Transcript Hamstring notes omi - Elite Physical Medicine

Paul Thawley
MSc, BSc (Hons), PgDip (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
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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
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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?
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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
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Developed by Graham Reid
Australian Hockey Physio
Injured player on tour
Captive audience
Good result
Progressive Running Program
Graham Reid
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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
Progressive Running Program
Graham Reid
• Once at 75% without pain, start acceleration
program
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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: 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
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 7:Fast strides and series of 150s at 95%
• Day 8: Rep 300s 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
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Final next evening
44.1 second split
Tight sensation up the final straight
Team won silver, just 1/100th 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 x2/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)
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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?