Transcript Hamstring UCL - Elite Physical Medicine

Paul Thawley
MSc, BSc (Hons), PgDip (Rehab), MCSP SRP
Senior Sports Physiotherapist Team GB
Hamstring Injuries
“Hamstring injuries occur in all sports
and effect elite and non elite
populations” (Brooks et al 2006)
Athletic Population
Non Athletic population
Epidemiology
FA Audit of Injuries study found that 12% of all injuries
reported over two seasons were hamstring strains. (Woods
Br J Sports Med 2004;38;36-41)
11-15% Cricket (Stretch 2003, Orchard et al 2002a)
16% AFL with a recurrence rate of 34% Seward et al (1993)
Incidence 0.30 per 1000 playing hours with average
severity of 17 days absent in English Rugby Union –
Brooks et al (2005)
Epidemiology
Epidemiological evidence suggests that hamstring strains are
associated with eccentric load, where the contracting muscle
is lengthened and there may well be a lack of neuromuscular
control.
Biggest risk of injury is previous injury
Biceps femoris most commonly injured
Increased incidence with age
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
 Adductor
 Myositis
magnus
Ossificans
Not to be missed
 Tumors
 Iliac
artery
insufficiency
Diagnosis
Listen Hx is key
Look
Move
Feel
Special tests
Neural Dynamics
Slump test as a diagnostic tool
Slump as a treatment modality
Significant effect on Fascia – Vleeming
et al 2005
Lumbar Spine
Age / Degeneration of L4/5 and L5/S1
associated with prevalence of hamstring injuries
Successful management of hamstring injuries in
Australian Rules footballers: two case reports
Chiropractic & Osteopathy 2005,
13:4 doi:10.1186/1746-1340-13-4
If your think the lesion is soft tissue
Dynamic Ultrasound or MRI are you
investigations of choice
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)
Possible causes of Muscle Injury
Musculoskeletal imbalances
Poor muscular co-ordination
Inappropriate training
Fatigue
Incomplete rehabilitation
Repeated micro-trauma
Intrinsic and extrinsic
factors
Musculoskeletal imbalances
Any breakdown in the effective function of the legs and pelvis
during running may predispose to injury. Examples include:
postural changes due to muscle tightness
lumbar or sacro-iliac joint stiffness
poor co-ordination of movement or early fatigue associated with
muscle weakness
leg length discrepancy (LLD) which will affect pelvic motion and
stride length. Note: LLD < 1.5 cm is usually not significant
prolonged or delayed pronation or supination of the foot, which
will alter the function of the leg and pelvis during the running
cycle
Intrinsic and extrinsic
factors
Poor muscular co-ordination
Running requires strength, power, endurance and coordination. Problem-free running cannot take place if the
hamstrings are weak, inflexible, or if there is poor
neuromuscular co-ordination. Loss of the normal ratio of
muscle power between the quadriceps and hamstrings may
also occur. The normal quadriceps/hamstrings ratio is 60:40.
Loss of the normal ratio may be due to excessive development
of the quadriceps, or due to existing weakness of the
hamstrings. A normal ratio is essential to prevent imbalances
from occurring during the running cycle.
Inappropriate training
“Inappropriate” comprises all the factors that may affect your
body’s ability to adapt to the varied stresses of running.
Factors include:
excessive mileage
rapid increase in mileage
inadequate warm-up and cool-down
poor stretching
cambered running surfaces
worn shoes or orthotics
Fatigue
Fatigue affects performance and may predispose you to injury.
At a physiological level, fatigue may be reflected in a
prolonged recovery time at neuromuscular junctions, which
diminishes effective muscle activation, slows the clearing of
metabolites from the muscle, and impairs the ability of the
muscle to contract. Fatigue therefore results in decreased
strength, power and endurance, and will increase the risk of
injury.
Incomplete rehabilitation
As runners, we are always eager to get back on the road as
soon as possible. If an injury is not properly treated, or if you
do not achieve your pre-injury levels of strength, endurance
and flexibility, the risk of re-injury is increased. Effective
rehabilitation (which means putting in the time with the
physio, or at the gym) will allow you to get back on the road
and stay there.
Repeated micro-trauma Often trauma to the hamstrings
may not always be significant enough to cause pain or
disability at the time of injury.The reduction in hamstring
function may be so gradual that it will not be detected until
there is a serious problem. This is often described as “the
last straw that broke the camel’s back”, where repeated
micro-trauma will finally result in pain and dysfunction. When
running, the hamstrings are often exposed to repeated
micro-trauma due to over-striding, as well as with a change
of pace. Over-striding, particularly when just starting to run
downhill, places the hamstrings under excessive eccentric
load as the muscle works to stabilise the knee joint. The
excessive eccentric load may result in micro-trauma to the
muscle fibres, leading to injury.
Treatment approaches
Muscle Injury

What are the consequences to the athlete of not treating a muscle
injury correctly?

How much damage is caused by inactivity on the athletes and the
doctors part?

Why is there no/little consensus on management of muscle injury?
Staring point with an Hamstring lesion
R.I.C.E
Compression the key
Gentle mobilisation
Partial weight bearing as tolerated
Electrotherapy modalities
When to stretch?
When to start running again?
Continued Rx
STR / MFR
Acupuncture
NSAIDs after 24 hours
Electrotherapy modalities
Correct Physical rehabilitation is paramount
in the management of hamstring injuries
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
 Stat
difference in recurrence rates over I year
period remain ISQ (Sherry et al, 2004. JOSPT, 34(3): 116-25)
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 (ie ligaments)
Prolonged immobilisation is detrimental
Early mobilisation of affected tissue increases density of scar
formation. (Jarvinen, 1975) What about remodelling???
Accelerated running program
Developed by Graham Reid
Australian Hockey Physio
Injured player on tour
Captive audience
Good result
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 or 10 degrees off full knee extension ? start running program
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 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
 40 – 20 –40
 35- 20 –35
 30-20-30
 25-20-25
 20-----20
 15-----15
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 is the most important aspect
to hamstring rehabilitation
My approach to pre running criteria
(how do you know when the athlete can run ????)
Adductor magnus bridges 5 sets of 12
reps
Seated knee extension = 10 degrees off
straight
Single leg long level bridge = pain free
Hamstring Exercises
Manual resistance
Manual therapy
Rehabilitation approach
Why does early mobilisation work?
Eccentric exercise in a controlled way is functional
Improved neural patterning/technical ability
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
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
Injury prevention
Extremely difficult!
Eccentrics???
Concentric
Eccentric
Characteristics of eccentric contraction
Produces more force than concentrics
Selectively recruits Fast fibers. Fast fibers are bigger and have greater potential
for growth than slow fibers.
During the eccentric phase of movement, the muscle absorbs energy. This work
is done “by stretching the muscle and in this process the muscle absorbs
mechanical stress This mechanical energy is dissipated or converted into one or a
combination of two energies.
1. Heat
2. Elastic Recoil
Key concepts in injury prevention
Improve the training regime so that it more accurately reflects
sports specific conditions with the goal of improving muscle
conditioning;
Try and improve fatigue resistance of the hamstring muscle
Try and induce a change in the viscoelastic properties of
muscle so as to increase energy absorption and decrease
load on the muscle-tendon unit for any given length
especially in body positions of function and vulnerability to injury.
Verrall et al 2005 Br J Sports Med
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
Most Studies used concentric measurements, Why when
we know hamstrings have an eccentric action? (Brockett et al,
2004: Med Sci Sports & Ex. 36(3))
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.
Can we predict/prevent hamstring
strains?
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)
Incremental Increase in Eccentric
Exercise
Drop-catch exercises
(Stanton and Purdam 1989 J Orthop Sports Phys Ther)
Nordic hamstrings
High-velocity eccentric exercises in the final phase
of rehabilitation (Geraci 1998)
Hamstring Exercises
Nordic Hamstrings
Icelandic curls research From: Bahr and Meahlum (2002)
Length-tension relationship
Tension
Length
Icelandic curls
Tension
Points to consider in Footballers

Body awareness

Requirements of the Sport

Limited neural aspects

Limited kicking etc. till full running

Ball work restricted in initial stages
Physical rehabilitation does not replace intensive hands-on approach

How to integrated this philosophy with the football management
Sports Specificity relating to hamstring
injury prevention
Think specific and generic
ie Football
Ladders
Change of direction
Backwards/sideways running
Shuttles
Chase and escape drills
Recreate load, stress, strain, joint angles, fatigue
index
Case Study
Primary hamstring lesion grade 1+ on US
Day 1
PRICE crutches 2/7 no NSAIDs
Day 3
STR / PNF local electrotherapy + NSAIDs
Seated SLR / passive mobilisations
Day 5 program
Active mobilisations / basic gym program
Day 7
Hamstring specific program (powerpoint)
Case Study Contd
Day 14
Re US scan good reduction in fluid
RTP day 18
Post injury
S&C lead eccentric program in place and a physio lead pelvic
neuromuscular patterning program with monitoring
Summary
Diagnosis is key, use correct imaging
modalities
Initial treatment is in line with any other soft
tissue injury; protection, RICE and early
mobilisation.
Understand that there is close relationship
between hamstring injury, the neural system
and lumbar spine pathology
Summary continued
Accelerated running programs can be utilised
Identify predisposing factors relating to the
hamstring injury in that individual athlete
Apply an eccentric injury prevention strategy
Develop your own strategy related to current
research evidence
Be sports specific in your approach
Questions/comments/discussion?
References
Kyro ̈ la ̈ inen H, Komi PV, Belli A. Changes in muscle activity patterns and kinetics with increasing running speed. J
Strength Cond Res 1999;13:400–6.
Pinniger GJ, Steele JR, Groeller H. Does fatigue induced by repeated dynamic efforts affect hamstring muscle
function? Med Sci Sports Exerc 2000;32:647–53.
Garrett WE. Muscle strain injuries: clinical and basic aspects. Med Sci Sports Exerc 1990;22:436–43.
Best TM. Soft-tissue injuries and muscle tears. Clin Sports Med 1997;16:419–34.
Stauber WT, Knack KK, Miller GR, et al. Fibrosis and intercellular collagen connections from four weeks of muscle
strains. Muscle Nerve 1996;19:423–30.
Stauber WT, Smith CA, Miller GR, et al. Recovery from 6 weeks of repeated strain injury to rat soleus muscles.
Muscle
References
Askling C, Saartok T, Thorstensson A. Type of acute hamstring strain affects flexibility strength and time back to pre-injury level. Br J
Sports Med. 2006;40:40-44.
Askling C, Tengvar M, Saartok T, Thorstensson A. Sports related hamstring strains—two cases with different etiologies and injury sites.
Scand J Med Sci Sports. 2000;10:304-307.
Brooks JHM, Fuller CW, Kemp SPT, Reddin DB. Incidence, risk, and prevention of hamstring muscle injuries in professional rugby union.
Am J Sports Med. 2006;34:1297-1306.
Connell DA, Schneider-Kolsky ME, Hoving JL, et al. Longitudinal study comparing sonographic and MRI assessments of acute and
healing hamstring injuries. AJR Am J Roentgenol. 2004;183:975-984.
De Smet A, Best T. MR imaging of the distribution and location of acute hamstring injuries in athletes. AJR Am J Roentgenol. 2000;174:
393-399.
Gabbe BJ, Bennell KL, Finch CF, Wajswelner H, Orchard JW. Predictors of hamstring injury at the elite level of Australian football. Scand
J Med Sci Sports. 2006;16:7-13.
Garrett WE, Rich FR, Nikolaou PK, Vogler JB III. Computed tomography of hamstring muscle strains. Med Sci Sports Exerc.
1989;21:506-514.
Gibbs NJ, Cross TM, Cameron M, Houang MT. The accuracy of MRI in predicting recovery and recurrence of acute grade one hamstring
muscle strains within the same season in Australian Rules football players. J Sci Med Sport. 2004;7:248-258.