Management Plan

Acute/Early stage

Hamstring injuries are common in many sports, including football and running.  Within the first 48 hours of the injury, the RICE (rest, ice, compression and elevation) method was followed. Gentle hamstring stretches were initiated to maintain muscle mobility and reduce the likelihood of scar tissue developing.

During his initial consultation, 3 days after the traumatic event, a personalised rehabilitation plan was designed.  The patient was encouraged to continue stretching for his hamstring until he could perform pain-free full knee extension.  Within 5 days, stretches exercises were progressed to focus on specific areas:

  • Hamstring stretch with contra-lateral knee flexion and applying a stretch on the affected lower leg with different degrees of internal and external rotation to maximize its effectiveness.
  • Hamstring stretch with knee bent in order to focus on the upper hamstring region.
  • Stretches of the antagonist muscles, quadriceps and iliopsoas were also incorporated.
  • Soft tissue therapy was limited to gentle effleurage and lymph-drainage technique to augment reduction of localized swelling.  Trigger point release was applied on the ipsilateral gluteal region.
  • Isometric strengthening exercises was commenced early to prevent loss of strength and muscular atrophy.  By the end of the early stage, eccentric self resisted contractions were incorporated.  Taking into consideration the possible mechanism of hamstring injury and the type of contraction required in fast sprinting, eccentric training was paramount to the patient sport-specific rehabilitation.
  • Core stability exercises were also incorporated focusing on pelvic mobilization and contraction of deep abdominals.

Middle stage

During the middle stage, as the swelling and bruising were considerably reduced, the rehabilitation plan progressed to:

  • Soft tissue therapy characterized by sustained compression forces, myofascial release with passive knee extension with the scope to reduce scarring formation.
  •  Strengthening exercises for concentric and eccentric hamstring contraction were progressed.
  • Lying on back with lower legs supported on stability ball and arms at sides. Squeeze gluts and lift hips so they are in line with ankle and trunk.  Bend knees and roll ball towards body, keeping hips high.  Slowly reverse movement and lower hips again.  To make exercise harder do not lower hips in between rolling.

  • Core stability exercises were progressed to plank, side plank and the hundred exercises.
  • Proprioception on wobble board in single leg stand with eyes open/closed and upper body disruption (catching ball) aimed to re-educate mechanoreceptors within the affected area.
  • Aerobic training on the static bike and cross trainer was incorporated to maintain aerobic fitness level.

Late stage

  • Eccentric training was progressed to Nordic hamstring exercise in order to produce maximal eccentric contraction and mimic the conditions likely to produce injury: eccentric contraction, high forces and near full knee extension.
  • In the final stage of rehabilitation, the focus was on sport specific drills in order to prepare the athlete to a full return to training and competition.  This included running with fast change of directions, sprinting and shuttle running.
  • Change of direction running.

Start slowly and always push off the outside leg.  Accelerate out of the turn. Set up 2 cones 5 meters apart. Increase speed and decrease distances canes are apart to progress.

  • A running programme was designed to maximize aerobic running capability prior to return to sports.

Clinical Markers for return to sport

Throughout the rehabilitation programme, we monitored specific clinical markers and we agreed on a full return to activity on:

  • 90% eccentric strength on injured leg compared to non-injured side
  • Pain free maximal concentric contraction
  • Functional tests: sprinting from standing start, sudden changes in direction while dribbling with ball, running and catch/stop a football
  • Completion of the running programme

Although there are no standard guidelines with regard to return to football after a hamstring injury, the criteria used were considered appropriate in this specific patient scenario.

Evidence based practice

Strengthening

Inadequate hamstring muscle strength has been determined to be an intrinsic risk factor in the occurrence of hamstring strains.  When keeping in consideration football kinetics, it is postulated that hamstrings are at higher risk of injury during the eccentric phase of sprinting, when the hamstring muscles work eccentrically to decelerate the forward movement of the leg, as well as during foot strike, in the transition from eccentric to concentric muscle action, (2) argue that strength training for the hamstring muscles should be eccentric.  In their study amongst elite football players, they reported that eccentric training with Nordic lowers reduces the risk of hamstring strains.  Their findings are in agreement with those from a study by Stanton and Purdham (2). It is well documented that strength training is mode specific and consequently assessing the role of eccentric exercises in hamstring injuries while sprinting.  They postulate that eccentric training will result in the musculo-tendinous structure being capable of both generating and withstanding higher eccentric and concentric forces.  Return of hamstring strength to a specific level is now a regular component of determination of fitness and return to play.

(4) Reports the injured side should reach 95% of the uninjured side strength using an eccentric protocol before allowing return to play.  However, recent studies suggest that the optimal joint angle of the torque: length curve is more relevant in predicting recurrent hamstring injury .

(5) In individuals having sustained a hamstring injury, peak knee flexor torque occurs at a greater knee flexion angle compared with both the contra-lateral side and a group of uninjured subjects.

(6) Reported that an eccentric programme with Nordic Lowers produced a significant increase in eccentric torque production after 10 weeks of training.

(7) Reported that football players with previous hamstring injury had significant less flexible hamstring muscle their uninjured side.  However, it appears difficult to determine whether stiffness is a predisposing factor in causing hamstring strain or possible sequelae to the injury.

(8) Provide evidence of a long-term muscle remodeling following a hamstring strain injury. They report that 79% of previously injured participants presented residual scarring at the site injury that persisted a minimum of 5 months after injury.

(9) Investigated the effect of flexibility training alone amongst football players and reported no effect on the incidence of hamstring strains. There appears to be minimal evidence that flexibility training alone is beneficial in hamstring injury prevention in football.

(10) Report that contra lateral hip flexors have as large influence on hamstring stretch as the hamstring themselves.

Stretches

The ability of connective tissue to absorb force is related to its resting length and the greater the resting length (flexibility), the greater the ability to absorb forces and avoid strain.  Therefore, stretches exercises have become an integral part of any rehabilitation for hamstring strain. Therefore, it appears that a multi-factorial rehabilitation and training regime is mostly effective in hamstring injury treatment and prevention in football.

Core Stability and Pelvic Stabilization

In fact, the iliopsoas can directly induce an increase in anterior pelvic tilt, which in turn necessitates greater hamstring stretch. Appropriate hip flexor muscle length is consequently vital to effective hamstring mechanics. Other proximal muscles acting on the pelvis such as abdominal oblique and erector spinae also substantially influence hamstring stretch. It appears that functional neuromuscular control of pelvis and trunk muscles can affect hamstring injury risk.  An exercise programme comprising stabilisation exercises has been shown to be more effective in promoting return to sport than a traditional stretching and strengthening exercise programme  alone.

References

  • Arnason A., Andersen T., HolmeI., Engerbretsen, Bahr R.  “Prevention of hamstring strains in elite soccer: an intervention study”.  Scandinavian Journal Medicine and Science in sports, 2006, 1-9.
  • Wood G., Marshall R., Strauss G.  “Electro-musculomechanical action of the lower limb in sprinting.  Insights into hamstring injury potential.”  Fourth meeting of the European society of biomechanics, Davos,switzerland, 1984.
  • StantonP. and Purdham C.  “Hamstring injuries in sprinting – the role of eccentric exercise”.  Journal of orthopaedic sports and physical therapy, 1989, 10(9), 343-9.
  • Croisier J.  “Factors associated with recurrent hamstring injuries”.  Sports Medicine 2004, 34, 681-695.
  • Orchard J. and Best T.  “Return to play following muscle strains”.  Clinical Journal of sport medicine, 15, 6, 2005, 436-441.
  • Mjolsnes R, Arnason A., Ostaghen T., Raastad T., Bahr R.  “A 10 week randomized trial comparing eccentric vs concentric hamstring strength training in well-trained soccer players”.  Scandinavian Journal of medicine and science in sport, 2004 14, 311-317.
  • Worrell T. and Perrin D.  “ Hamstring muscle injury: the role of strength, flexibility, warm-up, and fatigue”.  Journal of orthopaedic and sports physical therapy, 1992,16, 12-18.
  • Silder A., Heiderscheit B., Thelen, D., Enright, T. and Tuite M.  “ Mr observations of long term musculotendon remodeling following a hamstrinh strain injury”.  Skeletal radiology, 2008 December, 37 (12), 1101-1109.
  • Thelen D., Chumanov E., Sherry, M., Heidercheit, B.  “Neuromsuloskeletal models provide insights into the mechanisms and rehabilitation of hamstring strains”.  Exercise and sport science review, 34, 3, 135-141, 2006.
  • Sherry M., Best T.  “A comparison of 2 rehabilitation programs in the treatment of acute hamstring strains.” Journal of Orthopaedics and  sport physical therapy.  2004, 34 116-25.
  • Verrall G., Slavotinek J., Barnes P.  “The effect of sports specific training on reducing the incidence of hamstring injuries in professional Australian rules football players”.  British journal of sports medicine, 2005, 39, 363-368.
  • Best T., Garrett W.  “Hamstring strains: espediting return to play”.  The physician and sportsmedicine, 24, 8, 96.

 

 

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