Physiotherapy Management of Hamstring Injuries – Part Two

A remodelling stage can be said to exist up towards the sixth week after the muscle strain and later in this period the physiotherapist will assess the patient’s ability to make a full power hamstring contraction against resistance without pain or hesitation. If this is achieved then isotonic work with ankle weights can start such as in prone with light weight and higher repetitions, gradually adding weight with time. To prevent the possibility of injuring the muscle again or of developing a more long term problem the progression should be taken slowly in terms of the force put through the muscle tissue.

Concentric movements occur when the muscle is shortening during its action, and when the patient is doing well with this the physio will move them on to strengthening using eccentric muscle activity. By contrast, eccentric muscle work occurs while the muscle is contracting and lengthening at the same time under load. Contracting muscles eccentrically against load puts the most strain on them so this kind of exercise needs to be carefully managed. Patients are prone with an ankle weight, the starting position is 90 degrees knees bend (lower leg pointing up), and the exercise action is to lower the leg to the surface in a controlled movement.

This process continues as long as the injured area is not painful until the affected leg can perform as strongly as the unaffected leg (within 10 percent or so) then the programme can be progressed to a more active and vigorous one. During the whole programme the hamstring is regularly stretched to promote healing in a lengthened position and return it to the same length as the unaffected side. The functional stage of hamstring healing is the time from roughly two weeks to six months from the time of the injury, depending on the severity of the initial damage. Patients should have no apparent pain, a normal gait pattern and the ability to walk quickly.

Treatment can now include fast walking and once thirty minutes of this can be achieved without pain then the physio might add short lengths of jogging. If there are no further difficulties with thirty minutes or so of normal jogging then the patient should be instructed to run faster and add short sprints. Sprinting is increased in force applied and in length of time or number of times, with sudden stops, twists and sudden take-offs added to mirror the conditions in real competition, steadily growing more towards sport specific movements. Physiotherapists may then add plyometric work to the regime to heighten the forces through the muscle-tendon units and engender the required power and strength.

Plyometric work is characterised by stretching the muscle in the early part of the movement then contracting it concentrically, which often looks like jumping and bounding. Stretching a muscle facilitates its contraction and so allows a stronger effect to be produced as well as stressing the muscle more so it accommodates to increased force. Initially a less stressful exercise can be performed such as skipping (jumping rope) and progression under physio supervision to jumping sideways over benches, up onto higher levels and so on.

Returning to sporting competition can occur any time from around three weeks after injury up to six months or more for a very severe injury. It is important to test an athlete in detail to ensure he or she is not suffering from any deficits of strength, power, length, coordination or balance which may be subtle and not easily evoked. Warm up and stretching prior to playing competitively is emphasised although there is no clear scientific evidence to back up these recommendations. If patients have a more superficial muscle injury or have only injured a small portion of their hamstring muscle then they may be able to return to normal sport towards the earlier times.

One study showed that any athlete who needed more than a day to be able to walk without pain had an increased likelihood of needing more than three weeks of rehabilitation back to normal activity. Medication used to treat these injuries is typically non-steroidal anti-inflammatories to try and reduce the levels of inflammation and facilitate healing.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapy, back pain, orthopaedic conditions, neck pain, injury management and Local Sheffield Physiotherapist. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.