The Dodgy Hamstring
This blog article is going to help you to understand more
about your dodgy hamstring. It will look at the evidence that is out there, to
hopefully reduce the risk of injuring it in the first place and to help you to
recover and get back your sport faster.
Firstly what are the hamstrings?
They are group of muscle at the back of your upper leg.
Semitendinosus:
Attaches from the Ischial tuberosity to
superomedial aspect of tibia. Its principle actions are Hip extension, knee
flexion and medial rotation of knee in knee flexion.
Semimembranosus:
Attaches from the Ischial tuberosity to
posterior aspect of medial condyle of tibia. Its principle actions are Hip
extension, knee flexion and medial rotation of knee in knee flexion.
Biceps Femoris:
There are two parts, The long head and the
short head. The Long head attaches from the ischial tuberosity and short head
from the linea aspera and lateral supracondylar line of femur to lateral aspect
of head of fibula and lateral condyle of tibia. Its principle actions are Knee
flexion, hip extension and knee external rotation with the knee flexed.
What is the likelihood of injuring the hamstring?
Hamstring injuries are common in athletes and frequently
result in long delays in return to sport (Mason et al 2012).
You are 33% more likely to have a hamstring tear/strain if
you have previously had one and re-injured muscles may actually take longer to
recover than ‘new’ tears (Ekstrand et al, 2011). This therefore highlights that
you should be looking at this before rather than after. As they say prevention
is better than cure.
So what are the reasons for tearing the hamstrings?
It’s because of overload or over stretch. Basically tears
can occur in a one of event if the overload or over stretch is large enough and
it can occur cumulatively from progressive overloading and overstretching. Also
if you don’t allow enough recovery between loading activities then this too can
create the cumulative damage. You normally notice this as the common tightening
feeling that you get just before the hamstring ‘goes’.
So what causes the over loading or over stretching?
Fatigue: When the muscle is fatigued it’s contraction
strength is not as strong or fast, leading to the potential to tear. Exercise
can disturb proprioception through fatigue, this has implications for
musculoskeletal injuries (Proske & Gandevia 2012).
Lack of flexibility: If
the hamstring is too short for the activity at hand then it is easier to potentially
tear and if you don’t warm the tissue up before activity then the tissue is not
as pliable making it tighter and more likely to tear. Worrell et al (1991)
reported that the hamstring-injured group's injured extremity was significantly
less flexible than the non injured one. But is this a cause or effect?
Weakness: If the muscle isn’t strong enough and hasn’t been
trained to take the loads of the sport then it can overload and tear.
So what should I do to prevent tearing the hamstring?
Muscle-building exercises (strengthening) reduces the risk
of sporting injury by 68% (Lauersen et al 2013). So you need to perform
hamstring strengthening exercises (see muscle strengthening blog for more information). An example of a good
hamstring strengthening exercise is Nordic Hamstring curls. Nordic hamstring
curls reduces the incidence of hamstring injury recurrence by approximately 85%
(Peterson et al (2011):
The issue could also be muscular endurance especially if your tear or tears occur later in the activity due to fatigue. to find out more about muscular endurance click here: http://mathewhawkesphysiotherapy.blogspot.co.uk/2013/07/muscle-blog-series-part-5-muscular.html
Screening for flexibility issues relating to your sport needs to be done first and if inflexibility is an issue then
stretching training is required. (see muscle flexibility blog).
Warm-up is also important so that the muscles are warm and
pliable. Warm-up should involve submaximal intensity aerobic activity followed
by large amplitude dynamic stretching & sport-specific activities Behm et
al (2011). It isn’t static stretching! A dynamic stretching intervention
appears to be more suitable for use as part of a warm-up in young athletes.
(Carvalho et al 2012).
Overload or overstretch can happen from poor movement
quality so exercises correcting movement dysfunction reduces the time to return
to full activity & reduces the risk of re-injury of hamstring strains
(Mason et al 2012).
So what do I do if I have pulled my hamstring?
During the first 48-72 hours of injury:
Use: P.O.L.I.C.E.
This is the latest acronym that replaces the old R.I.C.E.
P: Protect the injury from further harm:
This can be
stopping the activity, using crutches, strapping it up, etc.
O.L: Optimal loading:
This means load it but don’t overload
it! This was put in place of rest because people were being too literal with
rest and actually doing nothing, which is bad! So the key here is to move it,
walk on it, etc. The key thing to remember is that as long as after doing the
activity it is no worse for doing it, you are fine but if it is worse
afterwards, then you have overloaded it.
I: Ice:
This is to minimise the amount of swelling that gets
to the injury site. You should wrap the ice in a damp tea towel and roughly
apply for 20 minutes. The cooling effect
should last for roughly 2 hours so you should re-apply it every 2 hours.
C: Compression:
Now most people think that ice is the most important aspect
but believe it or not it is actually compression. Compression helps control
oedema formation & reduces swelling by promoting re-absorption (Knight
1995). Compression can take the form of tubi-grip or strapping and the aim is
to create a back pressure that minimises the amount of swelling to the area.
This is vital, as the more swelling you have, the more painful the injury will
feel and the stiffer the area will become. It will inhibit muscle activity
leading to muscle atrophy and it decreases proprioception. The other thing is
that the more swelling there is, the longer it will take for your body to get
rid of it.
E: Elevation:
Basically keep the injury up as much as you
can (in between your optimal loading etc.)
What about pain relief or anti-inflammatory's?
You should use pain relief as you require. For example if
you are in so much pain that you aren’t moving the injury then you need to use
pain relief.
On the anti-inflammatory front, this isn’t as straight
forward as you may think.
This is because INFLAMMATION is NORMAL, NECESSARY and is controlled
by a wide range of CYTOKINES and other CHEMICAL MEDIATORS. So you don’t
necessarily want to lessen or get rid of it. You CANNOT heal without it!!!
My view is that you can then take them for the first 48-72
hours or until the throbbing and heat reduces.
How long will it take for the tear to recover?
This depends on how you did it and the severity of the tear.
If you injure early into the activity then recovery tends to
be faster than if it occurs after a longer time.
Stretching-type of injury takes a significantly longer time
to return to sport than a sprinting-type injury (Askling et al 2013). So over
stretching is worse than overloading.
The closer the injury is to the ischial tuberosity (Pelvis)
the longer it takes to recover (Askling et al 2013). To know where the tear isyou
need to feel for it as the maximal point of tenderness indicates where the tear
is (Askling et al 2013).
On average muscle takes between 2 and 6 weeks to fully heal.
So after the first 48-72 hours what should I do?
It is important to get the muscles lengthening and loading
as soon as safe to do so as MUSCLE STRENGTH DECREASES BY 2-6% FOR THE FIRST 8
DAYS OF IMMOBILISATION (Muller,1970).
Lengthening exercises for hamstrings rehab:
Extender: Twice every day, 12 repetitions x 3 sets:
Diver: Once every other day, 6 repetitions x 3 sets:
Glider: Once every third day, 4 repetitions x 3 sets:
Once the lengthening exercises are pain free and there is
full hamstring range of movement, a supine straight leg raise is performed at
maximal speed and through full range to determine whether the patient feels
insecurity in the hamstring. If there is no insecurity then this indicates that
the person can try returning to sports but if there is insecurity then
rehabilitation should continue and the person be re-tested in 3-5 days (Askling
et al 2010).
What else can I do to speed up the healing time?
Classic & deep massage had an immediate, significant
effect on hamstring length in female field hockey players (Hopper et al 2004).
The recovery rate of muscle is 50% greater with therapeutic
ultrasound (Dyson et al 1999).
So hopefully this helps you to finally sort out that dodgy
hamstring.
If you need any further information or would like to book an
appointment then call Hawkes Physiotherapy on 01782 771861 or 07866195914
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