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    Hamstring Injuries in Athletes

    Last updated 1 month ago

    Dr. Derek Ochiai

    Hamstring injuries in sprinting athletes are common injuries, as demonstrated by Jozy Altidore’s hamstring injury in the United States’ first World Cup match of 2014.  Fans of American football cringe when they see the speedy wide receiver be wide open down the field, all of the sudden to pull up and fall to the ground.  Unfortunately, these injuries can affect athletes of all levels, not just at the elite professional level.  This blog explains hamstring injuries and treatments.


    What are the hamstring?

    The hamstring are large muscles at the back of the thigh.  Their main function is to power the knee into flexion, as well as extend the hip.  They attach at the ischium (which is commonly called the “Sit Bone”) and attach just below the knee.


    Why are they important?

    The hamstrings are very important in sprinters, or any athlete who quickly accelerates.  Picture quick acceleration as the feet “grabbing the ground and pulling the ground backwards” similar to a climber doing this with their arms, and you can get a sense of how having powerful knee flexors can help with sprinting.  Recreation athletes and non-athletes also use their hamstrings, but the stress on their hamstrings is usually less, unless an accident is involved.


    How do hamstrings get injured?

    Hamstring injuries occurs from two major mechanisms.  The first is with rapid forward acceleration, where the hamstring muscles and tendons get quickly overloaded, and strains either the muscle bellies of the hamstring (in the middle of the back of the thigh) or at the starting point (origin) at the sit bone.  The second mechanism is usually by a fall, where the affected leg is forced forwards, and the athlete “does the splits” and over-stretches the hamstring.


    Is this a bad injury?

    First of all, most hamstring injuries heal adequately without surgical intervention.  However, the TIME it takes to heal can be quite prolonged.  This is an injury that can keep a professional football player out of multiple games, waiting for adequate healing.  In general, injuries at the “meat” of the hamstrings (or in the middle of the thigh) are muscular strains, and have the quickest healing potential.  Injuries where the pain is near the bone of the pelvis (ischium) have the longest healing potential, as this is a tendon injury, and tendon healing is prolonged, partly because of the decreased blood supply of a tendon relative to a muscle.  Tendon injuries are graded Grade 1-3, with one being least severe (a stretch) and three being the tendon has pulled completely away from the bone.


    What can be done to prevent hamstring injuries?

    In general, before undertaking athletic activities, an adequate strength and conditioning program should be undertaken, to ensure that the muscle strength is adequate.  Pre-activity stretching of the hamstrings and warming up are also helpful.  Two common hamstring stretches are shown below.

    How do I know if I injured my hamstring?

    Depending on the location of the hamstring injury, the pain can be in the back of the thigh or at the Sit Bone.  Many times, a patient with a hamstring injury will describe a sharp pain, and suddenly be limited in walking or unable to walk.  Back of the thigh bruising and swelling is common.


    How are hamstring injuries treated?

    First of all, this is not an injury to try to “gut through” and ignore.  Prompt medical attention is important.  A sports medicine trained physician can correctly diagnose the TYPE of hamstring injury, which can guide treatment.  Typically, I start physical therapy relatively quickly, to decrease stiffness and control the formation of scar tissue.  Anti-inflammatories can be helpful.  Until pain controlled such that the patient can walk without a noticeable limp, many times crutches are required.  In some cases, platelet rich plasma injections can be utilized to speed the healing process.  In Grade III hamstring tendon injuries, where the tendon has pulled completely away from the bone, many times the best option is surgical repair of the tendon, sewing the tendon back to the bone.

    If you have an orthopaedic injury contact Nirschl Orthopaedic Center at 703-525-2200 or visit our web site.

    Traveling For Surgery? What you need to know.

    Last updated 1 month ago

    By Dr. Derek Ochiai

    Our society is becoming more global and travel friendly.  Many times, patients with a specific medical issue may decide to travel out of town to have definitive medical treatment, including surgery.  While there may be very good reasons to want or need to do this, the patient may have additional issues and needs that must be considered prior to making this commitment.  As a surgeon who often sees patients who travel from out of town for a specialized procedure that I do, I am well aware of these issues.  This article will talk about what to ask and look out for when traveling for surgery.

    Patients have reasons that they wish to travel to have surgery.  The doctor or center that they are choosing may have a specific expertise for a medical condition.  The patient may also travel to be closer to their family to make for an easier recovery.

    There are four specific issues that a patient should consider prior to having surgery out of town.  First, how long can the patient stay away from home?  While a surgery may normally take a set amount of time for initial recuperation, the surgery may not be without complications.  If the surgeon wants you to stay an extra week after the procedure and you were not prepared to do so, is that personally and financially feasible?  Second, what happens if there is a late complication after the patient returns home?  The surgeon may request that you return for follow-up care and this can be an additional expense and time away from home and work.  If you cannot get back to that surgeon, are their other physicians local to you who would be willing and able to treat you?  Third, how communicative is the surgeon?  Many orthopaedic procedures rely on physical therapy and post-surgery protocols after surgery.  If the patient or other health care providers have questions regarding this, how does this get communicated to the surgeon?  Does he/she answer email?  Is the surgeon comfortable with treating a patient “over the phone”?  Finally, how comfortable is the surgeon treating a patient whom he/she will not be following long term?  Do they have a system in place to handle issues of communication and follow-up? 

    The most important step a patient can do is to research doctors and facilities ahead of time.  Many times, doctors who are accustomed to seeing patients from out of town have a system in place to accommodate this. The patient can gather their medical records, radiographic images and MRI’s, that can be mailed ahead of time for the surgeon’s review.  If a patient is thinking about having their surgery performed out of town, a call to the surgeon, asking if this system is in place, can save some unnecessary expense.  It is far better for patients to know ahead of time if they are an appropriate candidate for a procedure, rather than travel to the facility only to find otherwise.  A patient should also ask to speak to the billing department, as the center and surgeon either may not participate with their insurance or the specialized procedure may not be covered by their insurance.  By talking to the staff, the patient can definitely get a sense of how experienced the office is in dealing with patients from out of town, which can help with the patient’s comfort level.

    All patients should set up a pre-operative appointment well before an intended surgery.  This will relieve pre-surgery anxiety for the patient who now knows their doctor prior to having the surgery.  Sometimes, no matter how great a doctor looks on the internet or how convenient it would be to have the surgery there, a patient may meet the surgeon and decide to look elsewhere.  If the pressure of already scheduling the surgery is looming, this may unduly influence an important decision.  Keep in mind that many centers may also have a surgical cancelation fee.

    Medical tourism has its benefits and drawbacks.  If a patient actively researches and prepares before surgery, the benefits can be maximized, and the drawbacks diminished.

    Dr. Derek Ochiai is a board certified orthopaedic surgeon, specializing in Hip Arthroscopy and Sports Medicine, at Nirschl Orthopaedic Center for Sports Medicine and Joint Reconstruction.  Follow him on Twitter @DrDerekOchiai. For more information go to the web site at or call or office at 703-525-2200.

    OVERUSE INJURIES- What you need to know.

    Last updated 3 months ago

    By Dr. Robert Nirschl, MD, MS

    Sports injuries are classified as either an overuse or an acute injury. Most sports injuries are a result of overuse and they occur when the body has been pushed too hard, too fast or too long. Pain and swelling are the first indications of overuse injury, and, as is the case for acute injury, “PRICEM” is the rule of thumb for general treatment.

    Protect the injury or it may easily become an acute injury.  Don’t play through the pain. Stop the activity causing discomfort and rest. Put ice on the injured area as soon as possible, but be cautious about direct application that might cause “ice burn”. Compression reduces the swelling. Use an elastic bandage around the injury. Spandex clothing, a neoprene sleeve, or an elastic stocking may serve the same purpose and might also offer some limited measure of support and protection. Elevate the injury above the level of your heart and continue to do so even during sleep.

    It is important to let an overuse injury completely heal before subjecting the injured area to additional stress or abuse. Playing hurt has the same effect as ripping a wound open repeatedly before it can heal. It not only won’t heal, but it may result in a very serious or even irreversible problem. It is also important to reduce the irritative chemical inflammation to aid in the healing process. Compression, ice and elevation are all associated with that component, but medication may be needed as well. Frequently, aspirin or ibuprofen (Motrin, Aleve, Advil, etc.) in therapeutic dosages are effective, but cortisone or some other prescription drug may be necessary. Aspirin at that dosage may cause an upset stomach so buffered aspirin is recommended. Aspirin is not recommended for children because of the risk of Reye’s syndrome. It can also retard blood clotting (helpful to prevent strokes and heart attacks) but should not be taken 10 days in advance of surgery.

    Ice is effective in reducing the pain and swelling in an injured area when inflammation is present. Subsequent treatment with heat will facilitate healing by increasing blood flow to the region for removal of excess liquid and toxins that are a by-product of the injury, as well as enhancing nutrition and oxygenation. It is even possible to create a pumping effect with alternate heat (30 minutes) and cold (5-10 minutes) applications. Massage can also be used to aid circulation to the injured area. But care should be taken not to irritate or abuse the injury, and extreme caution should be used with a mechanical massager.

    The best way to prevent sports injuries is to follow a good warm-up and conditioning program. A regular exercise program with weights and resistance equipment will help structural development that can better withstand the physical stress that will be encountered during sports.  Stretching before and after sports activity will better prepare those muscles and tendons for future use. Some of the more common soft tissue injuries that result from overuse are:

    Sprains: A sprain is an injury to a ligament, a firm band of tissue that supports the joints. Three types of sprains can occur: Grade 1- the ligament is stretched; Grade 2- some of the fibers are torn; Grade 3 – the ligament is totally torn. Sprains are usually the result of twisting trauma, and most commonly occur in the ankle and/or knee joint.

    Strains: A strain is an injury to a muscle-tendon unit. Like sprains, strains can be classified according to severity – stretched, a partial tear, or a complete tear. Strains may occur when muscles lack strength and flexibility. Deficient warm-up or exposure to extreme cold or unusually stressful activity are additional important factors. Strains in the hamstrings and groin adductors (rear and inner muscles of the upper leg) are common, but strains in muscles of the shoulder girdle are becoming recognized as an important contributing factor to shoulder tendinitis as well as primary injury. Strains are always accompanied by weakness.

    Tendinitis/Tendinosis: Tendinosis is a degeneration or injury of a tendon and is generally caused by repetitive trauma. Tendinosis is common in tennis and other sports and repetitive use occupations. Tendinosis, rather than tendinitis, is the correct term as we now know that inflammatory cells are not present in the injured tendons. The most commonly affected tendons are the Achilles, tendon, tendons at the knee (runner’s knee), tendons of the posterior tibial muscles-tendon attachment (shin splints), and tendons of the elbow (tennis elbow) and shoulder (rotator cuff tendinosis). Treatment may include medication for pain control, physical therapy to heal, and control of overuse with counter-force bracing. As a last resort, surgery may be an option. Practicing proper sports techniques will also go a long way in preventing tendinosis.

    Bursitis: Bursitis is an overuse injury that results in the inflammation of bursa and is most common in areas near the elbow, shoulder, knee, heel and hip. Bursa are fluid-filled sacs found in regions where friction occurs. Their main function is to minimize friction between bones and tendons, tendons and ligaments or even bone and bone. The condition is frequently found in association with tendinosis and the bursal inflammation. Players with injury to the knee bursa have excessive swelling due to accumulation of fluids in the bursa over and just below the knee cap. Other common bursitis areas include the shoulder, tip of the elbow, outer hip and under the Achilles tendon. The bursa sometimes must be drained or even removed before proper healing can take place. Cortisone is very effective in reducing the bursal inflammation, but other anti-inflammatory drugs maybe sufficient.

    Contusions: A contusion, or bruise, is an injury to soft tissue or bone in which the skin is not broken. A hard direct blow is the most common cause and a collection of blood (a hematoma) may form beneath the skin in the injured muscles, tendons or bone. Icing or some other form of cold application that will contract the blood capillaries will minimize the damage by preventing accumulation and swelling.


    It takes a long time for most players to admit to themselves that they are not indestructible, and they usually learn the hard way. Loss of flexibility and dehydration of tendons and ligaments with age make aggressive senior players more subject to injury but even the young are vulnerable. Much of this can be avoided by maintaining good strength and flexibility programs, practicing good pre- and post- work out preparation, becoming well informed about injury potential, and by simply using good judgment and control of abuse by using functional counter-force bracing. Following those principles, young people and should be able to continue active sports through their senior years. The enjoyment of that endeavor should result in maintained good health and physical conditioning that will enhance and extend your quality of life.  

    If you have pain or any orthopaedic injury, contact the experts at Nirschl Orthopaedic Center  or Virginia Sportsmedicine Institute in Arlington, Virginia. Schedule an appointment with our orthopaedists today by calling 703-525-2200 or visit our web site.

    No Pain No Gain? How to stay safe and in the game

    Last updated 4 months ago

    Pain is … well, a “pain” for athletes. It can compromise your training routine and keep you out of the sports that you love. If you ignore it or push through it, you can cause more damage and increase the time you will need to recover. We have all heard the “No Pain, No Gain” or the “Pain is Weakness Leaving the Body” adages, but these motivational quotes can give young athletes, or, for that matter, athletes of all ages, the wrong idea. Eventually this can lead to significant injuries that require extended down time to heal.

    So how do you know what is “normal pain” vs. “abnormal pain”? What is unimportant muscle and joint discomfort or an injury waiting to get worse? Here at the Nirschl Orthopaedic Center for Sports Medicine and Joint Reconstruction we follow the pain phases of our founder, renowned orthopaedic surgeon, Dr. Robert Nirschl.

    These guidelines help athletes, parents, coaches, and trainers to better understand the type and intensity of pain they are dealing with, how to adjust their training routines or when it is time to follow-up with a sports medicine physician.



    Phase 0:  No pain or soreness.

    Phase 1:  Stiffness or mild soreness after activity, usually gone in 24 hours.

    Phase 2:  Stiffness or mild soreness before activity that is relieved by warm-up. Symptoms are not present during activity but return after, lasting up to 48 hours.

    Phase 3: Stiffness or mild soreness before specific sport or occupational activity. Pain is partially relieved by warm-up. It is minimally present during activity but does not cause athlete to alter activity.

    Phase 4: Pain is similar to but more intense than Phase 3 pain. Phase 4 pain causes athlete to alter performance of the activity. Mild pain may also be noticed with activities of daily living.

    Phase 5: significant (moderate or greater) pain before, during, and after activity, causing alteration of activity. Pain occurs with activities of daily living but does not cause a major change in them

    Phase 6: Phase 5 pain that persists even with complete rest. Phase 6 pain disrupts simple activities of daily living and prohibits doing household chores.

    Phase 7: Phase 6 pain that also disrupts sleep consistently. Pain is aching in nature and intensifies with activity.

    If an exercise or activity causes Phase 3 pain or greater, this should be considered indications of injury. You need to modify or adjust the activity if possible or stop the activity completely, check with your therapists or doctor, and work in a “pain free” range.

    Some ideas are as follows:

    a.      Decrease the length of time of the exercise/activity and/or

    b.     Decrease the intensity at which you are performing the activity

    c.      Decrease the speed you are performing the exercise/activity

    d.     Alter the technique of the activity

    If you are unable to find a “pain free” way to complete your exercise, it is a good indication that there is an underlying injury that needs addressing. It is important that you follow up with a sports medicine physician to get an accurate diagnosis. A physical therapist will design a program to get you back to your full work out without further damage.

    Remember “No Pain, No Gain” can sometimes put you on the sidelines for a very long time. Listen to what your body is telling you and take the proper actions to keep you healthy and strong. The pain phases may be a helpful guide. If you are unsure check with your doctor.

    Nirschl Orthopaedic Center is a leader in sports medicine and general orthopedic services. In addition Virginia Sportsmedicine Institute physical therapy has been rated one of the top sports medicine clinics in the area. If you have an orthopaedic injury, schedule an appointment with one of our doctors today by calling our Arlington, VA location at (703) 525-2200. Visit our websites at and to learn more about our services. For more info on orthopaedic issues visit our blog at

    The Importance of Core Strengthening for Pitchers

    Last updated 4 months ago

    The importance of the baseball player’s arm is often the main focus for their preseason and offseason work-out programs.  Often the core of the player is ignored and often neglected.  The strength of the legs and core can often lead to increased power in the correctly conditioned athlete.  If the core of the player is weak, the arm is often placed in increased tension and usually trails behind the body during the throwing motion, leading to increased strain on the shoulder girdle, namely the rotator cuff musculature.  Several studies have shown an increase in strain on the anterior, or front, structures of both the shoulder (capsule and rotator cuff) and elbow (ulnar collateral ligament). Weakened core can often be attributed to an increase in arm injuries in the younger athlete.  Focus on stability, balance, and strength of the lower half of the body should be a main focus for baseball players, in addition to proper conditioning of the throwing arm.

    While strength and conditioning of the arm is also of great importance, large parts of the athlete preseason workouts should be devoted to increasing the strength and balance of the core.  The core consists of many different muscle groups that all must work in concert in order to generate the most power under a well-balanced motion during the throwing process.  Attention should be paid to the gluteus, quadriceps, hamstrings, abdominal, and lower back muscle groups during preseason conditioning.  Several workout protocols can be found and followed in order to strengthen the muscles properly.  Several exercises that can be done in order to maximize your results are as follows: single leg lunges (with and without weights), squats, leg extensions, leg curls, oblique crunches, hyperextensions (for lower back), balance and stability exercises for the push off leg.  These exercises plus many different others will aid you in becoming stronger and generate more power through the throwing motion.  Not only can a stronger core increase your velocity but more importantly it will also greatly decrease the stress and strain on your arm, thus decreasing the chances of an arm injury during the season.

     If you have an orthopaedic injury, contact the experts at Nirschl Orthopaedic Center in Arlington, Virginia. Schedule an appointment with an orthopaedic surgeon today by calling 703-525-2200 or visit our web site.


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