Hamstring Injuries

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Paul Thawley MSc, BSc (Hons), PgDip (Rehab),
MCSP SRPSenior Sports Physiotherapist Team GB

• Hamstring Injuries

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Hamstring injuries occur in all sports and
effect elite and non elite populations (Brooks
et al 2006)
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Athletic Population
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Non Athletic population
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Epidemiology

• FA Audit of Injuries study found that 12 of all
  injuries reported over two seasons were hamstring
  strains. (Woods Br J Sports Med 20043836-41)
• 11-15 Cricket (Stretch 2003, Orchard et al
  2002a)
• 16 AFL with a recurrence rate of 34 Seward et
  al (1993)
• Incidence 0.30 per 1000 playing hours with
  average severity of 17 days absent in English
  Rugby Union Brooks et al (2005)

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Epidemiology
Epidemiological evidence suggests that hamstring
strains are associated with eccentric load, where
the contracting muscle is lengthened and there
may well be a lack of neuromuscular control.
Biggest risk of injury is previous
injury Biceps femoris most commonly
injured Increased incidence with age
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Posterior Thigh Pain Differential Diagnosis

• Hamstring muscle strain Acute / Chronic
• Hamstring muscle contusion
• Referred from Lx
• Neural structures Triggers points

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Less Common Posterior thigh pain

• Referred from SIJ
• Tendinopathy
• Bursitis
• Compartment syndrome
• Apophysitis
• Nerve entrapment
• Adductor magnus
• Myositis Ossificans

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Not to be missed

• Tumors
• Iliac artery insufficiency

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Diagnosis
Listen Hx is key Look Move Feel Special tests
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Neural Dynamics

• Slump test as a diagnostic tool
• Slump as a treatment modality
• Significant effect on Fascia Vleeming et al 2005

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Lumbar Spine

• Age / Degeneration of L4/5 and L5/S1 associated
  with prevalence of hamstring injuries
• Successful management of hamstring injuries in
  Australian Rules footballers two case
  reportsChiropractic Osteopathy 2005,
  134     doi10.1186/1746-1340-13-4

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If your think the lesion is soft tissue Dynamic
Ultrasound or MRI are you investigations of choice
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Common mechanism

• Late swing phase in running action
• Eccentric contraction to decelerate the shank
• Often accentuated in preparation to jump, kick
• Trunk flexion whilst running (Verral, 2005)

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Other mechanisms

• Stretch with knee fully extended (stretching for
  a ball, kicking)
• Forced trunk flexion with foot planted
  (waterskiing)

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Possible causes of Muscle Injury

• Musculoskeletal imbalances
• Poor muscular co-ordination
• Inappropriate training
• Fatigue
• Incomplete rehabilitation?
• Repeated micro-trauma?

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Intrinsic and extrinsic factors
Musculoskeletal imbalances Any breakdown in the
effective function of the legs and pelvis during
running may predispose to injury. Examples
include postural changes due to muscle
tightness lumbar or sacro-iliac joint
stiffness poor co-ordination of movement or early
fatigue associated with muscle weakness leg
length discrepancy (LLD) which will affect pelvic
motion and stride length. Note LLD lt 1.5 cm is
usually not significant prolonged or delayed
pronation or supination of the foot, which will
alter the function of the leg and pelvis during
the running cycle
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Intrinsic and extrinsic factors
Poor muscular co-ordination? Running requires
strength, power, endurance and co-ordination.
Problem-free running cannot take place if the
hamstrings are weak, inflexible, or if there is
poor neuromuscular co-ordination. Loss of the
normal ratio of muscle power between the
quadriceps and hamstrings may also occur. The
normal quadriceps/hamstrings ratio is 6040. Loss
of the normal ratio may be due to excessive
development of the quadriceps, or due to existing
weakness of the hamstrings. A normal ratio is
essential to prevent imbalances from occurring
during the running cycle.
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Inappropriate training? Inappropriate comprises
all the factors that may affect your bodys
ability to adapt to the varied stresses of
running. Factors include excessive mileage rapid
increase in mileage inadequate warm-up and
cool-down poor stretching cambered running
surfaces worn shoes or orthotics
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Fatigue? Fatigue affects performance and may
predispose you to injury. At a physiological
level, fatigue may be reflected in a prolonged
recovery time at neuromuscular junctions, which
diminishes effective muscle activation, slows the
clearing of metabolites from the muscle, and
impairs the ability of the muscle to contract.
Fatigue therefore results in decreased strength,
power and endurance, and will increase the risk
of injury.
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Incomplete rehabilitation? As runners, we are
always eager to get back on the road as soon as
possible. If an injury is not properly treated,
or if you do not achieve your pre-injury levels
of strength, endurance and flexibility, the risk
of re-injury is increased. Effective
rehabilitation (which means putting in the time
with the physio, or at the gym) will allow you to
get back on the road and stay there.
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Repeated micro-trauma?Often trauma to the
hamstrings may not always be significant enough
to cause pain or disability at the time of
injury.The reduction in hamstring function may be
so gradual that it will not be detected until
there is a serious problem. This is often
described as the last straw that broke the
camels back, where repeated micro-trauma will
finally result in pain and dysfunction. When
running, the hamstrings are often exposed to
repeated micro-trauma due to over-striding, as
well as with a change of pace. Over-striding,
particularly when just starting to run downhill,
places the hamstrings under excessive eccentric
load as the muscle works to stabilise the knee
joint. The excessive eccentric load may result in
micro-trauma to the muscle fibres, leading to
injury.
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Treatment approaches
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Muscle Injury

• What are the consequences to the athlete of not
  treating a muscle injury correctly?
• How much damage is caused by inactivity on the
  athletes and the doctors part?
• Why is there no/little consensus on management of
  muscle injury?

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Staring point with an Hamstring lesion

• R.I.C.E
• Compression the key
• Gentle mobilisation
• Partial weight bearing as tolerated
• Electrotherapy modalities
• When to stretch?When to start running again?

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Continued Rx STR / MFR Acupuncture NSAIDs after
24 hours Electrotherapy modalities Correct
Physical rehabilitation is paramount in the
management of hamstring injuries
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Early mobilisation versus strength/stretching

• Two rehabilitation programs
• Static stretching and progressive strengthening
• Progressive agility and lumber stabilisation
  program
• No stat difference in RTS times
• Stat difference in recurrence rates over I year
  period remain ISQ (Sherry et al, 2004. JOSPT,
  34(3) 116-25)

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Where basic science and clinical guidelines
collide

• Perception is that early mobilisation is against
  basic principles.
• RICE principle for 7 days minimises pain,
  swelling to offer best possible conditions for
  healing process. Kannus et all (2003)
• Studies cited were for non-contractile tissues
  (ie ligaments)
• Prolonged immobilisation is detrimental
• Early mobilisation of affected tissue increases
  density of scar formation. (Jarvinen, 1975) What
  about remodelling???

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Accelerated running program

• Developed by Graham Reid
• Australian Hockey Physio
• Injured player on tour
• Captive audience
• Good result

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Accelerated Running Program

• Day 0
• Ice, Electro modalities, /- CPM, /-Ice,
  Compression etc
• Day 1
• Continue as above.
• When range in sitting position (Lordotic spine)
  at 120 or -10 degrees off full knee extension ?
  start running program

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Progressive Running ProgramGraham Reid

• Jogging at variable speed up to 75
• Minimal acceleration/deceleration
• Approx 4 min/km pace
• Up to 2 kms
• Variable distances 100mx3, 90mx3, 80mx3, 70mx3,
  60mx3, 50mx3, 40mx3, 30mx3 Repeat x 2
• Backwards running 50 x 3 , 75 x 6, 40 x 3

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Progressive Running ProgramGraham Reid

• Once at 75 without pain, start acceleration
  program
• 40 20 40
• 35- 20 35
• 30-20-30
• 25-20-25
• 20-----20
• 15-----15

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Summary of running program

• Aggressive but controlled rehab
• Takes out a lot of the guess work with training
  loads
• Many variations needs to be tailored to the
  sport and then the individual athlete
• Addressing causative factors is the most
  important aspect to hamstring rehabilitation

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My approach to pre running criteria (how do you
know when the athlete can run ????)
Adductor magnus bridges 5 sets of 12 reps Seated
knee extension 10 degrees off straight Single
leg long level bridge pain free
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Hamstring Exercises

• Manual resistance

Manual therapy
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Rehabilitation approach
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Why does early mobilisation work?

• Eccentric exercise in a controlled way is
  functional
• Improved neural patterning/technical ability
• Allows progression as quickly as possible with
  consistent feedback
• CPM effect- decreases disorganised collagen
  formation. Maintain extensibility of the muscle
• Hamstring strains are almost never isolated
  strains
• Strengthening in a functional way

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Recurrences

• Scar at its weakest point 10-12 days after
  injury
• Time frames will vary - forced by time
  constraints
• Analogous to ACL return at 6 months

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Injury prevention
Extremely difficult!
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Eccentrics???
Concentric
Eccentric
Characteristics of eccentric contraction Produces
more force than concentrics Selectively recruits
Fast fibers. Fast fibers are bigger and have
greater potential for growth than slow fibers.
During the eccentric phase of movement, the
muscle absorbs energy. This work is done by
stretching the muscle and in this process the
muscle absorbs mechanical stress This mechanical
energy is dissipated or converted into one or a
combination of two energies. 1. Heat 2. Elastic
Recoil
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Key concepts in injury prevention

• Improve the training regime so that it more
  accurately reflects sports specific conditions
  with the goal of improving muscle conditioning
• Try and improve fatigue resistance of the
  hamstring muscle
• Try and induce a change in the viscoelastic
  properties of muscle so as to increase energy
  absorption and decrease load on the muscle-tendon
  unit for any given length especially in body
  positions of function and vulnerability to
  injury. Verrall et al 2005 Br J Sports Med

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Can we predict/prevent hamstring strains?

• Previously injured muscles developed peak torque
  at significantly shorter range than uninjured
  muscles
• Peak torque and quad / hamstring torque ratios
  were not significantly different
• Eccentric exercise possibly shifts length-tension
  curve to the right
• Most Studies used concentric measurements, Why
  when we know hamstrings have an eccentric action?
  (Brockett et al, 2004 Med Sci Sports Ex. 36(3))

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Predicting/ Preventing muscle strains

• Role of screening
• Hamstring range
• Strength components (Isokinetic)
• Joint ranges
• Traditionally, our biggest predictive factor to
  hamstring strains is previous history of
  hamstring strain.

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Can we predict/prevent hamstring strains?

• Decreased incidence in soccer players on an
  eccentric program
• Askling et al (2003) Scand. J. Med. Sci. Sports
  13 244-250
• Decreased hours lost, no of injury and weeks out
  with intervention program (Verral, BJSM 2005)

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Incremental Increase in Eccentric Exercise

• Drop-catch exercises
• (Stanton and Purdam 1989 J Orthop Sports Phys
  Ther)
• Nordic hamstrings
• High-velocity eccentric exercises in the final
  phase of rehabilitation (Geraci 1998)

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Hamstring Exercises

• Nordic Hamstrings

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Icelandic curls
research From Bahr and Meahlum (2002)
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Length-tension relationship

• Tension

Length
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Icelandic curls

• Tension

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Points to consider in Footballers

• Body awareness
• Requirements of the Sport
• Limited neural aspects
• Limited kicking etc. till full running
• Ball work restricted in initial stages
• Physical rehabilitation does not replace
  intensive hands-on approach
• How to integrated this philosophy with the
  football management

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Sports Specificity relating to hamstring injury
prevention

• Think specific and generic
• ie Football
• Ladders
• Change of direction
• Backwards/sideways running
• Shuttles
• Chase and escape drills
• Recreate load, stress, strain, joint angles,
  fatigue index

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Case Study
Primary hamstring lesion grade 1 on US Day
1 PRICE crutches 2/7 no NSAIDs Day 3 STR / PNF
local electrotherapy NSAIDs Seated SLR /
passive mobilisations Day 5 program Active
mobilisations / basic gym program Day 7 Hamstring
specific program (powerpoint)
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Case Study Contd
Day 14 Re US scan good reduction in fluid RTP
day 18 Post injury SC lead eccentric program in
place and a physio lead pelvic neuromuscular
patterning program with monitoring
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Summary
Diagnosis is key, use correct imaging
modalities Initial treatment is in line with any
other soft tissue injury protection, RICE and
early mobilisation. Understand that there is
close relationship between hamstring injury, the
neural system and lumbar spine pathology
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Summary continued
Accelerated running programs can be
utilised Identify predisposing factors relating
to the hamstring injury in that individual
athlete Apply an eccentric injury prevention
strategy Develop your own strategy related to
current research evidence Be sports specific in
your approach
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Questions/comments/discussion?
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References
Kyro la inen H, Komi PV, Belli A. Changes in
muscle activity patterns and kinetics with
increasing running speed. J Strength Cond Res
1999134006. Pinniger GJ, Steele JR, Groeller
H. Does fatigue induced by repeated dynamic
efforts affect hamstring muscle function? Med Sci
Sports Exerc 20003264753. Garrett WE. Muscle
strain injuries clinical and basic aspects. Med
Sci Sports Exerc 19902243643. Best TM.
Soft-tissue injuries and muscle tears. Clin
Sports Med 19971641934. Stauber WT, Knack KK,
Miller GR, et al. Fibrosis and intercellular
collagen connections from four weeks of muscle
strains. Muscle Nerve 19961942330. Stauber
WT, Smith CA, Miller GR, et al. Recovery from 6
weeks of repeated strain injury to rat soleus
muscles. Muscle
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References
Askling C, Saartok T, Thorstensson A. Type of
acute hamstring strain affects flexibility
strength and time back to pre-injury level. Br J
Sports Med. 20064040-44. Askling C, Tengvar M,
Saartok T, Thorstensson A. Sports related
hamstring strainstwo cases with different
etiologies and injury sites. Scand J Med Sci
Sports. 200010304-307. Brooks JHM, Fuller CW,
Kemp SPT, Reddin DB. Incidence, risk, and
prevention of hamstring muscle injuries in
professional rugby union. Am J Sports Med.
2006341297-1306. Connell DA, Schneider-Kolsky
ME, Hoving JL, et al. Longitudinal study
comparing sonographic and MRI assessments of
acute and healing hamstring injuries. AJR Am J
Roentgenol. 2004183975-984. De Smet A, Best T.
MR imaging of the distribution and location of
acute hamstring injuries in athletes. AJR Am J
Roentgenol. 2000174 393-399. Gabbe BJ, Bennell
KL, Finch CF, Wajswelner H, Orchard JW.
Predictors of hamstring injury at the elite level
of Australian football. Scand J Med Sci Sports.
2006167-13. Garrett WE, Rich FR, Nikolaou PK,
Vogler JB III. Computed tomography of hamstring
muscle strains. Med Sci Sports Exerc.
198921506-514. Gibbs NJ, Cross TM, Cameron M,
Houang MT. The accuracy of MRI in predicting
recovery and recurrence of acute grade one
hamstring muscle strains within the same season
in Australian Rules football players. J Sci Med
Sport. 20047248-258.