Paul Thawley MSc, BSc (Hons), PgDip (Rehab), MCSP SRP

1. Paul Thawley MSc, BSc (Hons), PgDip (Rehab), MCSP SRP Hamstring rehabilitation

2. Hamstring Injuries • Often occur during running or sprinting • Top three in soccer • Many Aetiological factors • Typically 3-6 weeks for RTS

3. Posterior Thigh Pain –Differential Diagnosis • Hamstring muscle strain • Acute • Chronic • Hamstring muscle contusion • Referred from Lx • Neural structures • Triggers points

4. Less Common Posterior thigh pain • Referred from SIJ • Tendinopathy • Bursitis • Compartment syndrome • Apophysitis • Nerve entrapment • Sciatic • Post cutaneous • Adductor magnus • Myositis Ossificans

5. Not to be missed • Tumors • Iliac artery insufficency

6. Well what is it??

7. 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

8. 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)

9. Other mechanisms • Stretch with knee fully extended (stretching for a ball, kicking) • Forced trunk flexion with foot planted (waterskiing)

10. 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?

11. Accelerated running program • Developed by Graham Reid • Australian Hockey Physio • Injured player on tour • Captive audience • Good result

12. Progressive Running ProgramGraham 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

13. Progressive Running ProgramGraham 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

14. 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

15. Accelerated Running Program • Sports specific - More emphasis on this in Football • Ladders • Change of direction • Backwards/sideways running • Shuttles • Chase and escape drills

16. 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

17. 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!

18. 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)

19. 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

20. Jump series • Is the hamstring lesion the primary cause of the dysfunction?

21. 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

22. 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

23. 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

24. 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

25. 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

26. Case Study 2 • Final next evening • 44.1 second split • Tight sensation up the final straight • Team won silver, just 1/100th behind winning team

27. 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.

28. Length Length-tension relationship Tension

29. 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)

30. 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)

31. 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

32. Icelandic curls From: Bahr and Meahlum (2002)

33. Length Icelandic curls Tension

34. 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

35. 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

36. 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

37. 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

38. Questions/comments/discussion?