Physiotherapy Management of Hamstring Injuries

Diagnosing and determining the severity to the injury is the first and most important issue to be decided as this determines the expected course of recovery and the ultimate time it will take until the patient is back to normal function. Physiotherapy is the only treatment for these injuries and it is up to the physio to make the necessary judgements and take into account the time since injury and the level of injury. Scientific evidence for the management of these injuries is not available so the physio will determine the level and speed of rehabilitation by continually reassessing the status of the patient’s progress.

Initially the treatment of injuries to the hamstrings can be classified into three stages: the acute stage, the sub acute stage and the remodelling stage. Each stage is approached with a different plan of treatment and follows on from the previous in time. In the acute stage, up to the first week after the injury, treatment concentrates on limiting the levels of pain, swelling and inflammation resulting from the injury. The PRICE classification is the typical one followed here: protection; rest; ice; compression; elevation. Protection is intended to reduce the application of damaging stresses applied to the injury site, with bracing of the knee in a flexed position or the use of elbow crutches to limit weight bearing.

Rest is protective and important to reduce the stresses through the injured area and with athletes this is often a difficult concept to get across. Ice is very useful as a treatment primarily to reduce pain, applied for up to 20 minutes over the injured area provided the skin can take it. It may also reduce inflammation by limiting the metabolism of the area and so reducing the tendency to attract more blood supply and swelling. Compression is an important treatment and in knee effusions it may be more important than the cooling effects which physios attempt to provide. Elasticated bandages wrapped round the limb can provide compression.

Elevation of the injured area is advised for many injuries and raising the area above heart level drains the limb and prevents tissue fluid build up. It is hard to do this with the situation of the typical injuries to the hamstrings and in these injuries may not be needed. Once the inflammation and pain have receded to some extent the physiotherapist can begin moving the limb passively and giving assisted movements into flexion. Stretching is avoided as this will increase tissue damage. A mostly minor injury should recover quickly but they still need to be managed carefully to avoid a recurrence and ensure good progress.

Soft tissue injuries take at least six weeks to heal, even minor ones, so once feeling much better athletes should be encouraged to ease slowly into doing more stressful activities and should pay attention to strengthening muscles, stretching and balance to reduce the likelihood of the injury recurring. In the sub acute phase, which lasts until about three weeks after injury, the pain and inflammation of the acute injury should be reducing and so the physiotherapist can progress the treatment on to active range of motion exercises and then to muscle strengthening.

To facilitate hamstring rehabilitation without a high degree of weight bearing on the limb it can be appropriate to use pool therapy and patients can continue with their aerobic training to maintain their cardiovascular ability and arm training. The injured area will be exercised with sub maximal training effort. The phase of remodelling takes the injury towards the six week time after the injury and the physio will test to see if the patient can cope with a full strength contraction without any pain. If successful the rehab can be progressed via through range exercises (isotonic) with light weights and high repetitions.

Exercises in the pool can be very useful in hamstring rehabilitation to limit the amount of force applied to the injury yet allow very varied movements. Cardiovascular fitness should be maintained by appropriate aerobic exercises and upper limb work whilst the injured area is exposed to sub maximal resistance. Remodelling as a phase stretches to the six week marker after the muscle strain and then the physiotherapist can test the patient for painless full power isometric contraction of the hamstrings. If this is a success then the rehabilitation can move to isotonic, through range, exercises with lighter weights.

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