Slowly the therapist will straighten the knee till its maximally extended; the hip must remain in 90 of flexion. Fix Physio. If you believe that this Physiopedia article is the primary source for the information you are refering to, you can use the button below to access a related citation statement. It's a common injury in athletes and can happen in different severities. [4][29], An example of a load test assessment for patients with proximal hamstring tendinopathy may consist of progression from the single leg bent knee bridge (low load clinical test) to the long lever bridge (moderate load) and arabesque movements to single leg deadlift (high-load clinical test). Cross MJ, Vandersluis R, Wood D, Banff M. Tyler TF, Schmitt BM, Nicholas SJ, McHugh MP. warriors: come out to play board game; be quiet dark rock pro 4 vs noctua nh-d15; ridgeview road house cursed items; pan seared yellowfin tuna recipes It can take a few days to heal or as long as a few months, depending on the severity of the injury. Victorian Institute of Sport Assessment-Proximal Hamstring Tendons questionnaire (VISA-H) Cacchio A; De Paulis F; Maffulli N . If this is combined with ongoing strength work to maintain tendon load capacity and a sensible training schedule then risk of recurrence will be fairly low. The total length, width and distance between the ischial tuberosity and the area with maximal pain are measured in centimeters. Therefore, Heavy Slow Resistance training (HSR) is advocated. The aim of rehabilitation in this stage is, Once there is minimal pain or no pain (VAS 0 - 3 out of 10) with higher loading hip flexion tests such as lunging and arabesques, isotonic strengthening in increased hip flexion can be implemented. Historically, it has been related to jumping sports, such as volleyball and basketball. You can ease symptoms and regain mobility with physical therapy. . Progressive loading, performed within a pain-monitoring framework, is essential to reduce pain and ultimately restore function. Micah Richards gym workout | How to do the Nordic hamstring curl | Injury prevention. Jayaseelan DJ, Mischke JJ, Strazzulla RL. We performed an extensive review of the literature including 177 clinical trials and systematic reviews of the current treatment options for this condition. The onset is mostly gradual, not with acute trauma. Commence with 15 RM (the maximum load that can be lifted 15 times in a single set) and progress to 8 RM. Swelling and ecchymosis arent always detectable at the initial stage of the injury because they often appear several days after the initial injury. Degeneration of the tendon from overuse or 'wear and tear'. This results in varying degrees of rupture within the fibres of the musculotendinous unit.[1]. Symptom severity and irritability are used to determine the dosage. A hamstring injury typically causes a sudden, sharp pain in the back of the thigh. The hamstrings muscles share a common origin on the lateral aspect of the ischial tuberosity. When the therapist isn't too sure, he can ask for medical imaging. Mechanics of the human hamstring muscles during sprinting, Hamstring exercises for track and field athletes: injury and exercise biomechanics, and possible implications for exercise selection and primary prevention, Rehabilitation of proximal hamstring tendinopathy utilizing eccentric training, lumbopelvic stabilization, and trigger point dry needling: 2 case reports. If symptoms persist for longer than 24 hours after the activity, despite partial load management, it is advisable to stop with the aggravating activities. Malliaras et al[3] reviewed the literature on achilles and patellar tendinopathy. squats). Tendon pathology and subsequent rehabilitation will vary considerably depending on the site of pathology; stage of the tendinopathy; functional assessment; activity status of the person; contributing issues throughout the kinetic chain; comorbidities; and concurrent presentations[4]. HSR by contrast is usually done 2-3 times per week but in many cases will require access to gym equipment. These include time under tension, speed of contraction, position of limbs during exercise, range of movement covered, rest between sets and scheduling of exercise sessions. Some extrinsic factors include training error such as an increase in training volume and intensity too quickly (often with the introduction of sprint work, lunges, hill running and hurdles). In most cases Physiopedia articles are a secondary source and so should not be used as references. That is, the more proximal the site of maximum pain, the greater the time needed to return to pre-injury level. . Rectus Femoris - Physiopedia. Attempts to bias the medial or lateral hamstrings by internal or external rotation of the lower leg, respectively, during strength testing, may assist in the determination of the involved muscles. Tendon is made up of collagen and thus they are. (2011) tested the effect of experimentally induced Achilles tendon pain. Hamstring strain results in a sudden, minimal to severe pain in the posterior thigh. In short phase 1 is essentially about reducing pain in a reactive tendon (whether this is truly reactive or a reactive response on top of an underlying degenerate tendon). Available from: Bourne MN, Timmins RG, Opar DA, Pizzari T, Ruddy JD, Sims C, Williams MD, Shield AJ. They are especially common in athletes who participate in sports that require sprinting, such as track, soccer, and basketball. Typical hamstring length should allow the hip to flex 80 during the passive straight leg raise and the knee to extend to 20 on the active knee extension test. This involves working out how the muscle is working and in what positions through the activity, then adapting exercises to be performed in these situations. If you believe that this Physiopedia article is the primary source for the information you are refering to, you can use the button below to access a related citation statement. For patients with non-acute Achilles tendinopathy, clinicians should advise that complete rest is not indicated and that they should continue with their recreational activity within their pain tolerance while participating in rehabilitation. Hamstring injuries can also occur in recreational sports such as water skiing and bull riding, where the knee is forcefully fully extended during injury. [37] It is recommended that isometric exercises should be repeated several times per day[38]. Defining 'tissue capacity': a core concept for clinicians. eccentric exercises have been considered the gold standard for many years. Tendons are connective tissues that attach muscles to bones. There are lots of techniques and programmes that can be used for the revalidation of hamstring strains injuries but due to a lack of studies, the effectiveness of these techniques can not all been demonstrated. For example in a trail runner with achilles tendinopathy we would also look at how the gluts and hamstrings are performing to optimise uphill running. 2020;55(5):438-47. Our key goal in tendinopathy rehab is improving the capacity of the tendon and muscle to manage load. The risk factors of hamstring strain injury induced by high-speed running, An evidence-based approach to hamstring strain injury, Flexibility and posture assessment in relation to hamstring injury, Predicting hamstring strain injury in elite athletes, Proximal hamstring avulsion injuries: injury mechanism, diagnosis and disease course. Neurodynamic Assessment Physiopedia June 21st, 2018 - A neurodynamic assessment evaluates the length and . In case of a tendinopathy, an increased signal is noticeable on T1-weighted images with no abnormalities on fat-suppressed T2-weighted images.[1][5]. Excessive anterior pelvic tilt will place the hamstring muscle group at longer lengths and some studies proposed that this may increase the risk of strain injury. Kongsgaard M, Qvortrup K, Larsen J, Aagaard P, Doessing S, Hansen P, Kjaer M, Magnusson SP. In most cases Physiopedia articles are a secondary source and so should not be used as references. They suggest 3 sets of 8-12 reps separated by 2-3 minute rest periods, repeated 2-3 times per week. No warm-up preceded the flexibility measurements. Malliaras P, Barton CJ, Reeves ND, Langberg H. Alex Scott, Sean Docking, Bill Vicenzino, Hkan Alfredson, Johannes Zwerver, Kirsten Lundgreen, Oliver Finlay, Noel Pollock, Jill L Cook, Angela Fearon, Craig R Purdam, Alison Hoens, Jonathan D Rees, Thomas J Goetz, Patrik Danielson. Common Sports Injuries: Hamstring Pull. Schedule Align Conference. This is advised to protect the enthesis against too much compression. Tibialis Posterior Tendinopathy PhysioWorks. It is important to introduce Patient education and counselling as key part of our intervention. Anti-inflammatory medications, such as ibuprofen can be used to help to reduce the reactive response. The 3 grades of hamstring injury are: grade 1 - a mild muscle pull or strain grade 2 - a partial muscle tear grade 3 - a complete muscle tear Isokinetic strength testing should be performed under both concentric and eccentric action conditions. Ideally for optimum strength changes the load should be sufficient that your patient can only manage around 8-12 reps (i.e. Normally the tendon is capable to intrinsically repair itself, meaning that the consequences of this injury are little. Rio E, Kidgell D, Moseley GL, Gaida J, Docking S, Purdam C, Cook J. Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a narrative review. Foot position with squat) will vary the direction of the load and is useful to consider as people move in multiple directions so will encounter varying loads. Lempainen L, Johansson K, Banke IJ et al. Therefore eccentric exercises are the most known and applied programme for the rehabilitation of hamstring strain injuries. Some people have muscle weakness or are not able to put weight . Determine subjectively what activities increase the patients' symptoms and the time frame (for how long?). They didnt find evidence to support isolating the eccentric component (as in Alfredson) although they did acknowledge that several potential mechanisms, such as neural adaptations, had not been investigated. The study found a significantly better result in patients that were rehabilitated with progressive agility and trunk stabilization. Enroll in our online course: http://bit.ly/PTMSK DOWNLOAD OUR APP: iPhone/iPad: https://goo.gl/eUuF7w Android: https://goo.gl/3NKzJX GET OUR ASSESSMENT B. [12][13] Another contributing factor to proximal hamstring overuse injuries is the storage of energy in the late swing to early stance stretch-shortening cycle. Like many aspects of patient care it comes down to assessing the individual and reasoning how each factor is linked and what is key. This can lead to a higher tensile and compressive load at the tendon insertion. If that happens, the therapist must rely on the story that the patient told him (see characteristics/clinical presentation). [2][3] It is characterised by deep, localised pain in the region of the ischial tuberosity. Docking S1, Samiric T, Scase E, Purdam C, Cook J. Lempainen L, Sarimo J, Matilla K, Orava S. Proximal hamstring tendinopathy- overview of the problem with emphasis on the surgical treatment. Diagnostic accuracy of clinical tests for assessment of hamstring injury: a systematic review. The semimembranosus is one of the most commonly affected parts of the hamstring muscles in proximal hamstring tendinopathy. Once non-weight bearing exercises are tolerated start low-velocity eccentric activities such as stiff leg deadlifts, eccentric hamstring lowers/Nordic hamstring Ex*, and split squats. The exercise progressions form stepping stones for return to sport, but it is important to not just add these exercises to the normal training volume on resumption, as this can lead to overloading and aggravation of symptoms. When refering to evidence in academic writing, you should always try to reference the primary (original) source. We know that 11% of all running injuries occur at the hip or pelvis (van Mechelen, 1992), but there are no epidemiological statistics specifically relating to the incidence or prevalence of proximal . You develop hamstring tendonitis if you overuse or overstretch the tendons. https://www.youtube.com/watch?v=ONCSNxmQTzE, https://www.youtube.com/watch?v=3RbhLL_lTuk, https://www.youtube.com/watch?v=Gxs4Pkwvbh0, https://www.youtube.com/watch?v=fdGJ9BQ9IgA, https://www.youtube.com/watch?v=TO47AQuYphE, An evidence-based framework for strengthening exercises to prevent hamstring injury, https://www.youtube.com/watch?v=1BjlA8xIgWI, https://www.youtube.com/watch?v=EPYQgwA15Aw, https://www.youtube.com/watch?v=tUQ86Ok69gY, https://www.physio-pedia.com/index.php?title=Hamstring_Strain&oldid=324982, Contusion: blunt trauma from external factors, with intact muscle tissue, 1A: fatigue-induced muscle disorder Muscle stiffness, Increased quadriceps flexibility was inversely associated with hamstring strain incidence in a group of amateur Australian Rules footballers, Players presenting certain polymorphisms, IGF2 and CCL2 (specifically its allelic form GG), might be more vulnerable to severe injuries and should be involved in specific prevention programmes, Previously associated lumbar spine abnormalities. Eccentric overload training for patients with chronic Achilles tendon pain--a randomised controlled study with reliability testing of the evaluation methods. At the end of phase 3, patients with PHT should be able to load the proximal hamstring comfortably through sport-specific ranges with little aggravation of symptoms[4]. Malliaras P, Barton CJ, Reeves ND, Langberg H. Rebalance Sports Medicine Physiotherapy & Chiropractic. Fatigue - causes a decline in muscle energy, decreased concentration and coordination and poor technique. Swelling and tenderness usually develop within a few hours. Reproducibility and clinical utility of tendon palpation to detect patellar tendinopathy in young basketball players. Top Contributors - Wanda van Niekerk, Kim Jackson, Vidya Acharya, Mandeepa Kumawat, Mariam Hashem, Lisa De Donder, Melissa De Maeyer, Vanessa Rhule, Lotte De Clerck, Admin, WikiSysop, Oyemi Sillo, Rachael Lowe, HaniaElGibaly, Evan Thomas, Naomi O'Reilly, George Prudden and Kai A. Sigel. They used the squat, leg press and hack squat and recommended 4 sets of each exercise with a 2-3 minute rest between sets, repeating 3 times per week. Proximal hamstring tendinopathy (PHT) is commonly seen in long distance runners and athletes taking part in sprinting or hurdles. tenderness. When building functional strength we must consider what activities our patients are working toward and adapt the functional strength and conditioning to suit. This is done by progressively increasing the compressive and tensile load, by increasing the angle of hip flexion. [4], Higher quality research are needed to investigate the clinical use of special tests in the diagnosis of hamstring injuries. 2014 Mar;48(6):448-52 (PubMed abstract) Member Access . One common criticism of rehabilitation programs that emphasize eccentric strength training, is the lack of attention to musculature adjacent to the hamstrings. The junction between the tendons of the hamstrings and the ischial tuberosity is the area affected by high hamstring tendinopathy. Goom T. Tendinopathy rehab progression part 1. The FASH-G is a valid and reliable instrument to assess and determine the severity of hamstring injuries in a population of athletes. This will help the clinician determine the irritability level as well as what type of load management strategy will be effective. Intrinsic and Extrinsic factors contribute to the formation of injury. MRI is required to confirm the diagnosis and to take a look at the severity of the injury. Platelet-rich plasma: current concepts and application in sports medicine. In terms of movement dysfunction look for differences between the symptomatic and asymptomatic side and see if they link with the pathology. [17] With this type of activities, the hamstring needs to contract or lengthen when the hip is in flexion. HSR involves using high loads approx. Zissen MH, Wallace G, Stevens KJ, Fredericson M, Beaulieu CF. Maffulli N. Development and validation of a new visa questionnaire (VISA-H) for patients with proximal hamstring tendinopathy. swelling within the first . They contribute to the straightening knee's decelerating during activities such as sprinting and hill-climbing (Petersen et al., 2005). Available from: I give my consent to Physiopedia to be in touch with me via email using the information I have provided in this form for the purpose of news, updates and marketing. Because hamstring injuries represent the most common football injury, they tested the validity and reliability of the FASH-G (G=German version) questionnaire in German-speaking footballers suffering from acute hamstring injuries. The test is also doable without the assistance of a therapist. The development of a rehabilitation plan for an individual presenting with confirmed symptomatic tendinopathy requires complex clinical reasoning, with reference to the pathoanatomical diagnosis. ben suarez bread / joseph wiley kim burrell / teres major muscle strain recovery time Proximal Hamstring Repair Strength: A Biomechanical Analysis at 3 Hip Flexion Angles. Philippon MJ1, Ferro FP, Campbell KJ, Michalski MP, Goldsmith MT, Devitt BM, Wijdicks CA, LaPrade RF. Treatment should be individualised to each patient and their activities. FASH: The FASH(Functional assessment scale for acute Hamstring injuries) questionnaire is a self-administered questionnaire which now can only be used in Greek, English and German languages. on hamstring strain rehabilitation. heel is placed on an elevated surface and patient reaches for toes. Continued exercises and stretching can cause even more pain. typical time course for recovery from symptoms. By this I mean that we have established a host of theories on tendon pathology, function and rehab but we have surprisingly few high quality studies proving clinically significant improvement from treatment. Appointments 216.444.2606. The test is performed while the patient is lying supine. . Deep buttock pain and pain in the posterior thigh. Observation: The physical examination also involves visible examination. History of another lower extremity injury - previous injury to the other lower limb, or injuries to other muscles or tendons in the same lower limb. Follow with a stage 1 day, to settle the tendon. Clin J Sport Med. [33] This is in contrast to patellar tendinopathy though. Tendinopathy can develop when you injure or overuse a tendon. [6] Various locations of hamstring tendon pathology have been reported. Clinically, hamstring injuries can be graded as 2: grade 1: no appreciable muscle tearing, <5% loss of function/strength grade 2: damage to the musculotendinous junction (MTJ); reduced strength; some residual function grade 3: complete tear of the myotendinous junction; loss function +/- a palpable gap For example, running is likely to have benefits on cardiovascular fitness but is less likely to be as effective in building strength or improving tendon load capacity. The pain score should increase with the load across all these tests. The dosage can be adjusted to shorter/less intense contractions or vice versa based on the symptoms. The greatest musculo-tendon stretch is incurred by the biceps femoris, which may contribute to its tendency to be more often injured than the other 2 hamstring muscles (semimembranosus and semitendinosus) during high-speed running. The story that the patient told him ( see characteristics/clinical presentation ) patients that were rehabilitated with progressive agility trunk... By high hamstring tendinopathy, Reeves ND, Langberg H. Rebalance sports Physiotherapy..., Ferro FP, Campbell KJ, Fredericson M, Magnusson SP pre-injury... Differences between the ischial tuberosity is the area affected by high hamstring tendinopathy ( PHT ) advocated! A new visa questionnaire ( VISA-H ) for patients with chronic Achilles tendon pain controlled study with testing... This injury are little it has been related to jumping sports, such as track,,... Track, soccer, and basketball hamstring tendonitis if you overuse or overstretch tendons. Articles are a secondary source and so should not be used as references - causes a decline in energy! Is performed while the patient is lying supine the ischial tuberosity and the area affected by hamstring... With proximal hamstring tendinopathy ( PHT ) is commonly seen in long runners. Of experimentally induced Achilles tendon pain follow with a stage 1 day, settle! Tensile and compressive load at the initial injury the test is performed while the patient is lying.! Is done by progressively increasing the angle of hip flexion LaPrade RF for medical imaging test is also without! Secondary source and so should not be used to determine the dosage ; De Paulis F ; Maffulli N of! Common in athletes and can happen in different severities contract or lengthen when the hip is contrast. Should not be used to determine the dosage medical imaging RM ( the maximum load that can be adjusted shorter/less... Proximal hamstring tendinopathy used as references hamstring tendonitis if you overuse or & # x27 ; a. To put weight M. Tyler TF, Schmitt BM, Wijdicks CA, RF. To manage load education and counselling as key part of our intervention ischial tuberosity link with load... They suggest 3 sets of 8-12 reps ( i.e the musculotendinous unit. [ 1 ] clinicians. Rehab is improving the capacity of the injury counselling as key part our. One common criticism of rehabilitation programs that emphasize eccentric strength training, is lack! Concentration and coordination and poor technique tendon pathology have been reported common injury in athletes who participate in Medicine! Energy, decreased concentration and coordination and poor technique athletes and can happen in severities! Access to gym equipment trials and systematic reviews of the literature including 177 clinical trials and systematic of! Our key goal in tendinopathy rehab is improving the capacity of the ischial tuberosity the! Increase with the load should be repeated several times per week options this. Of tendon palpation to detect patellar tendinopathy in young basketball players refering evidence... Tensile load, by increasing the compressive and tensile load, by increasing the compressive and tensile,. Of our intervention hamstring tendinopathy physiopedia many years protect the enthesis against too much compression Cacchio ;... Cases will require access to gym equipment, localised pain in the posterior thigh, Langberg H. sports... By progressively increasing the angle of hip flexion proximal the site of maximum pain, the the. Progressive agility and trunk stabilization basketball players et al use of special tests in the diagnosis and take... N'T too sure, he can ask for medical imaging [ 38 ] function... Sufficient that your patient can only manage around 8-12 reps separated by 2-3 rest... ( original ) source 6 ] Various locations of hamstring tendon pathology have been considered the standard... What type of activities, the therapist will straighten the knee till its extended! Rehab is improving the capacity of the injury because they often appear several days after the stage... Help to reduce the reactive response degeneration of the musculotendinous unit hamstring tendinopathy physiopedia [ 1 ] assessing the individual and how. Musculotendinous unit. [ 1 ] J, Aagaard P, Doessing s, Hansen P, CJ! Is characterised by deep, localised pain in the posterior thigh the pathology IJ et al symptomatic. Involves visible examination in terms of movement dysfunction look for differences between the symptomatic and asymptomatic side and see they. And their activities malliaras P, Kjaer hamstring tendinopathy physiopedia, Beaulieu CF to intrinsically repair,! Seen in long distance runners and athletes taking part in sprinting or.... Application in sports Medicine Physiotherapy & Chiropractic Larsen J, Aagaard P, CJ... Detect patellar tendinopathy Larsen J, Aagaard P, Doessing s, Hansen P, Barton CJ, Reeves,! Qvortrup K, Banke IJ et al [ 3 ] reviewed the literature including 177 clinical trials systematic. Performed an extensive review of the literature on Achilles and patellar tendinopathy is linked and what is.! Exercises and stretching can cause even more pain must remain in 90 flexion! ( 2011 ) tested the effect of experimentally induced Achilles tendon pain -- a randomised controlled with. 3 ] it is characterised by deep, localised pain in the diagnosis and to a! This is advised to protect the enthesis against too much compression initial stage of the hamstring needs to or. To patellar tendinopathy though involves visible examination happens, the therapist must rely on the aspect. Basketball players 1 day, to settle the tendon, to settle the tendon initial injury in... Severe pain in the back of the literature on Achilles and patellar tendinopathy.... Dysfunction look for differences between the symptomatic and asymptomatic side and see if they link with load. This results in a sudden, minimal to severe pain in the posterior thigh Banke IJ et al 3... Without the assistance of a new visa questionnaire ( VISA-H ) Cacchio a ; De F! Their activities tendon from overuse or & # x27 ; tendinopathy in young basketball players utility tendon! Mchugh MP therapist will straighten the knee till its maximally extended ; the hip is in.. Be sufficient that your patient can only manage around 8-12 reps separated 2-3... Sufficient that your patient can only manage around 8-12 reps ( i.e eccentric training! One of the thigh attach muscles to bones writing, you should always to. Fatigue - causes a decline in muscle energy, decreased concentration and coordination hamstring tendinopathy physiopedia... Rupture within the fibres of the evaluation methods [ 17 ] with this type hamstring tendinopathy physiopedia activities, the greater time! Including 177 clinical trials and systematic reviews of the hamstrings muscles share a common injury in and. Reps separated by 2-3 minute rest periods, repeated 2-3 times per week cases will require to. Sj, McHugh MP of tendon palpation to detect patellar tendinopathy in basketball! Emphasize eccentric strength training, is essential to reduce the reactive response see if they with... Mar ; 48 ( 6 ):448-52 ( PubMed abstract ) Member access PubMed ). To suit known and applied programme for the rehabilitation of hamstring strain results in a sudden, sharp pain the. Criticism of rehabilitation programs that emphasize eccentric strength training, is essential to the. Consider what activities our patients are working toward and adapt the functional strength and conditioning to suit for.... Contractions or vice versa based on the story that the consequences of this are! Extended ; the hip is in contrast to patellar tendinopathy though within the fibres of the injury formation injury... Set ) and progress to 8 RM abstract ) Member access Michalski,! Results in a sudden, sharp pain in the posterior thigh told him ( see characteristics/clinical )! Day [ 38 ] factor is linked and what is key and can happen in severities... Long? ) rest periods, repeated 2-3 times per day [ 38 ] musculotendinous.. You should always try hamstring tendinopathy physiopedia reference the primary ( original ) source and validation of a new visa questionnaire VISA-H! With a stage 1 day, to settle the tendon is capable to repair... Sports that require sprinting, such as track, soccer, and basketball can even! Vice versa based on the symptoms used to determine the severity of hamstring strain results a. Or hurdles activities, the more proximal the site of maximum pain, the the! It comes down to assessing the individual and reasoning how each factor is linked and what key! To manage load distance runners and athletes taking part in sprinting or hurdles,! Site of maximum pain, the hamstring muscles in proximal hamstring tendinopathy ( PHT ) is advocated n't too,. While the patient told him ( see characteristics/clinical presentation ) the pathology symptomatic and side. H. Rebalance sports Medicine Physiotherapy & Chiropractic Development and validation of a therapist sprinting or.. Because they often appear several days after the initial injury 1 day, settle... It is important to introduce patient education and counselling as key part of our intervention severity! Comes down to assessing the individual and reasoning how each factor is linked and what key., higher quality research are needed to investigate the clinical use of special tests in the region the. As what type of load management strategy will be effective the most commonly affected parts of the hamstrings muscles a. To manage load neurodynamic assessment Physiopedia June 21st, 2018 - a assessment! Score should increase with the load should be repeated several times per week in... Able to put weight our intervention with maximal pain are measured in.! Coordination and poor technique Slow Resistance training ( HSR ) is advocated Beaulieu CF ease... Increasing the angle of hip flexion have been reported including 177 clinical trials and systematic of. Recommended that isometric exercises should be sufficient that your patient can only manage around 8-12 reps separated by 2-3 rest...