.  Cycling, swimming, and other forms of aerobic exercise can also be incorporated.  However, walking programs show the greatest improvements.

An individualized muscle strengthening program is prescribed for patients with knee arthritis.  The quadriceps and hip muscles are targeted.  These muscles are important for walking, climbing stairs, and transferring from sitting to standing.  Weakness of the quadriceps muscle on the front of the thigh is common in people with knee arthritis.  Strengthening both the quadriceps and hip muscles has been shown to produce the greatest improvements in walking ability.   Sit to stand training is an excellent way to incorporate both of these muscle groups.

Knee arthritis results in stiffness of the joint capsule and ligaments.  The surrounding muscles shorten further limiting range of motion.  Stretching exercises to improve knee straightening (extension) range of motion is important to restore normal walking patterns.  Manual therapy performed by a physical therapist is often needed to achieve sufficient improvements in people with longstanding stiffness.  Manual therapy may be incorporated at the knee, hip, ankle, or spine joints.  This is because problems at the knee are often associated with problems at neighboring joints.

Closing Thoughts

Knee arthritis does not have to be a disabling condition.  Exercise can be very effective for improving pain, function, and quality of life.  Many people are unsure how to start and what type of exercise is best for their goals.  Meet with your physical therapist to develop an individualized exercise program that meets your needs.

References

  1. Goh SL, Persson MSM, Stocks J, et al. Relative efficacy of different exercises for pain, function, performance and quality of life in knee and hip osteoarthritis: Systematic review and network meta ‑analysis. Sport Med. 2019;49(5):743-761.
  2. Hislop AC, Collins NJ, Semciw AI, Tucker K, Deasy M. Does adding hip exercises to quadriceps exercises result in superior outcomes in pain, function and quality of life for people with knee osteoarthritis? A systematic review and meta-analysis. Br J Sports Med. 2019;0:1-10.

 

Total Knee Arthroplasty (Replacement)

Total Knee Replacement (TKR), also known as a Total Knee Arthroplasty (TKA), is a surgical procedure commonly used to relieve knee pain due to arthritis or in some cases trauma-related injury. TKR is a viable option when the individual’s function is extremely limited due to pain and when conservative care, an exercise program, and weight loss was not substantially effective in relieving symptoms. Greater than 600,000 TKR are performed each year with approximately 90% of individuals experiencing significant symptom reduction.

Knee Replacement Surgery

There are multiple surgical approaches with Total Knee Replacement with most common types being Traditional and Minimally Invasive Surgery (MIS). In both approaches, the damaged cartilage and bone surfaces are removed and replaced with prosthetic implants. The Traditional approach will typically result in an 8-12 inch scar, whereas the MIS results in a 3-4 inch incision. Research suggests outcomes for both procedures are similar over the long term, with fewer complications experienced with the Traditional approach.

The Role of Physical Therapy

Following TKR most individuals are fully weighted bearing on the involved lower extremity, but will likely have to use an assistive device for a short period (walker, crutches, cane). Best evidence supports that patients receive outpatient orthopedic physical therapy where the focus is on restoring normal knee motion, strength training, normalizing walking patterns and restoration of prior functional/recreational activities. Your physical therapist will work with you targeting your greatest impairments and develop a plan of care to help you achieve your goals. The entire surgery and rehabilitation process is typically 12 weeks in length with continued functional gains made after 12 weeks by the performance of a home exercise program.

A recent study suggests that approximately 98% of individuals who undergo TKR will be able to return work, including heavy work activities. Depending on the type of work patients with sedentary jobs can return to their work tasks as early as 1 month after surgery, whereas more strenuous jobs may take up to 3 months. Patients can expect to realistically return to walking without an assistive device, swimming, golfing, driving, light hiking, biking, dancing, and other low-impact sports. However, outcomes are specific to each patient and is based on prior levels of function.

Closing Thoughts

Physical therapy following knee replacement surgery requires a team approach between the patient, surgeon, and physical therapist.  If you are considering undergoing a knee replacement, or have recently undergone this procedure, please call one of our physical therapists to learn more about your recovery and return to function.

 

-Dr. Jermemy Boyd, PT, DPT, OCS