Hamstring strains are one of the most common injuries in sports. And as many of us know, it often can be recurring.
In this podcast episode, we discuss why this may be the case and what you can do to minimize recurrence.
To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 323: How to Deal with Recurring Hamstring Strains
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That’s me. All right, so Jason from Los Angeles asked, “With the start of the NFL season, I’m amazed at how many hamstring strains I see, especially reoccurring. Why do you think hamstring strains reoccur so much in these athletes and what can we do better?”
Awesome, Tiffany. Thank you so much. Jason, excellent question. I’m going to start off by saying this, it’s the fall, right? That’s when we’re recording this at least, and it’ll go live probably in the fall. Jason’s saying this because he just watched week one in the NFL, we’re already starting to see strains, but we’re seeing this in every sport. It’s not just football, right? Hamstring strains are the number one injury in major league baseball right now other than pitching injuries. So this isn’t isolated to just the NFL and it isn’t isolated to just field sports either. So something to kind of keep in mind as we go through this answer here, but I thought it was real timely.
So why don’t we start talking about these hamstring strains in general. I know a lot of us on this, deal with a decent amount of hamstring strains in our practice. Who wants to start, maybe talking about why we’re seeing these hamstring strains and why we’re seeing them recurring, before we get to what we can do better? Kevin, you want to jump in?
Yeah, like you just said, the strains are super prevalent. If you look at the research, it looks like, with most running-based sports, it leads the way in injuries and then in terms of who’s going on to recur, about a third of them end up getting a recurring hamstring strain. And so, what the research seems to show with that is after they return to sport in the first two weeks, they’re getting their next hamstring strain.
So it’s obviously a problem and something that we need to do better from a rehab standpoint. But in terms of why I feel like they’re seeing so many early in the season, it does seem like we get a lot when the football season ramps up or when the baseball season ramps up. And I wonder if that’s a problem of acute chronic workload issues. So potentially, I think even at the high levels you see this, and you definitely see this at the lower high school or college levels where in the off season these kids might not be doing the proper volume of sprinting and then when the season starts, it’s a whole new stress that they’re not adapted to.
They could be doing a bunch of normal strengthening in the gym, but if they’re not doing what the sport demands regularly, once you get 70, 80, 90% sprint speed, the EMG on the hamstring just becomes super high and it’s hard to replicate that unless you’re doing it. So in terms of why they’re happening early in the season, I would guess it’s that change for people. And then especially if it’s someone with a previous hamstring injury, like other injuries, that seems to be a big risk factor for hamstring strains. Maybe those people in particular need to be doing a lot of preventative stuff in the off season and making sure their chronic workload is relatively high to challenge the hamstring.
That’s awesome, Kevin. I really appreciate that perspective. I know for us with team sports, and maybe Jonah can jump in and talk about the Red Sox a little bit here, but we’ve put a huge emphasis on that acute chronic workload ratio with our sprints. And it’s something that with technology, we’re able to now monitor a little bit. But I think you’re right, that’s in season. I think a lot of these people were coming into the season ill-prepared and they didn’t have that chronic workload buildup and they’d have an immediate spike in their acute chronic workload ratios with sprints, and that’s why we get all these early season type things.
So Jonah, I don’t know if you want to jump in from your perspective with the Red Sox. I know with us, with the White Sox, we have a, I don’t want to say new, but over the last several years, we have a very regimented, onboarding sprint progression that we do in the off season. How much focus are you guys as a team putting on maintaining this acute chronic workload and building up their chronic workload? Do you have any insight on that?
Yeah, I guess the main thing, because I wasn’t there in the off season at all, but the main thing I can say throughout the season is, not just relying on games to make sure that people are getting running in and getting true sprinting in. And then a big piece of that on the rehab side, even if a player’s coming back not from a hamstring injury, but is truly building up their sprints and building up sprints in different ways for them. So not just doing linear sprinting and baseball players doing base running because that’s obviously going to be a way that we can strain hamstrings and doing curved running and different things like that, to just make sure that we’re actually getting ready for those demands of the sport and making that a big piece of rehab or a training program for anybody regardless of whether or not they have that hamstring injury, but then obviously that much more important for somebody who is coming back from a hamstring.
The other piece in general related to it I think is just with the strength training side of it for the hamstring, focusing on it in multiple ways. Nordics have obviously become a big thing everybody loves to talk about, but there are more ways to train the hamstring than just Nordics. And there are more ways to train the hamstring eccentrically than just Nordics. And I think a lot of people tend to kind of be prone to those hamstring injuries, all your guys who live in lumbar extension. And oftentimes when they do Nordics, they end up just feeling it in their back or their calves. So finding ways to get people doing exercises where they’re actually feeling it where we want to and using muscles we want to, whether it’s trying to prevent the recurring injuries that Kevin was talking about or preparation for the season. I think we have a lot of the right ideas, but it’s just are we implementing properly?
Awesome. That’s great input there, Jonah. I love that. Let me ask maybe an elephant-in-the-room question, right? Sports have been going on for centuries, right? Hamstring strains are on the rise. There’s no doubt that the prevalence is going up and up and up, over and over again, in multiple sports. I think more so now than ever in the past, we are doing off season training and preparing as best as we can, yet the injuries are worse. So maybe that’s the elephant-in-the-room question, but what is it that we’re doing wrong in our preparation? I know we talked about a little acute chronic workload ratio, but it’s more than that, right? In the ’80s, nobody got ready for the major league baseball season like they’re doing now and they weren’t straining their hamstrings as much as we are, just as an example. So I don’t know. Anybody have insight on that? Maybe Dan, I don’t know if you have anything. Dave? but what’s different with athletes nowadays that they’re more susceptible to this maybe? Dan?
I didn’t have anything in particular. Dave, if you want to go for it?
Yeah, Tim Gatt had a pretty big paper that changed my mind a lot on hamstring strains, which is that the biggest predictor of hamstring strains was the amount of time spent in high speed running toward the end of their prep for off season. And I think that that’s really lost on most people. It’s kind of maybe echoing what everyone’s saying here, but Tim’s research and many others have shown that to build up to a really high chronic workload of doing multiple ballots of repeat high intensity sprints, takes six to eight weeks. And I think that when you combine the fact that all sports have become bigger, faster, stronger at the highest level, so NFL, MLB, you have much bigger, much faster, and much stronger requirements on the hamstring and then the amount of time that they expect you to get ready in pro settings and college settings is getting shorter and shorter and shorter and shorter.
They want you to be reaching a higher level, what Tim calls the ceiling, at a faster time length than ever before. And I feel like just in my last 10 years of working in high level sports, you just see it getting compressed more. They want to get more games in, more preseason work, more high intensity. And we all know working with high level athletes is that you can only ask an athlete to be at its tippy top, 95 plus percent intensity for so long before they need a long bout of recovery. So if the demands are super high and then you also have people that are not spending enough time in high speed running, I think that’s kind of setting people up for disaster.
And my last point on that is that there’s no amount, especially at the pro level and the college level, there’s zero amount of training that you can do in the gym that mimics live action, one-on-one or two-on-one in what Tim calls the most demanding patches of play. So I don’t know exactly position-wise, but say you take someone who is a running back, maybe, this is my naivety. But someone who in practice takes one every 40 seconds, one every 60 seconds, they’re hitting games and then when a game comes up, they have really good action and they’re going play after play after play after play after play, cutting and pivoting, getting hit. That’s really fast passing to play. So Tim sets up those things in rugby to make sure you’re doing exactly what the game’s hardest, most awful moment might put on your hamstring or your body, and I feel like most people are not tapping into that in their practice stuff.
That’s awesome. What about the concept? So I think you said that really well. Kevin also mentioned earlier, EMG of the hamstrings is enormous when you start sprinting. I mean are we bigger, faster, stronger? Is that a part of the issue too or are athletes are getting so much stronger and so much more powerful that sprinting is just more stress than it used to be? They’re faster, they’re more powerful. Is that part of it? And is that something that can be… Can we combat that a little bit with this chronic workload buildup? Anybody have any thoughts? Yeah, Dan?
I was going to say I think that sometimes we have to have a little bit of grace just because we feel like we can just prevent everything. And I think that’s just oftentimes unreasonable. We kind of expect bodies to be able to handle extreme amounts of running, speed of running, and just never get hurt. And I think that is just unreasonable for bodies to be able to handle. Can we reduce these? Obviously, yes, but the other part is that I think we need to give ourselves a bit of grace just to realize what we’re throwing on the body is probably more than it’s able to handle. That’s all I have to say though.
Well and to your point too, we’re always working at… We’re trying to get peak outcomes at all times, so we want to get the maximum of our body. When we do that, we’re flirting with that edge, that tippity top where we’ve done too much. So that’s a good point, Dan. But Diwesh, what do you think?
Yeah, the one thing that comes to my mind is are we maybe ignoring the recovery? I think especially in high level sports now, training is pretty intense. Games are obviously intense. Off season preparation is really intense. Do we ever have any bit of downtime where the hamstring maybe just gets a little bit of rest? I get the need for building up that chronic workload, but that chronic workload probably doesn’t need to be high all year round. You know what I mean? Like Dave mentioned, the six to eight weeks is probably the time it takes for us to prepare and build up that chronic workload, but do we need 52 weeks of super high chronic workload on the hamstring? That’s kind of where my head goes.
That’s a good point. Jonah, what else?
Kind of summing up one thing that Dave said and applying it in the football season. Yes, athletes are bigger, faster, stronger, and also from what I can tell, they’re playing less and less preseason games. I know they play three now instead of four. And I feel like players themselves are playing way less snaps. And I bet in practice, where hopefully they’re building up their workloads, but say a running back does break open, where in a game they would go for 60 yards, in practice, I question whether or not they actually run hard for their 60 yards or they kind of just scamper out of bounds.
So those toughest plays, the ones where they are most susceptible, I do wonder if, as we’re trying to build up their workloads, if they’re just not doing it nearly at the intensity that they would within a game and then we see week one or we see that last preseason game where a guy’s fighting for the top spot in a depth chart or whatever it is, and it’s really their first time actually going at 100%, multiple plays in a row. And especially because they are so much more powerful now, that combo of more power and faster with less buildup does seem like a bit of a recipe for disaster.
Well, Jonah’s comment segues well into what I was going to say was, it seems like the injuries happen early in the season, right? In general baseball, April, May, laying out a ball to first base. NFL, a good chunk of the ACLs. The ACLs happen all season long, don’t get me wrong, but you’re going to see them early on more so and I think, I don’t know if it is a preparation, they’re prepared, trust me, don’t get me wrong, they’re prepared. But is it that they’re not used to that new acute spike in workload that they get week one, the first month of the season, where there are maybe guys are still fighting for positions or they’ve been in an off season for so long and there’s just this extra amount of energy that they have that slowly dissipates as the season goes on.
Guys are just not as fast probably, week 15 or in August in the Texas Rangers organization when it’s 98 degrees out, then they are week one or in April, May of a baseball season. And so I think just that, yes, they’re trained, they’re prepared, maybe we are doing a disservice by not having them play as much in preseason. Having them ready and playing for three hours in a football game in September in Kansas City where it could be 100 degrees or in Miami, your body is just going to get beat down from all that. And so the early part of the season is when we see most of the injuries, statistically.
Yeah. Mike, did you have something to add too?
I was just going to kind of touch on it from a slightly different standpoint. Looking at, with a previous hamstring strain, I think these athletes also suffer neuromuscular control. They have deficits in neuromuscular control, so they’re utilizing their hamstrings in a slightly different way. And it seems like according to at least one study, that they’re actually using their hamstrings at higher EMG and earlier in a single leg stance exercise.
So there seems to be this neuromuscular component that may get overlooked in our rehab. So for example, if we put a lot of emphasis on strength training, I think that’s obviously needed, but maybe more core, trunk, neuromuscular control, more balanced exercises, maybe we need to adjust our rehab a little bit to incorporate more of a neuromuscular challenge to kind of help with, when they get back on the field, how they’re utilizing their hamstrings during the task.
Yeah, I’m glad you brought that up too, Mike because I think that kind of gets it and I think that’s a good wrap up of, I think we answered what can we do better through these questions. I’m glad you brought that up. So I did a podcast recently with Holly Silvers on the Sports PT Podcast, and she talked about this a little bit. She’s involved quite a bit in soccer and the NFL Task Force for Hamstring Strains, and she brought that up, Mike, exactly like that. Essentially she said, “Sometimes people are strong, but when we look at EMG during their activities, they’re just not using their hamstring the way they’re supposed to, right?”
So I think that’s right. So maybe wrapping it up real quick, I think we answered the question pretty thoroughly, to be honest with you. It sounds like we’re building bigger engines in the off season, but maybe we’re not getting that acute, chronic workload ratio built up, to be able to handle those forces a little bit more appropriately, especially earlier in the season when we have that acute workload. So what can we do? I mean, I think we have better onboarding into the season, making sure that we’re building up and ramping up the intensity of their sprint work, increasing their capacity with hamstrings eccentrically, like Jonah said, in various outputs I think is the way to do it as well. But then also paying attention to neuromuscular. So I think if you hit it from all those angles, like everybody kind of mentioned, I think you’re going to be a lot more successful with hamstrings, hopefully getting back. So awesome. So great question. Jason, thanks so much for submitting that to the podcast. We really appreciate it. If you have a question like that, head to mikereinold.com, click on that podcast link, and fill out the form to ask us a question and we’ll see you on the next episode. Thanks so much.