Hamstring Injuries A Discussion of Physiotherapy Rehab

10/03/14 23:42 Hamstring Injuries: A Discussion of Physiotherapy Rehab | Physio Development
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Hamstring Injuries: A
Discussion of
Physiotherapy
Rehabilitation
image by oropeza
Hamstring muscle injuries are the
most common soft tissue injuries
in competitive, high speed
running sports such as football
1
,
athletics
2
and cricket
3
.
There is a high recurrence rate of
hamstring injury, with the greatest
risk found in the first month after
returning to full competition
4
.
Unfortunately, despite continued
quality research into hamstring
injury rehabilitation, there has
been no significant reduction in
these injury rates
5
.
A particular challenge observed
from a research perspective is that
hamstring injuries are
heterogeneous, consisting of
various injury types, locations and
sizes
6
. This proves difficult in
recommending specific
rehabilitation protocols, as well as
outlining healing times
7
.
In this post, I wanted to highlight
two recent studies that have
investigated and compared clinical
outcomes of multi-dimensional
rehabilitation protocols. The first
study was conducted by Asking et
al (2013)
6
, which compared the
effectiveness of two rehabilitation
protocols following acute
hamstring injury in Swedish elite
footballers
6
. This evaluated the
time needed for full
return/participation in training
and availability for match
selection
6
. The two rehabilitation
programs involved:
A protocol emphasising
lengthening (eccentric) exercises
(37 players), and
A protocol consisting of
conventional exercises (38
players).
The lengthening (eccentric)
rehabilitation group performed
the following three exercises, as
seen in the video below:
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Video credit: Christopher Johnson
The second, conventional
rehabilitation group conducted
the following three exercises:
Hamstring contract/relax in
standing. The heel of the injured
leg placed on a stable support
surface in a high position (near
maximum length) with the knee
in approximately 10 degrees
flexion. Performed twice every
day; three sets of four
repetitions
6
.
Open chain hip extension (cable
resistance) in standing. Once
every other day, three sets with
six repetitions
6
.
Single-leg bridge. Every third
day, three sets of eight
repetitions
6
.
The lengthening (eccentric)
rehabilitation group demonstrated
a significantly shorter time to
return to training (mean 28 days),
compared to the conventional
exercise group demonstrating a
mean of 51 days to return
6
.
Similarly, Brukner et al (2012)
recently published an open-access
article investigating the success of
a proposed 7-point programme via
the use of a single case study of a
26-year old professional footballer
with a Grade II biceps femoris
musculotendinous junction
strain
8
. This article can be
accessed in full at the following
link:
Brukner P, Nealon A et al 2012,
Recurrent hamstring muscle
injury: applying the limited
evidence in the professional
football setting with a seven-point
programme, Br J Sports Med,
doi:10.1136/bjsports-2012-
091400.
The 7-point rehabilitation
protocol used in this case study
involved
8
:
Biomechanical assessment and
correction
Neurodynamics
Core stability
Eccentric strengthening
An overload running
programme
Injection therapies (local
anaesthetic) and
Stretching/relaxation
(supervised yoga twice per
week).
This study reported that the
professional footballer returned to
full participation 42 days post
injury, and did not suffer further
re-injury of his hamstring for the
remainder of the season
8
. An
issue in interpreting the clinical
significance of this study is that it
would be difficult to identify the
relative contribution of each
modality to the final outcome.
This was also not compared to a
control subject.
In a recent physioedge podcast,
Kieran OSullivan (University of
Limerick, Ireland) discussed with
David Pope some useful clinical
concepts, referencing his current
Ph.D and extensive review of the
literature. You can access this
podcast here. I highly recommend
it.
In discussing the current evidence
available, Kieran summarised the
following important rehabilitation
concepts
9
:
A considerable risk factor for
hamstring injury is an excessive
and inappropriate increase in
training load.
Appropriate and timely
progression from isometric, to
concentric, and
eventually eccentric hamstring
strengthening is critical. This
appears to be the most effective
way to improve the
musculotendinous units ability
to undertake load. The earlier
the patient starts appropriate
strengthening, the better.
Principles of R.I.C.E. in acute
management have limited
evidence in improving
hamstring recovery times. The
most relevant evidence reaffirms
early strength training to
improve the hamstrings load
capacity.
Eccentric strengthening
exercises moving through a
greater range of available
muscle length may be more
effective in stimulating
appropriate adaptation to
loading.
Pain reported the day after an
exercise program may be a
better indication of whether the
chosen exercise (loading) is
appropriate, as opposed to
reporting pain during the
exercise.
Stiffness experienced in the
morning (without excessive
discomfort) is ideal. Once the
patient is waking up without
muscle stiffness, this would
indicate an appropriate time to
increase exercise load.
The inclusion of principles of
hip/foot biomechanics, reduced
muscle length and muscle
activation patterns are still
clinically useful, however there
is limited evidence to suggest
that they prevent hamstring re-
injury. Their relevance is
important when considering the
subsequent load occurring
through the hamstring during
specific tasks.
There is no definitive test to
suggest an athlete is safe to
return to full participation. A
reasonable guideline would be
for the athlete to train at full
capacity twice in the week prior
to returning to on-field.
Successful management of
hamstring injuries should
include continued
rehabilitation, even after the
athlete has returned to full
participation. This will involve a
maintenance phase, to
continue appropriate
musculotendinous loading and
to improve functional capacity.
Summary
The rehabilitation of hamstring
injuries continues to challenge
clinicians and researchers around
the world. In light of current
scientific evidence, we can be
confident that after careful
assessment, commencing
appropriate strength training as
soon as possible is important.
Like all rehabilitation protocols,
theres no all-encompassing set of
guidelines for exercise
prescription that would be
appropriate for athletes across the
board. Continued experience and
practice is needed to determine
what level of loading is
appropriate for each athlete, as
well as progressing the individual
with regard to their sports-specific
loading demands.
If anyone has any other resources
or accompanying material to
share, or would like to share
clinical experience on this topic, it
would be great to hear from you.
Luke McManus.
References:
1. Arnason A, Sigurdsson SB,
Gudmundsson A, et al. 2004,
Risk factors for injuries in
football, Am J Sports Med, vol.
32, (1
Suppl):5S16S. PMID: 14754854
2. Alonso JM, Tscholl PM,
Engebretsen L, et al 2010,
Occurrence of injuries and
illnesses during the 2009 IAAF
World Athletics
Championships, Br J Sports
Med, vol. 44, pp.
11001105. PMID: 21106775
3. Orchard JW, James T, Portus
MR 2006, Injuries to elite male
cricketers in Australia over a 10-
year period, J Sci Med Sport,
vol. 9, pp.
45967. PMID: 16769247
4. Brooks JH, Fuller CW, Kemp
SP, et al 2006, Incidence, risk,
and prevention of hamstring
muscle injuries in professional
rugby union, Am J Sports Med,
vol. 34, pp.
12971306. PMID: 16493170
5. Ekstrand J, Hagglund M,
Walden M 2011, Epidemiology
of muscle injuries in
professional football (soccer),
Am J Sports Med, vol. 39, pp.
122632. PMID: 21335353
6. Askling C, Tengvar M and
Thorstensson A 2013, Acute
hamstring injuries in Swedish
elite football: a prospective
randomised controlled clinical
trial comparing two
rehabilitation protocols, Br J
Sports Med, vol. 47, pp.
953959. PMID: 23536466
7. Askling C, Saartok T,
Thorstensson A 2006, Type of
acute hamstring strain affects
flexibility, strength, and time to
return to pre-injury level, Br J
Sports Med, vol. 40, pp.
4044. PMID: 16371489
8. Brukner P, Nealon A et al 2012,
Recurrent hamstring muscle
injury: applying the limited
evidence in the professional
football setting with a seven-
point programme, Br J Sports
Med, doi:10.1136/bjsports-
2012-091400. [Link]
9. David Pope, interview with
Kieran OSullivan: Physioedge
podcast, published 29 June
2013. [Link]

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10/03/14 23:42 Hamstring Injuries: A Discussion of Physiotherapy Rehab | Physio Development

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