Hamstrings rehab

Physiotherapist Chris Mallac continues his series on rehabilitation of muscle injuries, focusing this time on hamstrings

Most hamstring-injury management is based on ‘old-school’ sports trainer techniques and not on evidence-based practice. Furthermore, the different requirements of certain sports will determine the rehabilitation of these injuries. Sprinters, for example, who need top-end speed in a straight line will have different functional needs to a soccer player who must constantly change directions at sub-maximal speeds.
Immediate management

All sport medicine textbooks have a chapter on the immediate management of muscle injuries. The most important procedure in the management of soft-tissue injuries in sports people is initial icing while moving the muscle, known as ‘cryokinetics’. This is done by sitting with an ice bag under the hamstring and keeping the hamstring moving by bending and straightening the knee to the point of mild discomfort. This satisfies the immediate goal of reducing swelling and subsequent haematoma, and the addition of movement results in less ‘ice scarring’. Ice scarring is a phenomenon whereby the superficial fascia adheres to the underlying muscle and affects the overall gliding of the muscle in relation to its covering fascia. The end result is a muscle that moves with its adherent fascia whilst contracting. The quickest way to cause ice scarring is to over-apply ice to the injured area and to keep the muscle completely still while being iced. One must be certain before applying ice to a hamstring injury that a local muscle injury does exist. Icing a ‘neural hamstring’ with no local muscle pathology will result in more reflex muscle tone and more ice scarring.

Medical interventions
The use of non-steroidal anti-inflammatories (NSAIDs) has been a controversial issue in sports medicine since the mid 1990s when research showed that NSAIDs slow down the healing rate of muscle injuries. One must be careful with the overzealous use of NSAIDs in muscle injuries, especially the COX-1 inhibitors (e.g., Diclofenac, Ibuprofen). It has been suggested that the new range of COX-2 inhibitors (e.g.: Celebrex, Vioxx) have minimal delayed healing effects and are thus safer to use for an anti-inflammatory and analgesic effect.

Soft-tissue therapy

Any therapy that reduces muscle tone in the hamstring (both ‘neural’ and ‘muscle’ pathologies) will be a useful adjunct in the treatment of this injury. This may be any soft-tissue massage or ‘trigger point’ injection therapy.

Strength re-training
A critical element is the rehabilitation of true muscle injuries. As stretch and contraction become pain-free, direct loading to the hamstring is necessary to increase the tensile properties of the healing tissue, as well as developing fatigue tolerance in the newly developed scar tissue and hamstring muscle tissue.

The commencement of direct rehabilitation should begin when range of motion and strength testing become pain free. The number of repetitions, sets and selection of exercises will be determined by the response of the muscle to stretch and contraction. If, for example, straight-knee bridging is pain-free but bent-knee bridging is not, then straight-knee bridges can be incorporated into the programme while bent-knee bridges can be incorporated at a later date.
A typical routine for hamstring rehabilitation may be as follows: Start with gentle cycling for 10 minutes followed by five minutes of straight-knee and bowstring stretches. The order for the hamstring exercises and relevant progressions are:

Heels on floor bent-knee bridging – hold contraction for five seconds, repeat five times. Progressions are one-leg bridges and increase time holding.

Heels on chair straight-knee bridging – hold contraction for five seconds, repeat five times. Progressions are one-leg bridges; vary the knee angle between locked-in extension to 90 degrees bent, bridge on a Swiss ball.

Resisted knee flexion – prone lying with theraband around the ankle. Incorporate short holds in varying parts in range. Beware of cramping in the hamstring with increasing degree of knee flexion. This can be progressed by adding in leg-curl machine with more weight.
Flicks and wobbles – gentle oscillating of the leg from flexion to extension. Initially done slowly with progress to ballistic movements. Also progressed by lying prone on the floor to lying over a bed with the hip bent to 90 degrees.

A word of caution when using rehabilitation exercises with ‘neural hamstrings’. If the hamstring problem is due to an increase in tone, then repetitive contraction of the muscle may actually increase tone and make the hamstring feel worse (read tighter). Clinical judgement in differentiating between true muscle injuries and neural problems is essential here. Clinicians cannot simply assume that all hamstring problems involve pathology and must therefore be ‘rehabilitated’.

This article was Borrowed from Here

Coach Dave