Transcript Hamstring injury’s

Ins and Outs of the Hamstring
 A couple of Questions that I asked myself:
 What can I do better to prevent hamstring strains
 What can I do better or different to prevent a
recurrence ?
Ins and Outs of the Hamstring
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Goals of this Talk
Anatomy of the Muscles
Research of Hamstring Injuries.
Intrinsic/Extrinsic factors of Hamstring Injuries.
Hamstring healing phase’s
Hamstring Rehabilitation
Ins and Outs of the Hamstring
Biceps Femoris Muscle - Short
Head:
Origin: Distal linea aspera and lateral
supracondylar ridge of femur
Insertion: Head of fibula and lateral
condyle of tibia
Actions on the leg
Flexes the leg at the knee: laterally rotates
leg when the knee is flexed.
Biceps Femoris Muscle - Long
head:
Origin: Ischial tuberosity of os coxa
Insertion: Head of the fibula and
lateral condyle of tibia.
Actions: on the thigh: Extends the thigh
at the hip ( it also flexes leg at knee and
laterally rotates leg if knee is flexed )
Ins and Outs of the Hamstring
Semitendinosus
Origin: It arises from the lower and
medial impression on the tuberosity of
the ischium,
Insertion: into the upper part of the
medial surface of the body of the tibia,
nearly as far forward as its anterior
crest.
Action: Flexes and medially rotates the
knee joint.
Extends and assists in medial rotation
of the hip joint
Ins and Outs of the Hamstring
Semimembranosus
Origin: is the ischial tuberosity
Insertion: medial condyle and
nearby margin of tibia;
intercondylar line and lateral
condyle of femur; and the ligament
of popliteal region.
Action: Flexes and medially rotate
the knee joint. Extends and assist in
medial rotation of the hip joint.
Ins and Outs of the Hamstring
 Marc A. Sherry, DPT, CSCS,1 Thomas M. Best, MD, Amy Silder, PhD
Darryl G. Thelen, PhD,and Bryan C. Heiderscheit, PhD.
 MECHANISM OF HAMSTRING INJURY
 Most hamstring strain injuries happen while running.
 In the terminal swing phase of the gait cycle.
 During the second half of the swing, the hamstrings undergo an
eccentric contraction and absorb energy from the swing limb before
foot contact.
 Thus, the hamstrings are stretched while subjected to load(eccentric
contraction), with the biceps femoris incurring the greatest amount.
Ins and Outs of the Hamstring
 A historical perspective.
 1902- first mention of muscle injuries
 1906- management of muscle tears conservative immobilization, cool
water.
 1930- first research increased interest in understanding the
histopathology .
 1936- RTP to soon was discovered at this time
 1950-1960 Cortizone injections were popular
Ins and Outs of the Hamstring
 1954- till present practice and principle of tx“…treatment must be
designed to minimize the haemorrhage and inflammatory reaction so that
there will be as little granulation (scar) tissue formed as possible…”
Delarue NC
 1960 -introduction NSAID
 1970-1980 introduction physiotherapy
 Last 20 years seen explosion of research understanding of
epidemiology, etiology, pathophysiology
Ins and Outs of the Hamstring
 Research into Hamstring Injuries.
 Lot of research is done in conjunction with ACL reconstructions.
 Some research has pointed to how many hamstring injuries will cost a
team in lost time.
 Some research has tried to look at intrinsic and extrinsic factors.
Ins and Outs of the Hamstring
 Feeley at all reported that
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Muscle strains account for 46% of practice injuries
Hamstring strains were the second most common preseason injury
1.79 per 1000 athletes exposures for practices
4.07 per 1000 athletes exposures for games
Ins and Outs of the Hamstring
 Marcus C. C W. Elliot MD, Bertram Zarins, John Powell, Phd, ATC,
Charles D Kenyon
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10 year review Professional NFL players
This study was done from 1989-1998
10 years 1716 hamstring strains 1129 different athletes.
Mean of totally lost days was 2222 in the 10 years.
About 47.3 % was during games
About 52.7 % was during practice preseason most
16.5 % of re-injuries practices/22% during games
Offensive more injuries than defense. Wide recievers/runningbacks
Secondary has the highest rate of injury.
Ins and Outs of the Hamstring
 Ekstrand J, Hägglund M, Waldén M
 51 football teams, 2299 players, were followed during the years 2001 to
2009.
 2908 muscle injuries were registered.
 92% of all muscle injuries affected the 4 major muscle groups of the
lower limbs:
 hamstrings (37%), adductors (23%), quadriceps (19%), and calf muscles
(13%).
 16% of the muscle injuries were re-injuries.
 Re-injuries caused significantly longer absences than did first time
 The incidence of muscle injury increased with age.
 When separated into different muscle groups, however, an increased
incidence with age was found only for calf muscle injuries
Ins and Outs of the Hamstring
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What can we conclude from this research
Hamstring strain cost a lot of time of the field .
Hamstring strains have a high recurrent rate.
Hamstring strains cost a team valuable assets that are
not able to perform.
 Is there anything we can do?
 Some research on intrinsic/extrinsic factors
Ins and Outs of the Hamstring
 Burkett Lee 1970
 Causative Factor in hamstring strains.
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12 hamstring strain subjects/18 track athletes
32 football athletes/ 6 were predicted to strain hamstring
Strength imbalance between knee flexors of both legs
Strength imbalance between knee extensors of both legs
Flexion-extension ratio
Bilateral muscle strength
Sit and reach test.
Results: Strongly indicated that reduction of strength imbalance
between limbs will be useful in the prevention of hamstring
strains.
Ins and Outs of the Hamstring
 Jean-Louis Croisier,* PhD, BenedicteForthomme, PT, MarieHelene Namurois, PT, Marc Vanderthommen, PhD, and JeanMichel Crielaard, MD, PhD.
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2002
26 athletes w/ recurrent hamstring strains.
Concentric/Eccentric isokinetic testing.
Aim was to see if normalization of the differences in
hamstring/quadriceps ratio would decrease recurrence of hamstring
 18 athletes had strength deficits, as determined by statistically selected
cutoffs of peak torque, bilateral differences, and the flexors/quadriceps
ratio.
Ins and Outs of the Hamstring
 Continued
 Showed a eccentric peak torque deficit and a significant reduction of
the mixed eccentric/concentric quadriceps ratio.
 athletes with muscle imbalances followed a rehabilitation program
individually adapted from their strength profile emphasizing eccentric
training
 10-30 sessions which resulted in normalization of the isokinetic strength
testing.
 After 12 months of following the athletes none sustained an recurrent
injury
Ins and Outs of the Hamstring
 Fousekis, Tsepis,Poulmedis, Athanasopoulos, Vagenas.
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Nov 2010
Prospective cohort study 100 soccer players intrinsic factors.
Soccer players 19.4-27.8 old
Looked at composite effects in asymmetry
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muscle strength flexibility,
proprioception,
physical characters,
knee joint stability
previous history of strains.
 Study looked at several different variables together
Ins and Outs of the Hamstring
 Results Cont’d:
 Three significant predictors for Hamstring strains when put together
are:
 Functional leg length asymmetry
 Excessive isokinetic asymmetry
 Previous hamstring strain
 Other intrinsic factors such as age, cross sectional periphery, muscle
flexibility, functional knee strength ratio, knee joint laxity and proprioceptive
traits proved to be irrelevant
Ins and Outs of the Hamstring
 Marc A. Sherry, Thomas M. Best, MD, Amy Silder,
Darryl G. Thelen, PhD and Bryan C. Heiderscheit, PhD,
 June 2011
 To decrease the recurrent rate this research proposes to
incorporate into the rehabilitation process:
 Dynamic warm-up
 Integrating Neuromuscular control
 Trunk stabilization
 Functional eccentric strengthening.
Ins and Outs of the Hamstring
 Brukner, Nealon, Morgan, Burgessand Dunn
 Dec 2012 Casestudy.
 Recurrent Hamstring injuries 12-63 % 1 month highest risk to reinjure.
 7 point program to reduce recurrent injury
 26 year athlete ® 5 hamstring injuries in 5 months
 Prior injuries included ® MCL strain,® Achilles tendinopathy , (l) Add strain
 Neurodynamics ( SLR and slump test)
 Biomechanical assesment
 Core stability/lumbar strengthening
 Increase strength thru eccentric
 Overload running program
 Injection therapy
 Stretching/yoga/relaxation.
Ins and Outs of the Hamstring
More Intrinsic factors to keep in mind associated with
Hamstring Injuries are :
Lumbo-pelvic status
Muscle flexibility
Strength training
Running mechanics
Ins and Outs of the Hamstring
 Lumbo-Pelvic Status:
 pre-existing lumbar spine pathology
 pelvic muscle imbalance – pelvic muscle tone
 80% population will have right TFL, Illiacus, Psoas stronger then
the left gluteal medius
 stability and joint control.
Ins and Outs of the Hamstring
 Muscle flexibility.
 Studies have not definitively concluded that hamstring strains
are due to inflexibility.
 Increase flexibility gradually .
 Look for tightness in the hip flexors for both legs.
Ins and Outs of the Hamstring
 Include in your Strength program
 Quad strength vs Hamstring strength
 Maximum strength and fatigue tolerance
 Eccentric strength.
 Running Mechanics
 Over striding. Excessive force on the hamstring leading
to fatigue and possible strain
Ins and Outs of the Hamstring
 So where does this leave us athletic trainers.
 Athletes with previous Hamstring strains are higher likely
to pull again.
 Strength deficits in the hamstring/quad ratio might be
something to keep in mind.
 Leg length differences might be something to look at.
 1st month after strain high incidence of re tear
 Rehab an athlete with neuromuscular, eccentric
strengthening, core, and go slow.
 All points to keep in mind.
Ins and Outs of the Hamstring
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4 basic stages of healing
The time of Injury
Inflammatory phase
Fibroblastic phase
Remodeling phase
Ins and Outs of the Hamstring
 Time of Injury
 Protect the injury
 Immobilization
 The more severe the longer it takes.
Ins and Outs of the Hamstring
 The Inflammatory phase:
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Last approx. 4-6 days
Bleeding- (inflammatory cells to injury)
Delicate framework
Scaffolding
Prevent moving muscle.
Clinically :
Rest/immobilization
Decrease inflammation via ice, rest compression, ultrasound,
avoid stretching or exercises
Ins and Outs of the Hamstring
 Repair/Regeneration phase
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5 days to10-12 weeks
Increased tensile strength in scar
Stop immobilization.
Clinically:
Start rehab to increase strength, stretching, soft tissue
mobilizations starting slowly.
Ins and Outs of the Hamstring
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Remodeling phase
Start 21 days continues 6-12 months
Scar strength increases and becomes smaller.
Clinically:
Stretching to optimal length
Rehabilitation vigorous enough to keep up with
demands of sports (functional)
Ins and Outs of the Hamstring
 Rehabilitation Old and New
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Bridge
Hamstring curls
Lunges
SLRDL
Slide board
SLB
Ins and Outs of the Hamstring
Ins and Outs of the Hamstring
Eccentric forward pull
Ins and Outs of the Hamstring
Ins and Outs of the Hamstring
 http://www.youtube.com/watch?feature=player_detailpage&v=AS9eqB_hZqo#t
=50s
Ins and Outs of the Hamstring
Ins and Outs of the Hamstring
Manual eccentric/concentric strengthening
Ins and Outs of the Hamstring
Leg dropping gently move the
leg around and suddenly drop
the leg tell the athlete to stop
the leg
Bridge on smaller ball
Ins and Outs of the Hamstring
Pogo butt kicks
Below is Hamstring curls with feet
stable on rolling cart
Ins and Outs of the Hamstring
Heel Toss with Med ball
Hamstring injury’s
 CONCLUSION.
 QUESTION