Understanding

UNDERSTANDING TENDINOPATHIES OF THE HIP & PELVIS BOOK THREE: Proximal Hamstring Tendinopathy Introduction Tendinopathies of the hip and pelvis represent a large burden on both the sporting and ageing populations. Growing evidence is shaping contemporary conservative management of tendinopathy.

This e-book series aims to provide readers with guidance towards a deeper understanding of tendinopathies of the hip and pelvis and more effective clinical management based on an emerging evidence base derived from scientific studies on structure and mechanobiological mechanisms, risk factors, impairments and the available information on effects of intervention.

Book 3 of this series details mechanobiological mechanisms of proximal hamstring tendinopathy and the clinical implications for assessment and management of this condition, common particularly in the running population. Local structural and functional anatomy, together with known patho-anatomy is examined prior to discussion of the pathoaetiological model. This model and evidence regarding impairments is reviewed and together these elements provide a basis for contemporary assessment and management of proximal hamstring tendinopathy. Available evidence from the scientific literature is combined with over 25 years of clinical experience to provide a wealth of information for immediate use within a clinical environment.

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This book is suitable for anyone involved For more information in management of tendinopathies of the hip and pelvis or prescription of email [email protected] exercise in at-risk groups – such as the phone (07) 3342 4284 athletic population or perimenopausal web dralisongrimaldi.com women. The content assumes readers have a basic knowledge of anatomy and muscle function in this region.

PAGE 2 OF 50 Copyright Alison Grimaldi 2018 BOOK CONTENTS

Chapter 1 IMPACT AND PREVALENCE ...... 4

Chapter 2 CLINICAL PRESENTATION...... 6

Chapter 3 REVIEW OF LOCAL ANATOMY...... 10

Chapter 4 PATHOLOGY & TERMINOLOGY...... 16

Chapter 5 PATHO-AETIOLOGY ...... 20

Chapter 6 IMPAIRMENTS...... 24

Chapter 7 DIAGNOSIS...... 26

Chapter 8 MANAGEMENT...... 33

REFERENCE LIST...... 46

PREVALENCE Athletes Sedentary population

IMPACT Sports participation & performance Employment

PAGE 4 OF 50 Copyright Alison Grimaldi 2018 The Impact & Prevalence of Proximal Hamstring Tendinopathy

The impact of proximal hamstring tendinopathy Limited evidence exists regarding the impact and can be substantial for athletes, most unable to prevalence of proximal hamstring tendinopathy. train or compete effectively (Nicholson et al. Information available is from surgical or small 2016, Puranen & Oravo 1988). As the condition conservative rehabilitation case series, rather often becomes chronic, it may have longer term than large population based prevalence studies. impacts on participation and performance and Proximal hamstring tendinopathy presents most for elite athletes has the potential to end their commonly in athletes, particularly those involved professional career. Even for the recreational in middle and long distance running or sports runner, interference with their normal running involving running such as triathlon, heptathlon, schedule can have secondary impacts on decathlon (Fredericson 2005, Lempainen et al. general health, mental health and quality of life. 2009, White 2011). While for many athletes the main impact is on Proximal hamstring tendinopathy may also their sporting activities, for some and certainly present in athletes competing in field sports for the non-athletic population the primary such as the various football codes, ice hockey impact is on their ability to sit comfortably. This and baseball and sports involving jumping and can become a major issue, with consequences landing such as long and triple jump and ballet for those in occupations that are primarily (Lempainen et al 2009). In these sports, high performed in sitting at a desk or in a motor ranges of hip flexion are regularly used, often vehicle. at speed and/or under load, placing high loads on the hamstring complex.

This condition may also present however in the older, non athletic population who spend more prolonged periods sitting (de Jesus et al. 2015, Puranen & Oravo 1988). In clinical practice, presentations in older individuals often involve co-morbidities. From a mechanical perspective, there may be some form of co- existing functional limitation down the kinetic chain (knee or ankle). Co-presentation of gluteal and proximal hamstring tendinopathy is also not uncommon in post-menopausal females. They often present with a diagnosis of gluteal tendinopathy or ‘trochanteric bursitis’, but also have ischial pain and signs consistent with proximal hamstring tendinopathy that has gone undiagnosed.

AREA & NATURE OF PAIN

PAINFUL POSTURES & ACTIVITIES

HISTORY OF SYMPTOM ONSET

PAGE 6 OF 50 Copyright Alison Grimaldi 2018 Area & Nature of Pain Proximal hamstring tendinopathy is recognised as pain in the immediate vicinity of the ischium, that may extend to the mid- posterior thigh. (Fredericson 2005, Lempainen et al. 2009, 2015, Nicholson et al. 2016)

The pain associated with an isolated hamstring tendinopathy is generally described as a deep ache, does not usually refer to or below the knee, and peripheral neurological signs and symptoms are absent (Lempainen et al. 2009, 2015). In some sufferers however, the adjacent sciatic nerve becomes involved secondarily, tethered within fibrotic adhesions (Fredericson 2005). In these cases the patient may complain of symptoms of sciatica with pain extending more distally, sometimes sudden and stabbing or burning in nature. Parasthesia in the distribution of the sciatic nerve may also be reported. This complication has been referred to as ‘ Proximal Hamstring Tendinopathy-related Sciatic Nerve Entrapment’ (Mattiussi & Moreno 2016).

Copyright Alison Grimaldi 2018 PAGE 7 OF 50 Painful Postures & Activities Prolonged sitting and driving are problematic, and sitting on a hard surface is much more painful. Patients often offload their buttock by side shifting their trunk and lifting their ischium off the chair, sitting with their buttock half off the chair, or with their hands under their proximal thighs. You might notice the patient offloading in these ways during their patient interview, or they may prefer to stand while you discuss the problem.

Other aggravating activities include walking upstairs or uphills, squatting/deadlifting and lunging (worst if deep or if trunk is inclined forward), and forward lean activities such as putting something in the bin, loading the dishwasher, weeding the garden from a standing position. Golfers may report pain when leaning over to place their ball on the tee or when climbing out of a bunker.

Running athletes may experience most difficulty when running uphill or at higher speeds where stride length and loads increase. Particularly with milder presentations, the pain may ease as the patient runs but worsen on cooling. As the condition progresses, pain may be evident throughout their whole run and impact on their gait pattern. Runners frequently report they are no longer able to stride out, feeling like their hamstrings are short and unable to lengthen during late swing phase.

PAGE 8 OF 50 Copyright Alison Grimaldi 2018 History of Pain Onset Taking a careful history to identify any loading Most commonly, the pain of proximal hamstring errors will be critical tendinopathy develops gradually or insidiously. However, for some the onset is rapid, usually for both recovery induced by some sudden strain or stretch across the hamstring complex (Lempainen et and prevention of al. 2009, Puranen & Oravo 1988, Cacchio et recurrence in the al. 2011). Onset of lower buttock pain of high intensity following a sudden hamstring strain longer term. raises suspicion of a partial or full thickness tendon tear.

Full proximal hamstring origin avulsion may occur with an eccentric hamstring load during forceful hip flexion with the knee extended. An audible pop is usually heard with a full rupture, and substantial bruising is common, tracking down towards the knee. Common mechanisms include a slip into the front splits position, waterskiing and martial arts (Chahal et al. 2012).

Questioning the active patient about recent change in loading patterns is useful. A common clinical presentation is the patient who has increased their hill walking/running or speed sessions leading up to an event, often leaving inadequate recovery time between sessions. They may have joined a walking or running group that includes lots of hillwork to which they are unaccustomed. Joining group training classes that involve dynamic deep split lunges, stair bounding, burpees or kettlebell swings might initiate symptoms, particularly in an older individual who may have some pre-existing degenerative tendon change.

THE HAMSTRING MUSCLE GROUP Biceps Femoris long and short heads Semitendinosus Semimembranosus

ISCHIAL ANATOMY Tendon Insertions Adjacent anatomical structures

FUNCTIONAL ANATOMY Implications from morphology EMG and functional MRI studies

PAGE 10 OF 50 Copyright Alison Grimaldi 2018 The Hamstring Muscle Group

The hamstrings muscle group consists of the semimembranosus whose muscle belly sits most medial on the posterior thigh, the semitendinosus which sits centrally and the biceps femoris long and short heads that sit most laterally on the posterior thigh. The long head of the biceps femoris and the semitendinosus tendons emerge together proximally from a common origin on the superior region of the ischial tuberosity and travel together for about 10cm before diverging to their own muscle bellies (Miller et al 2007). The semimembranosus tendon originates from the superolateral aspect of the ischial tuberosity and runs deep to the common origin of the long head of biceps femoris and the semitendinosus (Figure 1).

ST BF SM SM

Figure 1: The Hamstring Muscle Group. SM:Semimembranosus; ST:Semitendinosus; BF: Biceps Femoris

Copyright Alison Grimaldi 2018 PAGE 11 OF 50 ISCHIAL ANATOMY while the quadratus femoris originates adjacent to the semimembranosus tendon The hamstring tendons of origin are described on the anterolateral aspect of the ischium as oval or crescentic in shape with structural ( Kassarjian et al. 2011) (Figure 2). Overlying dimensions of their footprints outlined in Table the ischial tendons is the ischiogluteal 1. The hamstring tendons have fibres that are bursa, separating them from the overlying confluent with the sacrotuberous ligament gluteus maximus muscle. Awareness of medially. Other structures in the ischial region that these close associations is important in the lie in close proximity to the hamstring tendons differential diagnosis of lower buttock pain. include the sciatic nerve, the deep hip external rotators and the ischial bursa. The sciatic nerve sits just 1 - 1.4cm lateral to the ischial tuberosity (Miller et al. 2007). The obturator internus and gemelli lie just proximal to the hamstring origin,

OI SN

QF BF & ST SM

Figure 2: Anatomy of the ischial region. BF & ST: Common origin of long head of biceps femoris and semitendinosis; SM:Semimembranosis; SN:Sciatic nerve; OI:Obturator internus; P:Piriformis; QF:Quadratus femoris.

PAGE 12 OF 20 Copyright Alison Grimaldi 2017 Conjoint Tendon - BFLH & ST Semimembranosus Tendon

Footprint 2.2 - 4.3cm 2.8 - 5cm Length

Footprint 0.9 - 2cm 0.6 - 1.6cm Width

Tendon 0.7 - 1.3cm 0.6 - 1cm Thickness

Miller et al. 2007, Feucht et al. 2014. Values include 1 standard deviation across both studies.

Table 1: Dimensional characteristics of the proximal hamstring origin. BFLH: Biceps femoris long head; ST: Semitentinosus

FUNCTIONAL ANATOMY The semitendinosus and biceps femoris short head have longer muscle fibres, more optimal for excursion. Semitendinosus particularly has Kellis et al. (2012) studied architectural a very long distal tendon and a more compliant differences within the hamstring muscle aponeurosis allowing greater and faster muscle synergy, with relevance for both predisposition shortening. The semitendinosus is able to to injury and for directed rehabilitation. They create low forces over large excursions, with its characterised the muscles as two pairs – the importance increasing at more extreme lengths medial pair being the semimembranosus and (Kellis et al 2012). the semitendinosus and the lateral pair being the two heads of biceps femoris. They described The other architectural difference of note is distinct architectural differences that suggest that both the semimembranosus and biceps that within each pair one muscle is designed for femoris long head have the larger bulk of their force production, and one for excursion. muscle belly more distally, particularly the semimembranosus that has a long proximal Both the semimembranosus and the long head tendon and significant distal bulk (Figure 1). of biceps femoris have shorter, pennated fibres Having this bulk more distant from the hip which are best suited for power production but joint centre provides a greater mechanical over ranges where muscle length is within an advantage for acting across the hip joint. The intermediate range. Kellis et al.’s model proposes semitendinosus in contrast has a long distal that the semimembranosus and biceps tendon, with relatively more bulk distributed femoris long head produce most force over the proximally, improving its mechanical advantage intermediate (mid) range of hamstring muscle to work across the knee joint (Ono et al. 2010, length, and through this range are responsible 2011) (Figure 3). for almost 80% of the total hamstring force (Kellis et al. 2012).

Copyright Alison Grimaldi 2018 PAGE 13 OF 50 Findings from EMG and functional MRI studies active during these tasks, likely due to the are consistent with the model of specific high range of motion, semitendinosis and hamstring function developed from muscle biceps femoris short head were much more morphology. The semimembranosis and biceps active than the biceps femoris long head and femoris long head are more highly recruited semimembranosis muscles during knee flexion during tasks involving hip extension, such as a tasks, such as a Nordic hamstring curl or a straight leg deadlift or a 45degree hip extension prone leg curl (Anderson et al. 2017, Bourne et task. While the semitendinosis is still highly al. 2017, Ono et al 2010,2011) (Figure 3).

ST & BFSH MORPHOLOGY SM & BFLH Longer fibres ST muscle belly more proximal MORPHOLOGY - better lever arm across knee Shorter pennated fibres Muscle bellies more distal - better lever arm across hip EMG/fMRI Most active in knee flexion EMG/fMRI: Most active in hip extension FUNCTIONAL ROLE Generate lower peak forces FUNCTIONAL ROLE Designed for excursion Designed for force production Important in outer range Most powerful in mid range Act most strongly across knee Act most strongly around hip

Figure 3: Morphological and functional differentiation within the hamstring muscle group. ST: Semitendinosis; BFSH: Biceps Femoris Short Head; SM: Semimembranosis; BFLH: Long Head of Biceps Femoris.

PAGE 14 OF 50 Copyright Alison Grimaldi 2018 Hamstring musculotendinous Bony morphology may also have an influence function during running on activation required in the hamstring muscles during locomotion. A modelling study demonstrated that individuals with longer The hamstring muscle group is active from limbs display significantly lower activity in mid - late swing phase to decelerate the leg and the hamstrings during walking and running. A bring the foot underneath the body’s broad pelvis (inter-iliac distance) also reduced centre of mass ready for ground contact. In the requirement for hamstring activity during stance phase, the hamstrings help extend the locomotion (Wall-Scheffler et al. 2010). hip and stabilise the knee (Schache et al. 2012). As speed of running increases, magnitude of During dynamic locomotor tasks, lower limb hamstring EMG activation increases but tendons do not simply transfer the force the duration of activation remains constant generated by a muscle to a bone to induce (Schache et al. 2013). motion. Tendons and muscle aponeuroses store elastic energy while lengthening and releasing By collecting kinematic, electromyographic that energy during recoil (Alexander 2002). This (EMG) and ground reaction force data, function conserves metabolic energy, improves Chumanov and colleagues were able to use efficiency and attenuates high muscle forces by forward dynamic simulations to compare reducing rate of muscle fascicle lengthening and hamstring musculotendinous stretch, loading, rate of energy absorption (Konow et al. 2012). and work done during stance and swing phases of high-speed running (Chumanov et al. 2011). The hamstrings were shown to lengthen during swing phase loading, from 50-90% of the gait cycle, and shorten from late swing and throughout stance phase loading. While time of peak hamstring stretch remained consistent with increasing speed, the work done by biceps femoris increased significantly at higher speeds, particularly during swing phase (Chumanov et al. 2011).

The hamstring muscles have been shown to contribute significantly to horizontal force production in running and this was correlated with activation of biceps femoris in late swing and eccentric hamstring torque production capability (Morin et al 2015). When running uphill, the requirement for development of horizontal hip extension force is increased. In a study comparing influence of inclines on muscle activity in running, biceps femoris but not the medial hamstrings significantly increased its activity when running on an incline. The effect was strongest on stance phase activation of biceps femoris but increase in activation also occurred in late swing phase (Wall-Scheffler et al. 2010).

HAMSTRING INJURY Histopathology MRI Findings

PHT-RELATED SCIATIC NERVE ENTRAPMENT

ISCHIOGLUTEAL BURSAL PATHOLOGY

The most commonly injured regions of the hamstrings are interestingly both of the force producers, biceps femoris long Acute high head (BFLH) and semimembranosis, with speed injury their poorer ability to rapidly contract or lengthen over large ranges.

The BFLH is the most commonly injured muscle during high speed running type injuries, injury occurring most often at the muscle tendon junction (Askling et al. 2011) (Figure 4). Acute proximal tendon injury is seen most commonly at the semimembranosis origin. Askling refers Most common at to a second type of athletic hamstring Biceps Femoris Long Head injury which he calls a stretch type injury, occuring within the semimembranosis musculotendinous junction tendon most commonly, and associated with activities such as high kicking, slide tackling and sagittal splits, all performed with the knee fairly extended Slow stretch and maximum load across the hip joint injury or (Askling et al. 2007, 2011). As degenerative tendinopathy tendon tissue is more likely to tear it is possible that some of these acute ‘stretch type’ injuries may occur in athletes who have had underlying asymptomatic tendinopathy.

Most reports suggest that chronic proximal hamstring tendinopathy is also Most common at most common in the semimembranosis tendon (Bowman et al. 2013, Lempainen Semimembranosis et al. 2015). Certainly tendinopathy also proximal free tendon occurs in the conjoined tendon of BFLH and semitendinosis (Benazzo et al. 2013), particularly in more longstanding Figure 4: Most common regions of hamstring injury presentations. For complete avulsion to occur, tendinopathy is likely to have been present throughout the hamstring origin.

Lempainen and colleagues have investigated the Larger proteoglycans and the binding of more histopathological presentation of the hamstring water into a pathological tendon, resulting in tendons of patients with persistent signs of tendon thickening and increased signal intensity proximal hamstring tendinopathy. They also on MRI. DeSmet et al. (2012) in a large MRI study managed to obtain a normal control sample found that 90% of patients imaged in their clinic for comparison (Lempainen et al. 2009). showed increased internal signal intensity of the The symptomatic tendons display no sign of hamstring tendon of origin, despite less than acute inflammation with changes reflective of 10% of these tendons being symptomatic. They tendinosis or degenerative stage tendinopathy, considered that increased internal signal was as discussed in Book 1 of this series – rounding therefore not a good indicator of symptomatic of tenocyte nuclei, increased ground substance hamstring tendon pathology. associated with an influx of large proteoglycan molecules, collagen disorganisation and Features that separate symptomatic from disintegration, and neovascularisation. They also asymptomatic tendons: found adipocytes (fat cells) between collagen 1. An increase in tendon antero-posterior bundles of symptomatic tendons, suggesting diameter or thickness fatty replacement within areas of collagen 2. Increased peritendinous signal on T2 images degradation. (increased brightness around rather than just within the tendon) 3. Bone marrow oedema of the ischium (DeSmet et al. 2012)

RIGHT

a b Figure 5: Proximal hamstring tendon pathology on axial MRIs. In picture a, note the increased thickness on the right side and the increased internal signal intensity. In picture b, note the tendon thickness and increased internal and peritendinous signal. Pink arrows indicate proximal hamstring tendons. IT:Ischial Tuberosity.

PAGE 18 OF 50 Copyright Alison Grimaldi 2018 PHT-related sciatic nerve Ischiogluteal bursal entrapment pathology

Due to its close proximity to the lateral edge The ischiogluteal bursa may in some cases of the hamstring origin, the sciatic nerve may be abnormal in those with lower buttock be impacted upon by pathological processes pain. This is usually referred to as bursitis or occuring in the adjacent hamstring tendons. ischiogluteal bursitis. Ischiogluteal bursitis is Imaging and surgical studies have reported noted in the literature as a rare condition that occasional presence of adhesions between the may be infective or associated with a systemic sciatic nerve and the semimembranosis tendon inflammatory disease or cancer (Kim et al. within the ischial tunnel or compression of the 2002). While a health bursa is not visible on nerve by a large swollen tendon (Lempainen MRI or ultrasound, a pathological bursa may et al. 2009, Puranen & Oravo 1988, Mattiussi expand to a large, externally visible mass (Kim & Moreno 2016). et al. 2002, Cho et al. 2004).

Symptoms associated with PHT-related sciatic Bursal enlargement is also thought to arise nerve entrapment are usually worse in hip from mechanical compression and friction flexion, when the nerve is tensioned and further from sitting on firm surfaces especially with compressed by the adjacent tendon and ischium. added vibration. Traditionally referred to as Actions involving rapid hip flexion and extension ‘weavers bottom’, the condition may develop in may also be problematic due to an inability association with use of heavy, powered sewing of the sicatic nerve to slide freely within the machines (weavers), driving tractors or road ischial tunnel (Lempainen et al. 2009, Mattiussi equipment machines, rowing, horseback riding & Moreno 2016). or secondary to a heavy fall on the ischium (Cho et al. 2004). These mechanical forces may also negatively affect the proximal hamstring tendons resulting in a coexistence of proximal hamstring tendinopathy and ischiogluteal bursal pathology (Dierkman & Guache 2012).

IT IT

Figure 6: Ultrasound transverse at ischium Figure 7: Coronal MRI: Increased signal in the demonstrating relationship between hamstring ischiogluteal bursa in patient with lower buttock pain tendons (arrowhead) and sciatic nerve (circled). and proximal hamstring tendinopathy. IT: Ischial Tuberosity; GM:Gluteus Maximus. IT: Ischial Tuberosity;

MECHANICAL LOADS Compression Tensile Load The Influence of Joint Position - Hip Flexion Change in Loading

PAGE 20 OF 50 Copyright Alison Grimaldi 2018 General health risk factors for tendinopathy have been discussed in detail in Book 1 of this series. There is often a contribution of both mechanical and systemic health factors underlying the development of tendinopathy. With proximal hamstring tendinopathy, the younger group of runners are more likely to have a primary mechanical driver, whereas general health contributors may have greater influence in older patients with this condition.

Mechanical Factors

The combination of compressive and tensile Compression is thought to be an important loads is most damaging to tendon structure aetiological mechanism for this insertional (Soslowsky et al. 2002). For the hamstring tendinopathy, with compression of the deepest tendons, higher tensile loads will be induced tendon fibres occurring against the ischium in by positions of stretch - hip flexion and knee positions of hip flexion (Cook & Purdam 2012) extension. (Figure 8 & 9). The semimembranosis is most commonly effected as it sits deepest, running Tensile loads will be even greater when the behind the common origin of the biceps femoris muscle is active in positions of stretch. As we long head and semitendinosis. have already explored, the hamstrings group is highly active in late swing and early stance, reflecting a period of high compressive and Hip tensile loads for the hamstring tendons. During this phase the hamstring tendons will also Flexion be undergoing a period of significant energy storage and release, often referred to as a HOF stretch-shortening cycle.

Figure 8: Sagittal plane MRI. Note the insertion of the hamstring tendon (green arrowheads) onto the posterior aspect of the ischium. Pink arrowhead - hamstring muscle. Visualise the pulley effect as the hamstring tendons wrap around the ischium during hip flexion. HOF: Head of Femur; IT:Ischial Tuberosity

Figure 9: Diagrammatic representation of hamstring tendon compression under tensile load as the hip flexes with an extended knee. IT:Ischial Tuberosity.

PAGE 22 OF 50 Copyright Alison Grimaldi 2018 Sustained hip flexion scenario’s that may be contributing to the patients’s proximal hamstring tendon pain. Prolonged sitting represents a situation of sustained hip flexion where the body weight Postural forward trunk inclination in standing compresses the ischium and wrapped and walking may also be driven by other tendons against the weightbearing surface. deficits within the kinetic chain, such as a In this inactive position, the tendons are post-traumatic lack of ankle dorsiflexion or relatively stress-shielded from tensile loads, hip flexor shortening associated with adding to the poor stimulus for tendon degenerative hip pathology. structure. Sitting on hard surfaces or with the knees more extended, such as when driving Repetitive hip flexion under load with the seat well back from the steering Repetitive hip flexion with an extending knee wheel, may increase adverse hamstring will occur during running. Loads imposed tendon loading. on the hamstring tendons will be greater with higher ranges of hip flexion and higher High volumes of end-range, sustained hamstring activation, as occurs during high hamstring stretching may also stimulate speed and hill running. adaptive changes in tendon structure over time. Askling noted his ‘stretch-type’ Gym activities such as deadlifting, injury of the proximal semimembranosis particularly with straight knees and heavy tendon in dancers who spend long periods loads will induce high compressive and of time in sustained or repetitive stretch tensile hamstring tendon loading. Deep positions (Askling et al. 2007, 2011). Yoga lunges, high step ups and bounding upstairs is another recreational activity that involves will also be high load activities. long periods of sustained hip flexion with extended knees. Change in loading

Sustained trunk forward lean in standing may While these types of load over time may also over time negatively influence hamstring have adverse impact on tendon structure, tendon function. While a 10° lean is nowhere the onset of pain is often associated with near end range hip flexion, from a standing a change in load, to which the tendon is position with the knees extended, bringing the unable to adapt. Training errors such as trunk’s centre of mass anterior to the hip joint rapid increases in training volume, hill centre will stimulate the hamstrings to activate running or speed work are often reported to balance the body weight. Active tensile loads as inciting events (Jayaseelan et al. 2014, are then added to the moderate compressive White 2011). loads and accumulated if sustained for long periods. Sustained forward lean may be a frequent feature of certain occupations such as assembly line workers, nurses, massage therapists and physiotherapists.

In the home environment, some individuals will spend hours leaning over a low kitchen bench to cook, leaning over an ironing board or leaning over from the hips to clean or garden. Detailed subjective questioning may be required to fully elucidate negative loading

MUSCLE DEFICITS Muscle Strength - Hamstrings and Gluteals Muscle Length - Hamstrings and Hip Flexors

PAGE 24 OF 50 Copyright Alison Grimaldi 2018 Muscle Deficits Hip abductor weakness has also been noted in a couple of small case series (Jayaseelan et Unfortunately, there is no reliable evidence that al. 2014, White et al. 2011). Poor pelvic control delineates impairments associated with proximal appears to result in upregulation of activation hamstring tendinopathy. While Lempainen et al. of thigh musculature in a more global pattern (2009) reported no significant strength deficits in of stabilisation or co-contraction. patients with proximal hamstring tendinopathy, small case studies do report weakness in both No clear pattern of hamstring length variation the hamstrings and gluteals (Jayaseelan et al. has been established - short, normal and long 2014, White et al. 2011). muscle length reported. Hip flexor length is sometimes suggested to be a problem, Clinically, gluteal and hamstring weakness is associated with increased anterior pelvic tilt and common in patients presenting with painful presumably increased hamstring tendon loads proximal hamstring tendinopathy, more likely due to the relatively more flexed hip positions. in those with long standing and/or more severe The evidence is poor and does not provide a firm symptoms. Gluteus maximus weakness may evidence base for management at this stage. shift the balance within the hip extensor synergy, Clinically, patients presenting with painful resulting in higher hamstring loads. proximal hamstring tendinopathy appear to be at either end of the spectrum of deficits - Atrophy of the gluteus maximus may also result anterior or posterior pelvic tilted, short or long in increased compression at the ischium in in the hamstrings. This is similar to the bimodal sitting, due to the reduction of soft tissue presentation present in gluteal tendinopathy between the ischium and the weightbearing (Refer to Book 2). Much further research is surface. If unilateral, this may result in a shift required to establish the most common deficits of bodyweight towards the atrophied side when in this population. The clinician should address sitting, increasing compressive load unilaterally the deficits presenting in each individual. (Figure 10).

RIGHT

Figure 10: Axial MRI. Note asymmetry in gluteus maximus bulk - thinner on the side of symptomatic ischial pain (Right Side). IT:Ischial Tuberosity.

DIAGNOSTIC TESTS Puranen-Orava Test Bent Knee Stretch Taking Off The Shoe Test Standing Heel Drag Provocative Load Tolerance Tests Lumbar and Sciatic Nerve Assessment Palpation

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PAGE 26 OF 50 Copyright Alison Grimaldi 2018 Diagnostic Tests

Reiman et al. (2013) reviewed available studies Puranen-Orava Test to determine the diagnostic accuracy of clinical tests for hamstring injury. They concluded that The Puranen-Orava test was first described there was a paucity of studies and a need for by the named authors in 1988 (Puranen & higher quality research. Of the tests reviewed for Orava 1988). It is simply a standing hamstring proximal hamstring tendinopathy, three passive stretch, the patient placing their foot on a tests reported by Cacchio et al. (2012) - the bench at approximately 90° hip flexion and then Puranen-Orava test, the bent-knee stretch and leaning their trunk forward while maintaining the modified bent-knee stretch - had moderate to an extended knee (Figure 11). The important high validity and high sensitivity and specificity feature of all tests for diagnosis of proximal for diagnosing proximal hamstring tendinopathy. hamstring tendinopathy, is that a positive test is one that reproduces the patients ischial pain. Other tests have been described but not tested A stretch sensation in the posterior thigh is not for diagnostic accuracy or usefulness in the a positive sign but posterior thigh stretch or assessment of lower buttock pain. A description pain may accompany the ischial symptoms. of all the available tests will follow, however, due to the paucity of evidence, the clinician should not rely solely on these tests but use sound clinical reasoning principles. The examiner should draw on patient interview findings with respect to current symptomology and history and perform physical tests that not only assess the hamstring tendons but aim to rule out other alternative sources (eg lumbar spine, disorders of the deep gluteal space, ischiofemoral impingement, bony lesions).

Figure 11: The Puranen-Orava Test - Hamstring stretch in standing.

The Bent Knee Stretch was described by The BKS was modified by Cacchio et al. (2012). Frederickson et al (2005). From a supine The difference with this method is that the position, the examiner fully flexes the hip with examiner passively brings the hip to maximum a bent knee and then passively moves the knee flexion and then rapidly extends the knee, aiming slowly towards extension while maintaining the for higher pain provocation. As the patient may flexed hip position (Figure 12). This test wraps the instictively actively resist this rapid movement, proximal hamstring tendons around the ischium it likely combines passive compression with and adds a passive tensile load. A positive test active tensile load. However, care should be reproduces the patient’s ischial pain. taken with this test. In the case of a potential tear or partial avulsion of the hamstring tendons, there is potential for worsening the patient’s Bent Knee Stretch situation. This test may be one to leave as a with Resistance (BKS-R) final test if all other clinical tests are negative. While not described in the literature, applying principles learned from our gluteal tendinopathy Taking Off the Shoe Test (TOST) diagnostic testing research (see Book 2 of this Zeren and Oztekin (2006) reported that the series), adding an active tensile component Taking Off the Shoe test was very useful in may increase the usefulness of this test. From screening for biceps femoris muscle strains. the stretch position, the examiner requests the The test has not been examined in the literature patient to isometrically resist a knee extension with respect to diagnosis of proximal hamstring force, recruiting the hamstrings actively. This addition may be used when the standard BKS tendinopathy, however runners commonly is negative or equivocal. report the reproduction of their pain when they take their shoes off after a run. With some modifications, we may be able to make the test more specific for tendinopathy at the proximal origin.

The test described by Zeren and Oztekin (2006) requires the patient to stand and externally rotate the painful lower limb from the hip, place the heel in the medial longitudinal arch of the other foot and isometrically resist knee flexion by pushing into the other foot with approximately 20-25° knee flexion (Figure 13).

Figure 12: Bent Knee Stretch base position.

PAGE 28 OF 50 Copyright Alison Grimaldi 2018 Modified Taking Off the Shoe Test

(MTOST) The position of hip external rotation can be modified to a position of hip internal rotation, with the heel of the painful side now pressed MTOSTa - loading common origin into the front of the other shoe. A forward trunk The original test involves very little in the way of position is maintained for the compressive compressive loading at the ischium, assumed to element. The internally rotated and adducted hip be provocative for tendon pathology. However, position may possibly increase the compressive if the patient is instructed to flex forward from load around the lateral aspect of the ischium the hips, which runners often do when slipping where the semimembranosis attaches. These off their shoes, a compressive element can be modifications willnot remove all load from the added. A positive test for proximal hamstring other portions of the hamstrings. All portions will tendinopathy must reproduce pain at the ishium, be active with a resisted knee flexion task and rather than in the hamstring muscle belly or reproduction of the ischial pain may be derived musculotendinous junction. from any of the tendons. The modifications simply seek to fully test the region by applying MTOSTb - loading semimembranosis differing strains across the hamstring origin. The TOST was originally designed to target the There is no evidence to suggest that a specific biceps femoris, as this is the most common region of pathology can be determined in this site of hamstring muscle injury. As proximal manner. hamstring tendinopathy is more often present in the semimembranosis, further modification could be tested to direct the force towards the semimembranosis origin.

Figure 13: From left to right: The original Taking Off the Shoe Test; MTOSTa, MTOSTb

The standing heel drag was described by (MSHD) Bowman et al. (2013) within a battery of tests As with the TOST, modifications to increase to detect partial thickness hamstring tendon compressive load at the ischium may serve tears. The test involves the patient standing and to increase the provocative value of the test. placing the heel of the painful side out in front, The test can be performed with a forward flexing the knee of the weightbearing leg, then trunk inclination. An isometric test may also dragging the heel back along the floor (Figure serve to maintain higher levels of compression. 14). The description is not entirely clear, but it Testing both as isometric hip extension and knee appears the force applied and action is one of flexion action can also be useful, considering hip extension. A positive test is reproduction of the dominance for either knee flexion or hip the patient’s ischial pain. extension within the hamstring group.

Figure 14: From left to right: the original Standing Heel Drag; MSHD with isometric hip extension; MSHD with isometric knee flexion.

PAGE 30 OF 50 Copyright Alison Grimaldi 2018 Provocative Load Tolerance Tests

Cook and Purdam (2013) suggest that functional loading tasks are valuable for monitoring changes in tendon pain and load tolerance. For proximal hamstring tendinopathy, they recommend a bent knee bridge as a low load test and a bodyweight single leg deadlift as a Double Leg Bridge high load test. Goom et al. (2016) adds a single leg bridge with an extended non-weightbearing leg as an intermediate test. Adding external load or increasing speed of loading can be more provocative for milder presentations but base levels tests should always be trialled first.

The Supine Plank Test was recommended Single Leg Bridge - Short Lever by Frederickson et al. (2005) as a hamstring strength test. In clinical practice, this test is very useful as a load tolerance test, the patient often reporting pain and an inability to transfer load to their affected hip and lift their other foot from the floor. Pain reproduction over the ischium is useful as part of a diagnostic battery, but inability to transfer load without pain may simply indicate hamstring weakness. For patients that Single Leg Bridge - Long Lever are unable to weightbear on their elbows to perform the test in the manner described by Frederickson et al. (2005), pillows can be placed under the head and upper back and/or a block or foam roller under the ankles.

Younger patients will also be able to lie on the ground with their feet on a treatment plinth or Supine Plank a bench and perform a supine plank or a long leg bridge (with knee more extended) in this position. Resisted hamstring strength tests in prone may also be used as load tolerance tests if ischial pain is reproduced on testing.

Single Leg Deadlift Start with bodyweight load. Only add external load if appropriate for age, conditioning and severity

Figure 15: Graduated Provocative Load Tolerance Tests

As one of the primary differential diagnoses for buttock pain is lumbar referral, it is important for the examiner to complete a full assessment of the lumbar spine, which will not be discussed in detail here. A simple standing lumbar flexion test will often reproduce ischial pain in more painful cases of proximal hamstring tendinopathy. The area of pain and change in symptoms with modifications of lumbar or head position may provide information as to contributing sources. Slump and Straight Leg Raise tests are also useful for determining involvement of the sciatic nerve but do not serve to indicate the level of irritation (lumbar spine, deep gluteal space, ischial tunnel).

Palpation

The final diagnostic test is palpation of the ischial origin of the proximal hamstring tendons. Palpation has been shown to have variable accuracy in the diagnosis of tendinopathy (Cook et al. 2001, Grimaldi et al. 2017). For proximal hamstring tendinopathy, it can sometimes IT be difficult to elicit significant discomfort on palpation even in the presence of clear positive signs on other clinical tests. However, often a negative palpation result is due to inadequate exploration of the full extent of the hamstring origin, particularly of superior, lateral aspect of the ischium, at the semimembranosis origin. Palpation in a sidelying position usually provides better access to the ischium than a Figure 16: Palpate the ischial tuberosity in sidelying. prone position (Figure 16). A positive test is pain Ensure palpation includes the entire extent of the and tenderness over the ischial origin of the hamstring tendon origin and adjacent structures. hamstring tendons. IT:Ischial Tuberosity.

PAGE 32 OF 50 Copyright Alison Grimaldi 2018 CHAPTER EIGHT MANAGEMENT

LOAD MANAGEMENT Sitting Advice Advice for Activities of Daily Living Stretching Advice Activity Advice

EXERCISE Isometric Hamstring Loading Graduated Loading Program Exercise Considerations

Copyright Alison Grimaldi 2018 PAGE 33 OF 50 Traditional management for proximal LOAD MANAGEMENT hamstring tendinopathy has reflected management strategies used for hamstring Load management for proximal hamstring muscle tears - anti-inflammatory treatment, tendinopathy serves to reduce the most stretching and graduated strengthening in provocative combinations of compressive and tensile loads. Education regarding strategies positions that often apply high compressive that positively influence tendon loading in loads to the ischial hamstring tendons. the area, aims to empower a patient with the Stretching is now considered provocative skills to self-modify their loading and self- monitor their response to loading. As tendon for insertional tendinopathies and is usually compression is incurred in positions of hip not recommended in their management flexion, particularly with the knee extended, (Cook & Purdam, 2012, 2014, Goom et al. sustained use of such postures should be 2016, Beatty et al. 2017). minimised. Positions and activities that require high activation of the hamstrings in hip The more contemporary model of flexion (and particularly with knee extension), management proposed here is a two part are likely to be most provocative, especially approach, involving: if performed with high load, repetition or speed and with inadequate recovery between 1. Load management, aiming to minimise loading. Activities that involve high tendon exposure to provocative loads and graduate energy storage and release, such as higher speed running, bounding and plyometric activity levels appropriately and exercise are also likely to provoke tendon pain. 2. A graduated exercise programme aiming to improve load tolerance via a combination As discussed in Book 2, the transference of this information to a patient should be done in of graduated slow, heavy tensile loading a manner that avoids fear and hypervigilence to improve extensor strength and tendon but provides useful practical strategies for health and motor control retraining aiming self management. Compression, tension and to optimise lumbopelvic-hip control. energy storage are all endured by tendons in everyday activity and it is only cumulative excess loading that may become problematic. The overall aim is to minimise sustained, repetitive or loaded hip flexion (esp with knee Attend a practical extension) and direct compression over the workshop to develop ischial tuberosity while pain persists and then graduate activity within the load tolerance of specific clinical skills the tendon. to optimise your management of proximal hamstring tendinopathy www.dralisongrimaldi.com

PAGE 34 OF 50 Copyright Alison Grimaldi 2018 Sitting Advice

Reduce Try - prolonged sitting - sitting in deep/low chairs - a standing work station - sitting leaning forward (vary between sitting and standing) - sitting with feet up on a stool - a decompression cushion - sitting on hard surfaces (eg. an eggshell cushion or cutting holes out of thick, medium density foam for the ischia) - moving the car seat forward

NOT FOR REPRODUCTION WITHOUT PERMISSION

Reduce time spent in forward lean Share the load across the kinetic postures. chain.

NOT FOR REPRODUCTION WITHOUT PERMISSION

PAGE 36 OF 50 Copyright Alison Grimaldi 2018 Stretching Advice Activity Advice

Avoid activities that provoke pain Avoid hamstring stretching, at during or after the activity. Often least until pain settles, and then rest from the most provocative as appropriate/required. activities or provocative parts of an activity will allow continuation of modified activity.

Walking/running modifications - Avoid/reduce hills and stairclimbing - Reduce speed - Reduce stride length - Reduce impact force - Reduce volume

Avoid/reduce activities involving rapid stretch-shortening cycles, such as plyometric exercise - hopping, bounding, burpees.

Avoid activities involving high compressive loads

Avoid rapid increases in loading Monitor response to activity Sitting pain is a good barometer of how the hamstring tendons are tolerating loads. If sitting pain or pain on problem activities increases, the activities of the day or last couple of days have been too high and need to be modified. Pain after activity should have settled by the next morning. NOT FOR REPRODUCTION WITHOUT PERMISSION

Copyright Alison Grimaldi 2018 PAGE 37 OF 50 EXERCISE Key point: Select a level of loading Load management advice and a graduated that is appropriate for each exercise program aim to reduce pain and facilitate graduated return to painfree function. individual’s pain severity and As discussed previously, impairments can be physical conditioning. quite variable between individuals and will therefore require an individualised approach. LOW LOAD ISOMETRICS Generally, gluteal and hamstring strengthening will be key tenets in the rehabilitation program. Other deficits, for example in the hip abductors, hip flexors, quadriceps or calves may also need to be addressed to optimise load sharing and alignment control throughout the lower kinetic chain. Restrictions in hip flexor or calf length and knee and ankle joint range may require Isometric Knee Flexion ‘Preparation for Lift’ concurrent management to optimise the triple flexion pattern and pelvic orientation.

Isometric Hamstring Loading

Isometric exercise potentially provides benefits via a number of mechanisms: 1. Analgesic response (Hoeger Bement et al. 2008, Kosek & Kholm Isometric Knee Flexion with 1995, Kosek & Lundberg 2003, Rio et al. 2015). Small Ankle Weight 2. Neuroplastic effect (Boudreau et al. 2010, Rio et al. 2015, Tsao et al. 2010). 3. Local mechanotransduction (see Khan & Scott 2009 for review) These mechanisms have been discussed in detail in Book 2. Isometrics do not appear to be effective in delivering pain relief for all patients, Bridge Holds so the emphasis or inclusion of these exercises will determined by your aims and the response of each individual.

Isometrics for the Hamstrings

The level of load selected for isometric exercise will depend on pain severity and physical capacity. For example, a younger runner with good baseline conditioning and only mild symptoms will tolerate higher load isometrics than an older deconditioned patient Isometric Knee Flexion in Standing with quite severe symptoms. Requires ability to sustain single leg stance

PAGE 38 OF 50 Copyright Alison Grimaldi 2018 Graduated Loading Program Graduated loading includes components of HIGHER LOAD ISOMETRICS both targeted low velocity, high tensile load strengthening and more global lower kinetic chain functional strengthening. Aims are to optimise tendon structural health and load tolerance via re-adaptation to tensile loads and to address muscle and neuromotor impairments through strengthening and motor control training to optimise load sharing.

Supine Plank Versions Lower Load Knee Flexion with leg Progress to slow weight shift load, ankle weight or band - single leg

Isometric Holds on Hamstring Curl Machine Higher Load Knee Flexion on Hamstring Curl Machine

Increase load as tolerated MUST achieve >40% MVC to induce strength change Isometric Nordic Hamstring Curl Keep slow pace Only once reasonable strength & no pain with the exercise Add external pacing

Gluteal biased/short leg bridge Maintain neutral spine Ensure good gluteal recruitment Maintain pelvis level

Double Leg

Offset

Single Leg - Short Lever Hip Thrust

Single Leg - Long Lever

Add external load Add handweights or plate weight to pelvis

PAGE 40 OF 50 Copyright Alison Grimaldi 2018 Bridging Progressions Bridge - Curl Combinations

Hamstring biased/long leg bridge Hamstring biased Maintain neutral spine Maintain neutral spine Gluteals still active but hamstring Gluteals still active but hamstring dominant dominant Maintain pelvis level Maintain pelvis level

Double Leg Double Leg Bridge on Foam Roller

Single Leg - Short Lever Supine Curls on Foam Roller

Add external load Add band/cable resistance to hamstring curl

Single Leg - Long Lever Eccentric-only or eccentric bias for hamstring lengthening under load

Single Leg - Long Lever With Added Load

Introduce gradually Attention to lumbopelvic-hip control Monitor response to loading Ensure good gluteal recruitment Avoid pain at ischium

Double Leg

Offset

Single Leg Stance

Nordic Hamstring Curl

Single Leg Squat Start with small range hip flexion - monitor response monitor - Start flexion hip range small with

Many other hamstring loading exercises can be converted to eccentric-only or eccentric

biased (more time under tension in eccentric extra pacing, perturbation load, metronome .. externalAdd e.g. challenge mode) if indicated. See the following section for discussion. Step Up

PAGE 42 OF 50 Copyright Alison Grimaldi 2018 Addressing Other Deficits Dynamic Progressions

Abductor strength & endurance Introduce gradually Hip flexor strength & endurance Includes higher energy storage & release Trunk muscle strength, endurance, control Monitor response to loading Monitor response to loading

Landing Control Hip Abductor Loading

Direction Change

Hip Flexor Loading Progress to tasks specific Attention to Lumbo-Pelvic Control to the patients recreational, sporting or occupational requirements

- dynamic lunges - running drills - bounding - sled push

* Must monitor 24 hour response

Copyright Alison Grimaldi 2018 PAGE 43 OF 50 globally and add eccentric-only loading to Exercise Considerations enhance function at longer lengths. Further research is required to establish structural and Exercise Mode functional impairments in those with proximal hamstring tendinopathy which will help guide best management. While eccentric exercise has previously been the mainstay of loading regimes for tendinopathy, more recent studies have suggested that heavy, slow concentric- eccentric programs may be most useful due Outer Range Loading to better patient compliance and satisfaction Restoring outer range function is often an (Beyer et al. 2015) and a superior effect on important consideration for impairments of the tendon structure (Kongsgaard et al. 2010). The hamstring complex. However, exercises that are main focus of the graduated loading program will then be a slow, heavy loading concentric- commonly selected to work through this outer eccentric program performed 3 times per week range for musculotendinous junction injuries with the aims of achieving positive changes in have the inherent risk of high compressive muscle strength and tendon health. load at the proximal hamstring tendons. All exercise strategies may not then be readily transferred to rehabilitation of symptomatic Contraction mode has been shown to have hamstring tendon pathology. Stiff leg deadlifts a significant effect on muscle structure or Romanian deadlifts hold the highest risk due and neuromotor control. Eccentric exercise to the high degree of hip flexion and reliance programs have now been demonstrated to on the hamstrings group to control the load. result in increased hamstring muscle fascicle Two recently published rehabilitative programs length and addition of sarcomeres, resulting include progression to such high compressive in improved ability to generate torque at longer muscle lengths (Alonso-Fernandez load exercises (Goom et al. 2016, Beatty et al. et al. 2017, Lepley et al. 2017, Timmins et 2017). There is no evidence currently to support al. 2016). Importantly, these changes can or refute the efficacy of such an approach. be achieved with exercises such as Nordic Hamstring Curls, which do not require moving into outer range positions with high tendon compressive loading. Recent evidence has also demonstrated significant neuromotor effects with eccentric-only exercise enhancing recruitment in association with increases in central motor drive (Lepley et al. 2017).

Particularly for the subgroup of patients with restricted hamstring muscle length and pain at end swing phase, adding eccentric-only exercise may have additional benefits to that provided by the heavy slow loading program. There is no evidence for effect in patients with proximal hamstring tendinopathy and no clear guidance regarding at what timepoint to best introduce eccentric exercise. If a patient exhibits muscle weakness across contraction modes, it would seem prudent to use the heavy slow loading program to strengthen

While we await scientific testing of current clinical practice, it may be useful to reflect on the mechanobiological principles that underpin our current understanding of pathoaetiology of tendinopathy. If indeed type of load is a potent driver of tendon structure and health, as explored in detail in Book 1 of this series, our overall aim from this perspective, is to achieve a situation of relative homeostasis, where loading stimuli are relatively balanced. As the hamstring tendons are normally exposed to compressive load during everyday activities and even higher compressive loads with particular sporting activities, does it make sense to add maximal compressive load to a recovering tendon within the scope of rehabilitative exercises, or will this potentially tip the balance back in favour of tendon dysrepair? The argument within the recently published clinical papers is that these activities are preparing the athlete for return to sport, but if such loads were an important stimulus for the adverse tendon changes, it may be best to graduate slowly back to necessary functional activities while focussing on exercises in the gym that will balance those compressive loads, such as a heavy slow tensile loading program. Particularly with degenerative stage tendinopathy, long term management may involve minimising compressive load for 80% of the time, so the patient can tolerate necessary compressive loads 20% of the time within the sports or activities they wish to continue.

Stiff Leg Deadlift

Hip Extension Machine with Straight Legs Running uphill Running at speed Kicking Forward lean to play hockey, gather a ball off the ground, perform a ballet or gymnastics maneuver Emptying the dishwasher Putting shoes on Bending/lifting Heavy, slow tensile loads with low Gardening/Cleaning compression eg prone hamstring Forward lean at work curls

HOMEOSTASIS

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Copyright Alison Grimaldi 2018 PAGE 49 OF 50 With over 25 years of clinical experience, Alison is Principal Physiotherapist at Physiotec Physiotherapy in Brisbane, Australia and an Adjunct Research Fellow in the School of Health & Rehabilitation Sciences, University of Queensland. Alison has a special interest in movement, muscle dysfunction and optimising musculoskeletal loads and is a committed lifelong learner.

Alison completed a Bachelor of Physiotherapy at the University of Queensland in 1990, a Masters of Sports Physiotherapy in 1997, and her Doctorate in Philosophy in the Field of Physiotherapy (PhD) in 2008. Her PhD studies were concerned with improving our understanding of hip muscle function and the relationship with hip joint pathology and weightbearing stimulus. Alison continues to be passionate about extending our understanding of why we develop problems around the hip and pelvis, and what we can do to most effectively prevent and manage these problems. She has ongoing involvement in research studies investigating lateral hip pain, proximal hamstring tendinopathy, groin pain and function of the deep hip flexors and rotators.

It is one of Alison’s core beliefs that research should be relevant to clinical practice and helping the patients we treat every day, and that physiotherapists in the community should have access to this valuable information to allow them to transfer this knowledge into clinical practice as quickly as possible. To this end, Alison continues to publish, present and provide practical workshops for other health professionals. Alison has published many peer-reviewed papers in scientific journals, has contributed detailed information freely accessible via podcasts by PhysioEdge (itunes) and the British Journal of Sports Medicine (SoundCloud), and has recently contributed to 3 leading physiotherapy and sports medicine text books. She has presented her research and clinical teachings in Australia, New Zealand, England, Ireland, Scotland, Wales, Singapore, HongKong, the Netherlands, France, Belgium, the Unites States of America, Canada and the United Arab Emirates.

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