Conditions & Treatments - Hamstring Strain - PT Guide to Evaluation & Treatment

 

Acute hamstring strains are a common injury in sports, especially with sports which involve sprinting. In sports such as professional soccer, current statistics show the frequency of hamstring strains in males to be up to 16% of all injuries (1). To understand a hamstring strain, one needs to be familiar with its anatomy. The hamstring muscle group, consisting of the semimembranosus, semitendinosus and biceps femoris, is a biarticular set of muscles that span the entire length of the posterior thigh. Originating from the ischial tuberosity, the hamstrings course inferiorly to attach to the proximal medial portion of the tibia (semimembranosus and semitendinosus) and the head of the fibula (biceps femoris) and act concentrically to produce hip extension, knee flexion and knee internal and external rotation, respectively, when the knee is flexed (2). The hamstrings also work eccentrically to decelerate hip flexion and knee extension, an essential motion for high speed running (3). Click here to see patient version of hamstring strain article.

Mechanism of injury:
1) Terminal swing phase of high speed running – Running related hamstring injuries generally occur along the intramuscular tendon and adjacent muscles fibers with greater incidence of injury to the biceps femoris long head (4).
2) Concurrent hip flexion and knee extension – Activities such as dancing or kicking can place the hamstring in an excessively stretched position most commonly causing injury to the proximal free tendon of the semimembranosus (5).

Predisposing factors to injury:
Some common risk factors for hamstring strains are age, decreased hamstring strength, decreased hamstring endurance, poor hamstring flexibility, limited quadriceps flexibility, decreased strength and coordination of pelvic and trunk muscles, and inadequate eccentric hamstring strength to counteract concentric quadriceps action in terminal swing phase of running (6). Additionally, the recurrence rate of hamstring strain injuries is 33% with the second (7), typically more severe, injury requiring greater rehabilitation time than the first (8).

PT examination findings – Signs and Symptoms
Subjective: Sudden onset of posterior thigh pain from a specific activity, possible audible pop with proximal tendon injuries, possible pain at ischial tuberosity in sitting, painful muscle spasms, history of hamstring injury close to the current injury site (6).
Objective: The goal is to determine the location and severity of the injury. Strains are graded I-III with a type I strain involving ≤10% of the muscle fibers, type II strains involve a 10%-99% tear and type III representing a complete rupture (2). Severe type II and all type III hamstring strains often require surgical intervention. The following objective findings are more representative of type I-II strains (6):
¨ Observation: swelling, bruising (more common in high speed running injuries), gait abnormalities (6)
¨ Palpation: substantial local tenderness and possible palpable defect. Recovery time is longer for patients with strains that are closer to the ischial tuberosity, thus the closer the area of greatest tenderness, the longer the recovery time (6)
¨ Strength: decreased strength and increased pain provocation with manual muscle testing of hip extension and knee flexion. High speed running injuries tend to present with more severe weakness. To isolate the more medial semimembranosus and semitendinosus or the more lateral bicep femoris, perform strength testing with the lower leg internally or externally rotated respectively. Testing of the unaffected leg for bilateral comparison as well as strength testing of proximal and distal joints to address potential causative factors is crucial (6).
¨ ROM: decreased hamstring flexibility and increased pain provocation with passive straight leg raise (hip) and active knee extension test. High speed running injuries tend to present with a greater ROM loss (6).
¨ Differential diagnosis: Adductor strains and adverse sciatic nerve neural tension are two additional common causes of posterior thigh pain. It is important that the examination rule out these two conditions (6).

Treatment
The primary goal of therapy is to return the patient to their prior level of performance with minimal risk of injury reoccurrence (6).

Early stage: The focus should be to minimize pain and muscle atrophy, decrease edema, protect scar tissue formation, improve neuromuscular control and enhance lumbopelvic strength (6).
Treatment options include:
• Avoid excessive hamstring stretching: stretching in pain-free range (9), decreasing stride length, use of crutches while avoiding actively holding the knee in flexion for prolonged periods of time (6)
• Ice – 2-3x per day for 3-5 minutes with ice cup or 15-20 with ice pack (6)
• Therapeutic exercises: pain-free submaximal isometrics in a shortened muscle length (9), lumbopelvic isometrics, single leg balance exercises, and low intensity/short stride exercises of the entire lower extremity in the frontal plane (6)

Middle stage: The stage is initiated once the patient can walk normally and without pain, tolerate very slow speed jogging without pain and perform a pain-free submaximal isometric contraction. The aim of this stage is to increase range of motion and muscular control (6).
Treatment options include:
• Progressive increase in ROM while avoiding end-range hamstring lengthening, quadriceps stretch (6)
• Ice – as needed (6)
• Myofascial release
• Therapeutic exercises: neuromuscular control, transverse and frontal plane agility drills and trunk stability exercises with a progressive increase in speed and intensity (9). Submaximal eccentric strengthening in the mid-range of the muscle is targeted through functional movement patterns versus exercises that isolate the hamstring. Sports specific movements that avoid full lengthening of the hamstring muscle are also initiated in this stage and are progressed to incorporation of sagittal plane movements (6).

Final stage: Patient can progress to this stage of rehabilitation once they can achieve a 5/5 maximal effort isometric contraction while prone with knee flexed to 90° and jog backwards and forward at 50% maximum speed without pain. This stage focuses on aggressive sports-specific movement with no restriction on ROM to return to prior level of function (6).
Treatment options include:
• Ice – as needed
• Therapeutic exercises: Sports specific movements in all plane focusing on quick directional changes and technique training, trunk stabilization exercises including asymmetric postures and transverse plane motions to increase level of difficulty, eccentric hamstring strengthening through full ROM (6)

The patient can return to sport once he or she has achieved full ROM, strength and function without any complaints of pain or stiffness (6).

 
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Last revised: December 19, 2010
by Laura Nelson, SPT

 

 

References
1) Croisier J, et al. Strength imbalances and prevention of hamstring injury in professional soccer players: a prospective study. Am J Sports Med. 2008;36:1469-75.
2) Neumann DA, Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation. 2nd Edition. Mosbey, 2010.
3) Chumanov ES, Heiderscheit BC, Thelen DG. The effect of speed and influence of indi¬vidual muscles on hamstring mechanics dur¬ing the swing phase of sprinting. J Biomech. 2007;40:3555-3562. http://dx.doi.org/10.1016/j.jbiomech.2007.05.026
4) Thelen DG, Chumanov ES, Hoerth DM, et al. Hamstring muscle kinematics during treadmill sprinting. Med Sci Sports Exerc. 2005;37:108-114.
5) Askling C, Saartok T, Thorstensson A. Type of acute hamstring strain affects flexibility, strength, and time to return to preinjury level. Br J Sports Med. 2006;40:40-44. http://dx.doi.org/10.1136/bjsm.2005.018879
6) Heiderscheit BC, Sherry MA, Slider A, et al. Hamstring Strain Injuries: Recommendations for Diagnosis, Rehabilititation, and Injury Prevention.J Orthop Sports Phys Ther 2010;40(2):67-81, Epub 14 January 2010. doi:10.2519/jospt.2010.3047
7) Orchard J, Best TM. The management of muscle strain injuries: an early return versus the risk of recurrence. Clin J Sport Med. 2002;12:3-5.
8) Brooks JH, Fuller CW, Kemp SP, Reddin DB. Incidence, risk, and prevention of hamstring muscle injuries in professional rugby union. Am J Sports Med. 2006;34:1297-1306. http://dx.doi.org/10.1177/0363546505286022
9) Sherry MA, Best TM. A comparison of 2 reha¬bilitation programs in the treatment of acute hamstring strains. J Orthop Sports Phys Ther. 2004;34:116-125. http://dx.doi.org/10.2519/jospt.2004.1062


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