Interventions for prevention and

rehabilitation of hamstring injuries

Reza Rahimi-Moghaddam

Sports Medicine Association of Gilan

Province, Iran

Background

• Hamstring injuries are common

among amateur and professional

athletes

(Sebelien C. et al. 2014; Petersen J. et al. 2005)

• A frustrating injury for the injured

athletes, coaches and clinicians

Background

• 12-16% of all injuries in athletes with

a re-injury rate as high as 22-34%

(Naclerio et al. 2013; Schmitt et al. 2012; Mendiguchia et al.

2012; Arnason et al. 2008)

• One-third of the injuries will recur

with the greatest risk during the initial

2 weeks following return to sport

(Orchard & Seward, 2002)

Mechanism of Injury

Mechanism of Injury

• Most often injuries occur during maximal sprints

(Arnason, et al. 2008; Bahr, 2013)

• The majority of injuries involve biceps femoris

(Warren et al. 2010; Zorić, 2012; Opar et al. 2012)

• The higher the activation level of a muscle during

eccentric contraction, the more mechanical

energy the muscle would absorb before a muscle

strain injury occurs

(Liu et al. 2012)

Mechanism of Injury

• Biceps femoris is under greater strain during late swing phase.(http://running.competitor.com/2014/03/photos/best-ways-treat-hamstring-injuries_97314#lD1dATSZipXIAlpm.99)

• The hamstrings must change from functioning eccentrically, to decelerate knee extension in the late swing, to concentrically(Petersen & Hölmich, 2005; Sherry et al. 2011)

Hamstring Injury Classification

• Traditional Grading System(Petersen & Hölmich, 2005; Goldman & Jones, 2010; Heiderscheit et al.

2010; Mendiguchia et al. 2012; Opar et al. 2012)

• Modified Peetrons Classification(Hamilton et al. 2013; Ekstrand et al. 2012 & 2013; Mueller-Wohlfahrt et

al. 2012)

• MRI or Ultrasound Categorization(Chan et al. 2012; Ekstrand et al. 2013)

• British Athletics Medical Grading

System(Pollock et al. 2014)

Hamstring Injury Classification

• Clinicians and coaches use traditional

simple grading system widely

• In a preventive program, use of

traditional grading system is

insufficient

• The bottom line is always to offer the

injured athlete the best strategies to

reach a complete and safe recovery

Risk Factors

• Nonmodifiable

- Risk factor can not be changed

• Modifiable

- Risk factors can be changed

(Bahr et al. 2003; Petersen & Hölmich 2005;

Gambetta, 2006; Heiderscheit et al. 2010; Liu et al.

2012; Brukner et al. 2013; Sebelien et al. 2014)

Risk Factors

• Other Factors:

- Psychological factors

(Hoskins & Pollard, 2005)

- High number of type II fibers

(Garrett et al, 1984; Lieber & Fride´n, 1988; Woods et al. 2004)

- Poor level of aerobic fitness

(Porter & Rushton, 2003; Giacchino & Stesina, 2013)

Prevention

• No perfect way to completely avoid

hamstring injuries

• The risks can be minimized by paying

attention to the principles of preventive

program

• Complete rehabilitation of injuries

before return to play is important, but

primary prevention of initial hamstring

injuries is even more important

(Woods et al. 2004)

Prevention

• Reducing the risk of post rehabilitation

re-injury

• Use of exercise interventions such as

stretching and strengthening exercises to

reduce the risk of injury to athletes

(Porter & Rushton, 2015)

• Eccentric hamstring strength may be an

important protective factor

(Mjølsnes et al. 2004; Gambetta, 2006; Schache, 2012; Bahr,

2013; Malliaropoulos et al. 2013; Opar et al. 2014; Porter and

Rushton, 2015 )

Prevention

• Duration of 10-12 weeks, 2-3 sessions

per week for eccentric strengthening

during preseason program

(Askling et al. 2003; Petersen et al. 2011; Cowell et al. 2012)

• Nordic hamstring exercise, an

intervention targeting the prevention and

rehabilitation of hamstring injuries

• It has been shown to reduce the risk of

hamstring injuries

(Arnason et al. 2004; Brooks et al. 2006; Melegati et al. 2013;

Sebelien et al. 2014;)

Prevention

Starting position End positionMid position

Nordic Hamstring Exercise

Prevention

• Excessive overload will be placed on

the hamstring

• Uncontrolled performing, no positive

adaptation

(Naclerio & Goss-Sampson, 2013)

• No increase in concentric hamstring

strength

(Mjølsnes et al. 2004; Clark et al. 2005)

Prevention

• Combination of eccentric and concentric

specific training protocols would appear

to provide the best potential for reducing

the risk of hamstring injury

(Clark, 2008)

• Hamstring/Quadriceps (H:Q) balance

• Muscle strength imbalances may play a

larger role than strength in isolation

Prevention

• H:Q imbalances observed in

footballers who suffered

subsequent hamstring strain

(Prior et al. 2009)

• Performing preseason isokinetic

assessments in professional soccer

teams is needed

(Croisier et al. 2008)

Prevention

• Stretching exercises for prevention

and management of hamstring

muscle injuries

• Optimal level of flexibility that

prevents injury is not clear

(Dadebo et al. 2004)

Prevention

• No clinical significant differences

between hamstring flexibility and

injury rates

• Nothing in the literature to support

hamstring injuries are due to a lack of

stretching

(Roils & George2004; Arnason et al. 2008; Goldman &

Jones2010; Brukner et al. 2013; Rogan et al. 2013 )

Prevention

• Conflicting and insufficient evidence

regarding the need to increase

hamstring flexibility using pre-exercise

hamstring stretching

• Tooley (2009): pre-exercise stretching

may not reduce hamstring injury

• Chan et al. (2012): pre-exercise

stretching is beneficial and helps to

prevent hamstring strains

Prevention

• Type of stretching, time and frequency

of stretching exercise are still a matter

of conflict

(Malliaropoulos et al. 2004; Arnason et al. 2008; Marques et al.

2009; Fasen et al. 2009; Chan et al. 2012; Brukner et al. 2013;

Tomruk et al. 2014)

• Further investigations are required,

evaluating the effectiveness, frequency,

duration and type of stretching of

hamstring muscles

Rehabilitation

• The primary objectives of a

rehabilitation program:

- Returning the athlete to sport at prior

level of performance

- Restoration of function to the greatest

possible degree in the shortest possible

time with a minimal risk of injury

recurrence

(Petersen & Hölmich, 2005; Heiderscheit et al. 2010;

Hamilton, 2012)

Rehabilitation

• Concentrate on one of the main

problems, the extremely high tendency

of hamstring injury to become recurrent

(Croisier, 2004; Engebretsen et al. 2010; Thorborg, 2012)

• Early return to play, incomplete and

aggressive rehabilitation increases the

risk of re-injury in the early stage after

returning to sport

(Woods et al. 2004; Croisier, 2004; Croisier et al. 2008;

Engebretsen et al. 2010; Dellal et al. 2013)

Rehabilitation

• The first month after return to play is the

highest risk time for recurrence

(Brukner et al. 2013; Swinnen, 2015)

• Extremely difficult to decide when the

athlete is ready to return to sport

(Orchard et al. (2005); Heiderscheit et al. (2010); Dellal et al. 2013)

• Return to sport in 2-3 weeks: still ongoing

muscle regeneration in the presence of

mature scar tissue formation

(Orchard & Seward, 2002; Orchard & Best 2002; Croisier, 2004;

Engebretsen et al. 2010; Sherry et al. 2011)

Rehabilitation

• Increased muscle injury severity is

associated with longer times to

return to sport

(Ekstrand et al. 2013)

• Maladaptation may impact on time

to return to competition, and delay

rehabilitation process

(Hoskins & Pollard 2005; Mason et al. 2007; Opar et al.

2012; Fyfe et al. 2013)

Rehabilitation

• Rehabilitation also needs to integrate

exercises to promote core stability and

develop muscle strength

(Sherry et al. 2004; Chumanov & Heiderscheit, 2007; Clark,

2008; Mendiguchia & Brughelli, 2011; Brukner et al. 2013;

Melegati et al. 2013)

• Limited evidence to suggest that rate of

recovery can be increased with an

increased daily frequency of hamstring

stretching exercises

(Mason et al. 2007)

Rehabilitation

• Flexibility is a known factor in physical

fitness

• To avoid the hamstring muscle

becoming less flexible after the injury,

hamstring stretching can begin in the

third phase of rehabilitation program

(Petersen & Hölmich, 2005)

• Assessment is a must for return to play

Rehabilitation

• Little evidence suggesting a valid

functional test to determine return to

play

(Schmitt et al. 2012)

• Rely on subjective measures such as

“pain free movements” is not

sufficient(Mendiguchia & Brughelli, 2011)

Rehabilitation

• Multi-factorial approach to

rehabilitating hamstring injuries is

needed

(Mason et al. 2007; Mendiguchia & Brughelli, 2011;

Seagrave et al. 2014)

Summary

• Hamstring strain is a well-documented problem with a high re-injury rate within athletes.

• Most injuries often occur during maximal sprints and often involve biceps femoris.

• There are many risk factors that indicate the need to develop and improve prevention strategies for primary and recurrent injuries of hamstring muscles

Summary

• No perfect way to completely avoid

hamstring injuries, but the risks can be

minimized by paying attention to the

principles of preventive program.

• A history of hamstring injury, preseason

assessment, implementing eccentric

exercises specially Nordic Hamstring

Exercise, and considering H:Q balance can

play important roles in prevention program.

Summary

• In a prevention program, the effectiveness

of stretching exercise is not clear.

• Type of stretching, time and frequency of

stretching exercise are still a matter of

conflict.

Summary

• In a rehabilitation program, the

primary objectives are returning the

athlete to sport at prior level of

performance in the shortest possible

time with a minimal risk of injury

recurrence

• One of the main problems is the

extremely high tendency of

hamstring injury to become recurrent

Summary

• The first month after return to play is the

highest risk time for recurrence

• A history of hamstring injury in the

previous 12 months is a predictor of

hamstring injury recurrence.

• Early return to play, incomplete and

aggressive rehabilitation increases the

risk of re-injury in the early stage after

returning to sport

Summary

• Severity of the muscle injury, maladaptation,

and poor core stability affect the duration of

the lay-off and making decision.

• Limited evidence about the effect of flexibility

on reducing time to return to play

• However, stretching exercises help the

hamstring muscle becoming less flexible after

the injury.

• Rely on subjective measures such as “pain

free movements” is not sufficient.

Summary

• Multi-factorial approach to

rehabilitating hamstring injuries is

needed.

• By creating and implementing a

strategized approach to injury

prevention, more of the athletes time

can be spent competing and training

instead of rehabilitating.

THANK YOU FOR

YOUR ATTENTION