Paul Thawley MSc BSc Hons Pg Dip Rehab
Paul Thawley MSc, BSc (Hons), Pg. Dip (Rehab), MCSP SRP Hamstring rehabilitation
Hamstring Injuries • Often occur during running or sprinting • Top three in soccer • Many Aetiological factors • Typically 3 -6 weeks for RTS
Posterior Thigh Pain – Differential Diagnosis • Hamstring muscle strain • Acute • Chronic • Hamstring muscle contusion • Referred from Lx • Neural structures • Triggers points
Less Common Posterior thigh pain • • • Referred from SIJ Tendinopathy Bursitis Compartment syndrome Apophysitis Nerve entrapment – Sciatic – Post cutaneous • Adductor magnus • Myositis Ossificans
Not to be missed • Tumors • Iliac artery insufficency
Well what is it? ?
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
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)
Other mechanisms § Stretch with knee fully extended (stretching for a ball, kicking) § Forced trunk flexion with foot planted (waterskiing)
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?
Accelerated running program • • • Developed by Graham Reid Australian Hockey Physio Injured player on tour Captive audience Good result
Progressive Running Program Graham Reid • • • Jogging at variable speed up to 75% Minimal acceleration/deceleration Approx 4 min/km pace Up to 2 kms Variable distances 100 mx 3, 90 mx 3, 80 mx 3, 70 mx 3, 60 mx 3, 50 mx 3, 40 mx 3, 30 mx 3: Repeat x 2 • Backwards running: 50 x 3 , 75 x 6, 40 x 3
Progressive Running Program Graham 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
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
Accelerated Running Program Sports specific - More emphasis on this in Football • Ladders • Change of direction • Backwards/sideways running • Shuttles • Chase and escape drills
Case Study 1 • Day 0: 800 m 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
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 (200/300 s) at 85% • Day 7: Fast strides and series of 150 s at 95% • Day 8: Rep 300 s as per previous week!
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 • Prolonged immobilisation is detrimental • Early mobilisation of affected tissue increases density of scar formation. (Jarvinen, 1975)
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
Jump series • Is the hamstring lesion the primary cause of the dysfunction?
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
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
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
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
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
Case Study 2 • • Final next evening 44. 1 second split Tight sensation up the final straight Team won silver, just 1/100 th behind winning team
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.
Length-tension relationship Tension Length
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 • Study used concentric measurements » Brockett et al, 2004: Med Sci Sports & Ex. 36(3)
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)
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 x 2/week) • Weight training monitored. No new users
Icelandic curls From: Bahr and Meahlum (2002)
Icelandic curls Tension Length
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
Points to consider • Adequate range of movement • Address all issues – rarely isolated hamstring lesion • Controlled • Don’t go one to many – heed the warning signs • Number of reps dependant on the animal • Decrease volume as the intensity increases
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
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
Questions/comments/discussion?
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