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

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

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

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  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?

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