Physiotherapy Management of Hamstring Injuries – Part Two
The remodelling phase of the healing period occurs over the weeks up to the sixth week after injury and at this point the patient should be tested by the physiotherapist and be able to perform a full strength resisted hamstring contraction without any problems. Isotonic work in prone with ankle weight is the initial approach with lighter weights and higher repetitions to start with, moving on to heavier weights with lower repetitions provided the injury does not complain. Being too adventurous in increasing the weights can lead to re-injury or to the development of a more chronic and troublesome problem.
Once the concentric exercises (movements where the muscle is shortening as it is doing work) have progressed well then patients can start to do an eccentric strengthening programme. Eccentric muscle work occurs while the muscle is lengthening during the activity and while force is being applied to it and by it. Eccentric muscle contraction puts the maximum strain on muscle fibres so slow progress is to be expected as well as to be desirable. With the patient on their front and a weight round the ankle the knee can be bent to ninety degrees (foot pointing up towards the ceiling) and then the leg allowed to straighten in a controlled manner.
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.
A speed walking programme can now be started and when they can manage thirty minutes of this they could be progressed on to small periods of jogging. If there is no adverse reaction and thirty minutes of jogging is achievable then the patient can start to run faster and insert short sprints into the regime. Sprints can become more energetic gradually with sudden stops, turns and re-accelerations providing a gradually closer approximation to real sporting manoeuvres as specific movements related to the relevant sport are added. As therapy proceeds then plyometric exercises can be added to stress the muscular system more profoundly and promote power and speed which will be required.
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.
In a study it was found that athletes who required more than one day to be able to walk normally without pain were more likely to need a longer time of rehabilitation over the three week mark. Typical medications recommended are non-steroidal anti-inflammatory drugs to reduce the inflammatory reaction and potentially speed healing.
Author: Jonathan Blood-Smyth