Overview of the athletic hamstring injury with respect to mechanism, assessment, prognosis, rehabilitation, imaging, management, return to sport and prevention.

1. The Athletic Hamstring
www.sportsmedicinephysiotherapy.com
Nick Kane

2. Overview
 Mechanism
 Assessment
 Initial management
 Rehabilitation
 Prevention

3. AFL Statistics
 Most common muscle strain in athletes- 55% (Huard)
 2004-2013
 Incidence: 6 per club per season
 Prevalence: 21.3 games missed per season
 Re-currence rate – 20%
 Severity: 3.6 games missed
 Substitute rule
 Decreased injuries secondary to reduced overall speed??

4. The Athletic Hamstring
 Bicep Femoris most common – up to 80%
 MTn junction most often implicated
 Biarthrodial joint- Flexes knee, extends hip, tibial &
femoral rotation
 Short & long head: Dual origin, dual innervation-
potential in co-ord of contraction?
 Risk factors
 Age
 Previous H/S injury
 Reduced hamstring strength

5. Mechanism
 Stretch mechanism
 Ballistic hip flexion and knee extension- Judd
 Forced passive stretching- Ballet
 http://www.youtube.com/watch?v=QmnY6RPjP-M
 High speed running/ kicking
 Most common- 80% in soccer
 Eccentric load in lengthened position with increasing
acceleration and mass
 http://www.youtube.com/watch?v=UQP_EKmpuws

6. Assessment- Subjective
 Key predictors athlete will take longer than 3 weeks
for a successful RTP
 Mechanism- Video?
 Pain level at injury
 NSAIDS
 Acute management?
 Past history of hamstring injury
 Pain walking greater than 1 day post injury

7. Assessment- Practical
 Muscle length tests
 PSLR
 PKE
 AKE
 OTHER:
 PSLR with internal/ external rotation OR Add/abd
 ASLR (least
 PKE with full hip flexion
 Proximal structure/ neural/ other
 Slump (day 1-2??)
 Gait
 Lxsp, gluteal and hamstring palpation

8. Assessment- Muscle Power Tests
 Isometric MMT
 Prone @ 15 and 90 degrees (Degrees may vary)
 Supine resisted knee flexion @ varying degrees of hip flexion
 Supine resisted isometric hip extension @ EOR SLR*
 May add hip internal/ external rotation- Medial vs BF
 Dynamic Strength Tests
 Bridge progressions
 S.L bridge @ 45 hip flexion & 90 degrees knee flexion
 Prone hamstring flicks

9. Grade of injury
 Classification of Muscle injuries in sport- Munich
Consensus statement 2013- Functional vs. structural
Functional – no tear
Type 1: Over exertion
muscle disorder
a) Fatigue induced b) DOMS
Type 2: Neuromuscular
disorder
a) Spine related b) Muscle related
Structural: ‘tear’
Type 3: Partial muscle
tear
a) Minor b) Moderate
Type 4 a) Subtotal or complete
tears >50%

10. Imaging- MRI vs. US
 MRI
 Location, size of lesion, tendon involvement?
 Do in first 24-72 hours
 Won’t pick up tears <5mm
 MRI +ve (>60 mm in length or >10% cross section) +
clinical signs = ‘grade 2’ strain= > 3 weeks (Koulouris 2008)
 Strong predictor of severity using longitudinal length of the
lesion
 Ultrasound
 Better used for following the healing process
 Ax scar tissue & vascularisation
 Helpful with initial imaging- high sensitivity

11. Prognosis
 Incident- MOI
 PHx: Previous injury 12mths=>3wks
 Walk painfree: <1 day=1-3 wks, 1-2days= 3-4 wks, 4
days=>4wks
 AKE deficit: <10°= 1-2 wks, 10°-20°=2-3 wks, 20°-30°=3-4wks
 +ve MRI= <3 weeks
 <30yo= + 1 wk
 Lateral distal strain

12. Stages of healing & early management
 Inflammatory (0-72 hours)
 Hemorrhage (aim to minimise)
 Most marked at 2 days
 Regeneration/ proliferative (72- 6 weeks)
 Maturation of fibroblasst
 Significant localised fibrotic scar
 90% force production at 7 days
 Remodeling/ regeneration (6/52-6-12 months)
 Signs of tear remain visible on MRI

13. Rehabilitation
 Respect the tissue healing times
 3 phase proposed (Mendiguchia)
 NSAIDS
 Reduced muscle damage & functional deficit post injury
 Decreased pain inhibition = faster progression
 Improved time to RTS
BUT!!
 Negative effects on muscle recovery, adaptation of muscle & CT in
response to exercise
 Research indicates those who take NSAIDS in the acute stage
increases their chance of recurrence

14. Phase 1- Acute Phase
 Up to 3-7 days post injury
 Prevent re rupture and excessive inflammation
 Early immobilisation- 3-4 days (crutches??)
 Cyrotherapy- Ice and compression altered
 Hydrotherapy: +ve results- Immersion for 10 min at 25
degrees at hip level
 Ultrasound??
 Effleurage?
 Proximal treatment- Gluteal’s , Lxsp, SIJ
 Motor control/ timing
 Education ++
 No problems after 5 days= next stage

15. Phase 2- Sub acute/ rehab
Mobilisation, strength, flexibility, motor control
 Hip, pelvic control/ strength (“Core”)
 Swim, cycle*, deep water running
 Strength in outer range (Hip flex, knee extension)
 Sets & repetitions
 Flexibility- minimise asymmetries- Use AKE!
 Stretch no more than twice daily – bent & straight knee
 Identify & treat neural tension
 Motor control, Hip flexor length, manual therapy
 Running
 When to progress?
 Isometric to isotonic
 <10% asymmetrical AKE
 Symptoms increase= cease training

16. Phase 3- Functional
 Decrease asymmetries- strength, length, running
 Eccentric exercise= increases optimum angle of peak torque
 Correct strength imbalance- HS/Q ratio
 Hip extension strength- Lunges progressions
 Running asymmetries?- Woodward, GPS, force plate, Video?
 Lumber Rotation Capabilities: Torsional & functional
 Agility, running drills, ladders, cross over
 Strength under fatigue- (after running/ training)
 Training reintegration: gradual loads
 Watch for over training*

17. Phase Return to Play (RTP)
 Assess the risk
 a)- health status- Power, ROM, psychological state
 b)- specific demands of sport, position played etc
 Modify risk
 3 full paced training sessions (Warren)
 Rest middle 1/3 of quarters
 Not train day before game = increased risk
 RTP tests
 Askling apprehension “H” test
 Handheld dynamometry- power required for RTS?
 Gait analysis, Nordboard
 Isokinetic testing and endurance testing*
 GPS data- component?
 Palpation
 Speed tests, agility timed tests, functional triple hop test
 3 full paced training sessions with nil symptoms

18. Prevention
 Identification, screening, stretching, core stability,
conditioning, load management- GPS, RPE x time
 Schache’s hamstring MVC test
 Athlete monitoring- welfare (sleep, stress, fatigue)
 Nordic program
Week Session
p/wk
Sets Reps
1 1 2 5
2 2 2 6
3 3 3 6-8
4 3 3 8-10
5-10 3 3 12,10, 8

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20. REFERENCES
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May 24.
 Jan Ekstrand, Carl Askling,Henrik Magnusson, Kai Mithoefer (2013) Return to play after thigh muscle injury in elite football
players: implementation and validation of the Munich muscle injury classification. Br J Sports Med 2013;47:769-774
 Terminology and classification of muscle injuries in sport: The Munich consensus statement. Mueller-Wohlfahrt H,M Haensel, L.,
Mithoefer,K,. Ekstrand., J et al (2012) Br J Sports Med 2013; 0:1-9
 Grant Freckleton, Tania Pizzari (2012). Risk factors for hamstring muscle strain injury in sport: a systematic review and meta-
analysis. Department of Physiotherapy, La Trobe University, Melbourne, Australia
 C. M. Askling • J. Nilsson • A. Thorstensson. A new hamstring test to complement the common clinical examination before return
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 Robert-Jan De Vos, Gustaaf Reurink2,, Gert-Jan Goudswaard1, Maarten H Moen, Adam Weir, Johannes L. Clinical findings just
after return to play predict hamstring re-injury, but baseline MRI findings do not. Br J Sports Med doi:10.1136/bjsports-2014-
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 https://soundcloud.com/bmjpodcasts/hamstring-injuries-with-carl?in=bmjpodcasts/sets/bjsm-1
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 Warren P, Gabbe BJ, Schneider-Kolsky M, et al Clinical predictors of time to return to competition and of recurrence following
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 Askling C Types of hamstring injuries in sports. Br J Sports Med 2011;45:e2 doi:10.1136/bjsm.2010.081570.15