Disclaimer

As with Jaeger, it’s worthwhile noting that I have no inside information on Cyril. I have no professional links to the great man or the Hawthorn Football Club. The details in this article are another mix of Google-able media coverage of Cyril’s Hamstring issues and my many years of Physiotherapy experience. I want to emphasise again that I have great respect for Hawthorn and the way AFL medical teams go about their business. They do an amazing job. I’d hate for this to come across as casting judgement from afar, no stones thrown here!

For the purposes of this article I hope to assume that everything reported in the media is correct. If not, much like Jaeger, it probably doesn’t matter as even though this post is about Cyril’s fight for Hamstring supremacy, it’s not really about Cyril.

This is another light-hearted attempt to get my findings out there and create discussion, so please take it in the spirit that it’s intended.

For those who remain unaware, I am a Hawthorn supporter and long-term member. Unlike my experiences with Patella Tendonopathy, I have never had any serious Hamstring dysfunction. Weak heart and glass jaw – yes, fragile ‘strings – no.

As I mentioned last time, I am a huge nerd about this kind of thing. My passion for exploring injuries matches up perfectly with the my wife’s disdain towards the amount of AFL I consume.

Introduction

First things first. Thank you to everyone who took the time to read my last article. It reached far further that I could ever had imagined. The interest it generated across social media was breathtaking, and it was featured on some of Australia’s most popular social forums. Again, thank you. I expected some genuine backlash thanks to the way my industry tends to handle these types of things, but to a tee, literally everything I’ve seen has been positive.

Through Physio I’ve become skilled at pattern recognition. The more dysfunction you see, the easier it is to link things together. Things that may seem relatively obscure and harmless in isolation, but may form the foundation of an injury when considered in a broader sense.

I certainly know of a few great thinkers who already seem to be heading down the path I feel I’m on, so I’d like it known that I don’t think I’m the first to consider these ideas in regards to Hamstring injuries. But much like the back and it’s potential role in Patella Tendonopathy, the good ol’ Hammy might be more than meets the eye.

I again hope to use an AFL player’s past misfortune in a positive way to highlight what I’m finding clinically. Cyril Rioli has been a joy to watch as a Hawks supporter so far and I’ve always kept a close eye on his injury plight.

Just take a look at what this man can do on the football field to get a sense of why he is such a pleasure to watch.

I’ll tap in to the specifics of Cyril’s history below, but as an hors-d’oeuvre (call back) I feel my industry may be missing an important potential cause for Hamstring injuries.

It may also have ramifications for one of our most common treatment focuses.

Join me again, as I try to use what I’m finding here at Peninsula Physiotherapy to hopefully shed some light on why the common Hamstring remains so common. We’ll laugh together, we’ll cry together, we may even get matching butterfly tattoos together. Either way, let’s get dirty.

Cyril’s Injury History

Issue: A 6 year history of bilateral hamstring dysfunction. No significant re-occurrence in the last 2-3 years (huzzah!).

To highlight Cyril’s plight I’ve screen-grabbed an image from a news report from Cyril’s last Hamstring injury.

As you can see, one of the most freakishly skilled, agile and damaging players in the AFL was cruelled by recurring Hamstring complaints up until a few years ago.

After playing every game in a brilliant first year in the AFL, Cyril experienced SEVEN in-season Hamstring injuries in the next six years. Twice he suffered multiple injuries in the same year.

Here’s the breakdown:
2009: R11 RIGHT Hamstring (3 games missed)
2010: Elimination Final LEFT Hamstring (End of season)
2011: R5 RIGHT Hamstring (3 games) + R14 RIGHT Hamstring (3 games)
2012: No Hamstring injury
2013: R5 RIGHT Hamstring (9 games)
2014: R8 LEFT Hamstring (3 games) + R15 LEFT Hamstring (9 games)

Interestingly, Cyril has reached three publicly-reported rehab ‘milestones’.

  • 2010/11 off-season: After Cyril’s 2010 season ended prematurely, the Hawthorn medical team spent the 2010/11 off-season re-shaping his running technique. (Article)
  • June, 2014: Cyril was beginning to graduate from an elite small forward to an elite midfielder. However following another spate of Hamstring injuries, Hawthorn coach Alistair Clarkson stated that Cyril’s body may only allow him to remain up forward with the occasional cameo in the middle. (Article)
  • 2014/15 off-season: Following Cyril’s 7th Hamstring injury, the Hawthorn medical team modified his training to incorporate more targeted strength work through his trunk, hips and legs. Interestingly, although currently sidelined with a PCL injury, his Hamstrings have yet to fail him again in his last 53 games. (Article)

The Hamstrings

To get a little technical, the “Hammies” constitute three main muscles at the back of the thigh. They originate from around the sit bone at the bottom of the pelvis and insert to back of the leg below the knee.

Hamstrings like to bend the knee and extend the hip. They also help lower a straight back when leaning or bending over.

They also seem to get injured a lot.

So much so that most athletes would have had some Hamstring dysfunction at some point – whether it be some irregular tightness or a full blown tear/rupture. It’s a prolific beast.

Despite this, my industry hasn’t yet nailed the issue completely. There’s still some lingering grey areas.

In the AFL alone, new Hamstring injury rates have barely shifted for the best part of six years (Link).

The length of time out injured and the rate of re-occurrence have been similar for seven to eight seasons now. Things are certainly better than a decade ago, but the point remains the same. This is despite our AFL athletes being some of the best conditioned in the world and being conditioned by some the best in the world.

For proof, just check out the GWS Giants’ viral video of Dylan Shiel doing a ‘razor curl’.

It’s great to watch. Give it a go if you can, it’s hard to comprehend how good he is without understanding how bad the rest of us probably are.

If we look at the AFL injury list over the last 3 weeks (round 17-19), we see an average of 26 Hamstring complaints. (Link)

Each week is a revolving door of Hamstring dysfunction and rehab.

Why do they happen?

If you were to line up every Health Professional and ask why a Hamstring injury occurs, I’d imagine you won’t get a consensus. Most likely because I don’t think we currently have one. Clearly every Hamstring injury is a unique little flower in a field of unique little flowers, but the human body is essentially the same for everyone. A Hamstring is still a Hamstring. It’s still attaches to the same areas and is expected to function the same.

The factors that we currently look for are broad. You might hear a mixture of terms like “tightness” and “weakness” involving the Hamstrings, Quadriceps, Gluteals and “Core”. The term “imbalance” is often associated with Hamstring dysfunction. Environmental factors like footwear and poor warm-ups also seem to get blamed.

We often lean towards strength training to help improve the robustness of the Hamstring, Gluteals and “core” in the hope of preventing it’s onset and re-occurrence.

Yet despite all we currently understand about Hamstring function and injury management, we may, in my clinical experience, be missing the bigger picture.

Sometimes I feel that we don’t take a big enough step back and ask WHY the tissue is dysfunctional in the first place.

And this is where I’d really like the conversation to heat up NBA Jam-style.

What I’m finding clinically

If someone comes in with a Hamstring injury, as a Physio – I can go hunting. I can poke around and see what might be wrong with the system as a whole. More importantly, I can treat things and re-assess immediately. I can then re-test the same idea over and over again with different patients to establish a pattern. Not necessarily one dictated to by years of traditional research, but one hardened by years of clinical exploration and results.

With that in mind, I find one thing intrinsically linked to Hamstring injuries…

Low back dysfunction.

Please note: I hope the significance of this statement isn’t softened by my last article on Jaeger’s knee. The fact that low back dysfunction may also be the linchpin for this as well speaks volumes for it’s mechanical importance in my opinion.

The Low Back

The longer I’ve been hunting for solutions to physical problems, the more I keep coming back to the spine.

The “back-related” Hamstring injury may not be news to some, but it will to others.

Over the last few years, EVERY SINGLE patient that has come in to my clinic with the traditional Hamstring complaint also seems to have some low back dysfunction. Period.

Interestingly, they may have absolutely no awareness of any “issue” there at all. But it seems to be there, you often just have to look for it.

It’s worth noting that low back pain is a ridiculously common issue amongst Australians. The Australian Institute of Health and Welfare (AIHW) notes that a 2014-15 survey by the Australian Bureau of Statistics estimates that 70-90% of Australians will “suffer from lower back pain in some form at some point in their lives.” (Link)

That paints a rosy picture doesn’t it? And that’s just those in pain. It doesn’t even begin to cover those who just feel stiff and generally abnormal.

This clearly doesn’t mean everyone with a dodgy low back will go on to enjoy an injured Hamstring, but once injured hindsight seems to speak for itself.

So, what kind of low back “dysfunction” are we talking?

I find two major factors relevant to Hamstring injuries:

1. Joint Stiffness

Anatomically speaking, most joint stiffness seems to be around the L4/5/S1 area.

For the nerds amongst us, you may also recognise these as the general origin of the Sciatic Nerve. For those unaware, the Sciatic Nerve essentially goes straight down the back of the leg – along with the Hamstrings.

Mechanically I’m thinking that as the nerve becomes restricted, it may not “floss” as it’s supposed to. This may create the potential for mechanical dysfunction along any part of it’s path down the leg.

This is an important feature because we often seem to mistake Sciatic Nerve tightness for Hamstring tightness.

Try this out:

Stand up and put your heel onto a bench in a typical Hamstring-stretch position.

It’s interesting to note that most will feel tight somewhere down towards the back of the knee. It may even get tighter if you pull your foot back.

What’s also interesting is that’s a sign of neural tightness – not Hamstring tightness. A true Hamstring stretch should be felt more in the heart of the thigh where the muscle belly is.

Now, try this:

Lie on the floor and gently press a foam roller/rolled up towel in to your lower back. Take the time to stop and let the roller press in to any stiffness you find. Spend a few minutes on each spot

Now, stand up again and re-check that Hamstring stretch. With any luck that leg “tightness” may now feel freer.

Finally, try this one:

Stand up, bend over and try to touch your toes. Get a sense of how low you can go. How does it feel to do?

Now lie on your back and bend one hip and knee to 90 degrees with your ankle bent back as far as it will go. Next, clasp behind your thigh with both hands and gently straighten your leg from the knee. Touch the end of your range and come out again. Repeat this fifteen times. Make sure you keep your foot bent back at all times.

Now, bend over again and you should see an immediate improvement. Pretty cool, right?

Each test is a great example of how back stiffness/neural tension will compromise “flexibility” at the back of the leg.

The Sciatic Nerve should floss freely through/around all the structures it associates with at the spine, hips and leg. Clinically, any restriction seems to have a negative effect on the function of the back of the leg and our precious Hamstrings.

Consider for a moment what effect any low back restriction/increased neural tension may have on the system if you are sprinting at top speed. Now imagine Cyril at top speed…

2. Poor Spinal Stabilisation

At this point it’s important to make a clear distinction. When discussing trunk stabilisation, I’m not talking “core strength”.

I’m referencing our ability to consciously “activate” our trunk musculature and reinforce our spine. Clinically, it’s this activation or lack thereof that may slowly chauffeur our athletes to Hamstring Injury Town.

Clinically, it seems that a poorly stabilised spine recruits other tissue – hello Hamstrings, to help out. Essentially, the body may sacrifice our peripheral mechanics in order to prioritise central stability. In other words, the spine is more important than our legs.

To get a sense of the phenomenon, try this:

Lie on your back again with your hip and knee at 90 degrees.

Keeping your thigh in the same position at all times, straighten your knee. Use the roof to get a sense of how far you went.

This time, consciously activate your trunk and brace your spine. (For a simple HOW TO, go here).

Now, try and re-straighten your leg. You should see the leg now goes a little further.

This is a great example of how a well-braced spine allows the Hamstrings to function with more freedom.

Poor bracing (independent of how strong your trunk is) may leave our Hamstrings at a constant mechanical disadvantage.

Now put THIS into someone like Cyril at top speed…

IMPORTANT: If nothing else, these results alone should at the very least challenge our thinking of what a “tight” Hamstring actually is. Is it truly tight/weak or made to seem so by something higher up in the mechanical food chain?

Why, Why, Why, Why, WHY?

To put all this into perspective, let’s take the conversation further.

Why does a lower back get stiff?

Why does a trunk that’s inherently designed to self-stabilise, become poor at doing so?

This leads me to one of THE most boring and unsexy topics of conversation in the history of the universe and throughout all time and space…

Posture

Now this is absolutely NOT news to anyone. Everyone’s been pestered about slouching by their parents before.

The problem as I see it more often than not relates to sitting. Or as I discuss with my patients – the shapes we consistently get sucked in to.

It’s just such a big part of our modern lifestyles.

Everyone knows what a couch feels like. Everyone’s been in a car, used a computer or read a book.

Our elite athletes certainly aren’t immune either. Cyril still has to sit in team meetings and fly interstate. He’s still a human being like the rest of us after all.

The Slouch

Like most activities, I find that it’s not WHAT you do that matters, it’s HOW you do it.

And although the sedentary aspect of sitting is bad enough (Google “Sitting is the new smoking“), it’s the lounging or slouching that seems to take a toll here. Not an immediate one, but more of a “death by a thousand cuts”.

Forcing a constant hinge into your back seems to ask your spine to reinforce against it over time. Hello, stiffness.

Similarly, slouching is not an active position. It’s a passive one. So after years of constantly telling your trunk that you don’t need it to activate, what is it likely to do? Deactivate. This also highlights why I’d like to separate core strength from activation. You can be brutally strong and really well conditioned through that trunk, but if you slouch you may actually use none of it.

If it’s not too self-indulgent, I’d like to quote a paragraph from my last article.

“In my opinion, almost no injury is bad luck – or at least we give luck far too much credit. Every musculoskeletal problem happens for a reason. It’s just that that reason may not always be instantly obvious if you aren’t looking for it.”

With all this in mind, it seems that the positions we put our spines into on a daily basis may create the dysfunction that leads to Hamstring injuries. At least that’s what I seem to be finding clinically.

Let’s get (s)talking

In my last article I tried to find some images of Jaeger to highlight my point.

Unfortunately with Hamstring dysfunction the symptoms often seem to be more covert. I can’t source a pic of someone with a stiff back or a poorly activated trunk. I can however, show you what I believe to be the CAUSE of those symptoms. Interestingly, it’s not hard at all to find pics of Cyril in a poor resting spinal shape.

Obviously these photos of Cyril are just a moment in time and may not reflect his reality. But the pictures show what they show. In fact EVERY photo I could find of Cyril sitting has him slouching. Take that as you will.

What about the rest of the league?

There are three other AFL footballers at different stages of their return from recurrent Hamstring issues.

Hawthorn’s Jonathan O’Rourke:

Fremantle giant Aaron Sandilands:

And St Kilda’s Nathan Freeman (r):

Again, these photos just capture a small moment in time and don’t necessarily support anything, but they at least highlight one instance of bad spinal positioning. If they are in any way reflective of their daily, default shapes, then their low backs and Hamstrings may continue to teeter on a dysfunctional edge. In my experience they may need exceptional rehab to maintain a buffer against these shapes in the long term – perhaps like Cyril of late.

Where to now?

Despite the amount of time dedicated to all things Hamstrings, I’m not yet convinced we are completely out of the dark ages yet. Clinically, there seems to be a strong, repeatable pattern between poor spinal shapes, low back dysfunction and Hamstring complaints.

Again, I have no traditional research to present to those who thrive in that space, but I do have my repeatable and actionable clinical observations. By being able to assess and treat Hamstring dysfunction, I have the privilege of seeing things unfold in real time.

It’s often a weird sell to patients that their back may be getting in the way of their Hamstring function because most don’t have any overt spinal symptoms. But it’s likely to be there in my experience. You just have to go looking for it.

Deep down, I’m sure that everyone reading this will at least have some basic awareness of the importance of good “posture”, but how many of us actually take the effort to practice good spinal shapes ALL the time? Not many, if any (#Scribe).

Without it, we may just be creating a haven for poor trunk muscle function and stiffness – elite athlete or not.

Cyril may have the best strength, conditioning and rehab staff at his disposal, but when he’s not being athletic, what is he doing with his spine? Could something as simple as Cyril’s daily spinal shapes, one’s that have absolutely nothing to do with taking mark of the year, making game-saving tackles and kicking game-winning goals, have set his Hamstrings up to fail?

If the photos I could find are in fact a true representation of Cyril’s default spinal shapes, does that mean he may have another Hamstring injury on the horizon if his hard-earned strength and conditioning buffer starts to fade?

I’d love to find out for myself.

It’s important to note that the postural/positional conversation sucks. It’s boring and certainly a pain in the ass to practice. But we need to pay more attention to this at some point.

If not our Hamstrings may pay for it.

At this point it’s important to note that treating any spinal dysfunction and improving a our positional awareness clearly won’t cure a troublesome Hamstring on it’s own. If it’s become problematic, the Hamstring itself will need local Hamstring treatment.

But in my experience, improving our spinal function can a) potentially prevent Hamstring injuries, and b) speed up our recovery and potentially reduce the risk of re-occurrence.

We still need to have strength and mobility in our Hamstrings and surrounding structures, but in my opinion we can’t have any understanding of what true weakness and tightness feels like until we clear any vital spinal dysfunction and positional faults first.

So whether you are the mighty Cyril or not, your day-to-day spinal shapes seem to count. Get into a bad shape often enough and for long enough and there may be eventual consequences to the structures that rely on healthy spinal function… which to be fair, is literally everything.

Conclusion

I know this may not be news to everyone, but the back seems to matter with Hamstring injuries. Back dysfunction may never be a predictor of Hamstring injuries but hindsight may be clear enough on it’s own.

I hope those suffering from any Hamstring issue read this and feel inspired to take action.

Check this out for yourself. Don’t just take my word for it.

Speak to your relevant health professional and get them to check your back out. Hell, grab a foam roller and go hunting yourself. Learn/re-learn how to brace your spine effectively. It’s all safe, free and may be a missing piece to your rehab puzzle. It’s hard to argue with the results you may get.

Take the time to understand HOW you position your back when sitting. It may not just be sitting-related for some, but a good spinal shape is a good spinal shape regardless of the activity. Just keep an eye out.

As I mentioned in the Jaeger article, I hope that I can at least raise a little more interest towards this. I again hope that those with the ability to research and solidify this idea at least consider it’s merit. Selfishly, I still hope this promotes the kind of deeper exploration I really enjoy doing here at Peninsula Physiotherapy. Come at me bro’s and bro’ettes if you feel you need help.

Truth be told, I’m still a little uneasy about putting these articles out in to the world. My industry is often a little guarded when slightly left of centre ideas come out. I do appreciate why as there is a lot of bullsh*t out there. I hope this isn’t seen in the same light.

I’m always looking to broaden my thinking and I would love others who are also thinking in this space to get in touch and share ideas. I’m all ears, my future patient’s will thank you for it.

Finally, of MOST importance, I genuinely hope that this assists Cyril and the Hawks in some small way. My ego still isn’t anywhere near big enough to assume it will, but here it is nonetheless.

Discuss Grant’s breakdown of Cyril’s problem hamstrings in the forum

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Grant Frost
Grant is an experienced physiotherapist who currently practices at Peninsula Physiotherapy and Health in Melbourne.