ONE OF THE MOST COMMON INJURIES SEEN IN BOTH PROFESSIONAL AND RECREATIONAL SPORT.
HIGH RATE OF INJURY RECURRENCE.
A CHALLENGE TO TREAT FOR BOTH THE PRACTITIONER AND PATIENT.
SIGNS AND SYMPTOMS
We have all seen those videos of footballers and track athletes that suddenly pull up grabbing the back of their thigh. This is the dreaded hamstring strain: a sudden pain or feeling of tearing or popping that will stop you in your tracks and prevent you from continuing your sport. The level of damage and recovery times required are graded as shown below.
NOTE: THESE TIMELINES CAN CHANGE ACCORDING TO THE INDIVIDUAL. IF YOU HAVE SUFFERED PREVIOUS HAMSTRING STRAINS FOR EXAMPLE, YOUR RECOVERY MAY BE LONGER. A MORE DETAILED PROGNOSIS WILL BE PROVIDED WHEN YOU SEEK A PROFESSIONAL OPINION.
Grade 1: this involves the smallest amount of damage. There will be a few muscle fibres torn leading to some pain and sensitivity over the area. You will be able to walk but may feel some tightness or stiffness in the back of the leg preventing you from taking a long stride. There is often discomfort as you attempt to load the hamstring with any resistance and the muscle feels too vulnerable to run on. Recovery time ranges from 4-8 weeks +.
Grade 2: a larger number of muscle fibres are torn. This leads to increased pain, difficulty walking, bruising around the site of injury and weakness. There will be tenderness on palpation and crutches may be needed for a few days as the damaged tissue slowly settles. Recovery time ranges from 8-12 weeks +.
Grade 3: this can often affect the muscle belly as well as the tendon and will cause significant bruising and pain. At the more severe end there can be a complete rupture (Grade 4). There will be significant weakness into the muscle, often an inability to bend the leg and crutches will be needed to offload the effected limb. Recovery time can range from 6 months + and in more severe cases may need surgical intervention.
AM I AT RISK OF A HAMSTRING STRAIN?
There is constant debate about the risk factors involved in hamstring strains but there are common findings that I see in those that suffer with this injury and many of them are factors that you can change:
1: Previous hamstring injury: studies have highlighted this to be the most significant risk factor for a recurrent hamstring strain. In my opinion this is most likely to be due to suboptimal recovery/ rehabilitation following the initial injury. As a result, a weakness remains in the previously effected area and neuromuscular patterning (the system through which nerves and muscles interact) can alter leading to a reduced ability for the hamstring to tolerate imposed loads. The answer: don’t take a short cut with your recovery.
2: Hamstring weakness or an imbalance in quadriceps to hamstring strength ratio: Your hamstrings must work really hard to control the hip and lower leg as we accelerate or decelerate so if you think of how many times you do this during a game of football for example, it makes sense to condition this area to cope with such loads.
Additionally, the hamstrings work closely with your thigh muscles (quadriceps). As your leg swings through when you run the hamstrings will lengthen as they contract (eccentric muscle activation) as the prepare the foot to hit the floor and the quadriceps must relax. If the hamstrings are much weaker than the quadriceps then an imbalance in forces can lead to injury.
3: Poor hamstring flexibility vs strength and control: there is conflicting results in research on this point but based on my experience I look for a balance between strength and length and this can be very dependent on the sport you do. You may be very strong in your hamstrings and like to play football or rugby. But if you lack the length to extend your leg when reaching to kick a ball then risk of tears will increase. Alternatively, you may be a dancer or gymnast and have excellent hamstring length but an ability to control that hamstring as you extend it in a split leap or jump is imperative.
4: Increased age: unfortunately we can’t control this one but often as we get older we dedicate less time to the strength work in the gym in favour for a game of tennis at the weekend or a kick around with a ball with friends and family. In turn this renders us more vulnerable to injury as the muscular and neuromuscular system are not conditioned for the stresses imposed. Our tissues also take longer to heal and are less elastic.
5: Muscle fatigue: fatigue effects a muscles ability to cope with load leading to increased risk of injury. Injuries most commonly will be seen towards the end of a game.
6: Acceleration/ deceleration or change of direction: as mentioned above, a hamstring strain most commonly occurs at the second stage of the swing phase as the hamstrings are at their greatest length and as they generate maximum tension.
7: Lower back pathology: control around the lumbar spine and pelvis will influence hamstring length, activation and control. It is important to be aware of proximal/ trunk control in hamstring rehabilitation.
8: Poor technique or poor training programme: weakness, lack of flexibility and poor movement control can all result in poor technique when running, sprinting, kicking etc. Combine this with repetition then the hamstring becomes strained. Highlighting these problem areas early is key to reduce injury.
I HAVE INJURED MY HAMSTRING. WHAT DO I DO NOW?
We have come across the acronyms RICE and PRICE for early stage management of soft tissue injuries but there is a new one being shared around and not only is it my favourite but it has come at the perfect time for me to apply it this hamstring strain blog.
Immediately after the injury avoid further damage and apply some P.E.A.C.E
P rotect the area by offloading it and/ or restricting activities. The emphasis here is on modified rest NOT complete rest. Allow bleeding to settle and allow biology to do its thing.
E levate the area by placing the limb higher than the heart if possible. This will help promote fluid flow.
A void taking anti inflammatories. Inflammation is a necessary stage for tissue healing that leads to optimal regeneration of the damaged tissue. Taking anti inflammatories can potentially interrupt this and delay recovery. Ice is also considered to interrupt this process hence why it is also missed in this new model.
C ompress the area. This is a topic of debate but applying compression with a bandage around the site can help reduce swelling and maintain function.
E ducate this is where I and other healthcare professionals come in. Understanding what damage has occurred and what is required to recover is essential. There is no magic treatment and no one has the capabilities to beat biology so be aware of what your treatment will involve and what YOU need to do to return to sport.
A few days later you can add some L.O.V.E
L oad damaged tissue heals progressively according to the loads applied to it so exercise and movement is necessary to stimulate the formation of new bonds within the muscle fibres as they repair. Listen to your symptoms and gradually increase the load.
O ptimism your brain has an incredible power over your recovery and rehabilitation. Fear, depression and catastrophising over the problem can severely limit your recovery. Stay positive and focus on what you need to do to get back fighting fit.
V asuclarization returning to cardiovascular exercise in a pain free fashion can be started as early as day 2 or 3 post injury (depending on the severity of your injury). You may not be able to run, but a session on a bike will still help boost circulation and mood as well as maintaining neuromuscular activation. Focus on the things you can do and not what you can’t.
E xercise as you have seen from most the above points exercise is very important for your recovery. It will restore range of movement, strength, control and proprioception. Pain is used as a guide to change the type of exercise, load applied, frequency and intensity.
SO IN SUMMARY……….
Be aware of the risk factors to help prevent hamstring strains
A complete and comprehensive rehabilitation programme is essential to reduce recurrence
Apply P.E.A.C.E and L.O.V.E to manage the injury in its early stages