Paul%20Thawley%20MSc,%20BSc%20(Hons),%20PgDip%20(Rehab),%20MCSP%20SRP

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Paul Thawley MSc, BSc (Hons), PgDip (Rehab),
MCSP SRP
Hamstring rehabilitation
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Hamstring Injuries

• Often occur during running or sprinting
• Top three in soccer
• Many Aetiological factors
• Typically 3-6 weeks for RTS

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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
• Sciatic
• Post cutaneous
• Adductor magnus
• Myositis Ossificans

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Not to be missed

• Tumors
• Iliac artery insufficency

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Well what is it??
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Possible causes of Muscle Injury

• Range
• Muscle length, strength, control and coordination
• Postural position and control
• Technique related issues
• Training errors
• Sudden increase in speed, volume, intensity
• Change of running surface, gradient, shoes,
  spikes, boots etc
• Fatigue poor training cycles

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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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Where do we start?

• 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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Accelerated running program

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

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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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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 degrees knee ext, start running program

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Accelerated Running Program

• Sports specific - More emphasis on this in
  Football
• Ladders
• Change of direction
• Backwards/sideways running
• Shuttles
• Chase and escape drills

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Case Study 1

• Day 0 800m runner, Grade 1/2 hamstring. Unable
  to weight bear
• Ice etc
• Day 1 CPM with ice intervals 8 hrs
• Day 2 am CPM pm Start running program at 30
• Day 3 Running program at 50, start isokinetic
  conc/ecc exercise program

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Case Study 1

• Day 4 Continue running program at 70
• Day 5 Running program at 90
• Start eccentric strength program
• Day 6 Running program at 100 in am
• Pm. Over distance work (200/300s) at 85
• Day 7Fast strides and series of 150s at 95
• Day 8 Rep 300s as per previous week!

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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,
  swellingto offer best possible conditions for
  healing process. Kannus et all (2003)
• Studies cited were for non-contractile tissues
• Prolonged immobilisation is detrimental
• Early mobilisation of affected tissue increases
  density of scar formation. (Jarvinen, 1975)

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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 (37.4 v 22.2
  days)
• Stat difference in recurrence rates over I year
  period
• Sherry et al, 2004. JOSPT, 34(3) 116-25

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Jump series

• Is the hamstring lesion the primary cause of the
  dysfunction?

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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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Recurrence of strains

• 12.6 recurrence in the first week of return to
  play
• 87.4 will be OK in first week back
• 30.6 cumulative recurrence
• Persistently increased risk many weeks after
  return to play
• Therefore speed of return not the main problem

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Case Study 2

• Elite 400 m runner
• Hamstring strain 6 days before Commonwealth Games
• Sharp pain in back of leg whilst sprinting
• Pain on stretch, resisted contraction and to
  palpate
• Positive slump

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Case Study 2

• Day 1 Caudal epidural
• Traumeel and Activegan injections into hamstring
  lesion.
• Release work in deep hip rotators, psoas, QL,
  hamstring above and below lesion and treatment to
  lumbar spine.
• Stretches to above with exception of hamstring

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Case Study 2

• Progress running. Only at 50
• Decided unable to race individual event, but
  wanted to try for relay race in further 6 days
• Continued to improve through the week
• Heat run 8 days post strain. 45 second split.
  Some aggravation, but not to bad

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Case Study 2

• Final next evening
• 44.1 second split
• Tight sensation up the final straight
• Team won silver, just 1/100th behind winning team

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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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Length-tension relationship

• Tension

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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 quadhamstring torque ratios were
  not significantly different
• Eccentric exercise possibly shifts length-tension
  curve to the right
• Study used concentric measurements
• Brockett et al, 2004 Med Sci Sports Ex. 36(3)

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Can we predict/prevent hamstring strains?

• Isokinetic testing -Re-injured hamstring often
  stronger
• Is position of testing important?
• 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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Intervention Program (Verral, 2005)

• Higher level of anaerobic running. Retest with
  shuttle runs, not middle distance time trials)
• Stretching when fatigued
• Specific training drill in trunk flexion (5 mins
  x2/week)
• Weight training monitored. No new users

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Icelandic curls
From Bahr and Meahlum (2002)
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Icelandic curls

• Tension

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Why does early mobilisation work??

• Eccentric exercise in a controlled way
• Neural patterning/technical aspects
• 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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Points to consider

• Adequate range of movement
• Address all issues rarely isolated hamstring
  lesion
• Controlled
• Dont go one to many heed the warning signs
• Number of reps dependant on the animal
• Decrease volume as the intensity increases

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Points to consider in non-athletes (eg
Footballers)

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

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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 the most important
  aspect to hamstring rehab

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Questions/comments/discussion?