Physiotherapy Management of Hamstring Injuries
The first and vital issue is the correct diagnosis of the injury and its severity as this will dictate the whole course of the treatment and indicate the speed of progression to be expected and the length of time taken until the injury is recovered. Physiotherapy is the main treatment course and the physiotherapist will judge the programme depending on the severity of the injury and how long it is since it has occurred. There are no reliable scientific guidelines for this kind of injury management and rehabilitation so the programme will need to be individually set and adjusted to suit the changing needs of the patient.
The management of hamstring injuries can be divided into three initial phases: the acute, sub acute and remodelling phases, each with a different strategy of treatment and each for a different time since the injury. The acute phase incorporates the first week after injury and the treatment is targeted at reducing the inflammation, pain and swelling associated with a soft tissue injury. The principles of treatment follow the PRICE format: protection; rest; ice; compression; elevation. Protection involves reducing the likelihood of inappropriate stresses being applied to the injured area and for this purpose the knee may be braced in a bent position or the patient taught to use crutches to reduce the weight bearing through the leg.
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 is a very useful technique for many injuries and if the part is raised above the level of the heart then the collection of tissue fluid in the part will be reduced. In the hamstrings this is difficult to achieve due to the location of the injury and may in many cases just not be necessary. Once the pain and inflammation have been brought under control the physiotherapist can start doing gently movements either passively or assisting the active movements of the patient. No stretching is attempted at this stage. If someone has a relatively minor injury and begins to feel much better over a few days they should still be carefully managed.
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.
Hydrotherapy exercises may be useful in this phase as they allow hamstring exercise without the weight bearing stresses being fully applied to the limb. Patients can take up aerobic training for cardiovascular fitness and upper limb training whilst performing sub-maximal exercises for the injured area. The remodelling phase is indicated as taking the patient forward to the six week point and they should be able to manage isometric contractions at full effort without pain. Now the exercises can be progressed to isotonic (through range), with low weights and higher numbers of repetitions.
The patient starts this process in prone with light ankle weights, progressing to heavier and heavier resistance provided the pain in the injured area is not provoked. The progression of weights should be conservative as too rapid an increase may lead to relapse and a more long term problem. Once the patient has achieved good strengthening with the muscle shortening (concentric contraction) they should be progresses to strengthening with the muscle lengthening (eccentric contraction).
Author: Jonathan Blood-Smyth