Hamstring Strains: Recurrence, Sequelae,& the Rehab Programme w Zero Reinjuries

For instance,  athletes with a previous hamstring injury have  up to a six-times greater risk of future ham string injury.3 Authors have speculated that  higher recurrence rates would be connected to  inadequate use of rehabilitation, less effective  physiotherapy techniques by some providers,  and/or premature return to play.1 This bulletin  updates the information provided in our 2019  bulletin regarding hamstring strains. 

Most patients can return to relatively normal,  non-athletic function with rest and restricted  activity. Therefore, some may choose to re serve rehabilitation for certain circumstances.  On the other hand, a poorly healed hamstring  can limit future athletic activity as well as  create postural imbalances that can lead to  long-term spinal complaints.4 Given the poten tial to reduce high recurrence rates and future  sequelae, the most current practice guidelines  call for exercise therapy for all hamstring  strains.2 

Of course, not all physiotherapy programmes  are created equally. For instance, many of the  high recurrence rates reported are with formal  rehabilitation programmes. Fortunately, en couraging modern data suggests three im portant elements that can optimise outcomes.  Firstly, physiotherapy should begin as prompt ly as possible. Compared to patients seen in  two days, patients with thigh or calf muscle  strains seen nine days after injury took 33%  longer to recover.5 Compared to usual rehabil itation programmes, programmes including trunk stabilisation accelerated return to play  and reduced reinjury rates 79% (from 38% to  8%).6,7  

Even more encouraging is the data regarding  eccentric strength training. While most studies  have found that injured legs tend to return to  normal strength, more specific data finds that  the peak strength occurs at earlier degrees of  

knee extension in the injured leg, due to ham 

string shortening. In 2019, this bulletin shared  the results of a study out of Monash University.  Camilla Brocket and colleagues reported that  a shorter optimum angle for peak torque  correlates with injury recurrence.8 Currently,  this conclusion may appear somewhat contro versial given new publications finding no  correlation between preseason eccentric  strength and hamstring strain risk.9 However,  these more recent studies included all athletes,  while Brocket et al. focused on previously  injured athletes.  

Regardless, the studies focusing on the out comes of eccentrically biased rehabilitation  techniques have produced consistent results.  Three studies have evaluated eccentrically  biased rehabilitation programmes paying  attention to strength at varying degrees of  extension.10-12 These studies covered 108  patients combined and measured zero reinju ries during follow-up periods ranging from one  to three years. Additionally, recovery was  accelerated. Current guidelines emphasise the  importance of eccentric training in the rehabili tation of hamstring strains.2 

Data suggests that earlier referral to physio therapy along with programmes biased to ward trunk stabilisation and eccentric loading  have potential to greatly improve the out comes of hamstring strains.

 

References 

1. Heiderscheit BC, Sherry MA, Silder A, Chumanov ES, Thelen DG. Hamstring strain injuries: rec ommendations for diagnosis, rehabilitation, and injury prevention. Journal of Orthopaedic &  Sports Physical Therapy. 2010 Feb;40(2):67-81.  

2. Martin RL, Cibulka MT, Bolgla LA, Koc Jr TA, Loudon JK, Manske RC, Weiss L, Christoforetti JJ,  Heiderscheit BC, Voight M, DeWitt J. Hamstring Strain Injury in Athletes: Clinical Practice  Guidelines Linked to the International Classification of Functioning, Disability and Health From  the Academy of Orthopaedic Physical Therapy and the American Academy of Sports Physical  Therapy of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physi cal Therapy. 2022 Mar;52(3):CPG1-44.  

3. Engebretsen AH, Myklebust G, Holme I, Engebretsen L, Bahr R. Intrinsic risk factors for groin  injuries among male soccer players: a prospective cohort study. The American Journal of Sports  Medicine. 2010 Oct;38(10):2051-7.  

4. Freckleton G, Pizzari T. Risk factors for hamstring muscle strain injury in sport: a systematic re view and meta-analysis. Br J Sports Med. 2012 Jul 1:bjsports-2011.  

5. Bayer ML, Magnusson SP, Kjaer M. Early versus Delayed Rehabilitation after Acute Muscle In jury. New England Journal of Medicine. 2017 Sep 28;377(13):1300-1. 

6. Sherry MA, Best TM. A comparison of 2 rehabilitation programs in the treatment of acute ham string strains. Journal of Orthopaedic & Sports Physical Therapy. 2004 Mar;34(3):116-25.  

7. Silder AM, Sherry MA, Sanfilippo J, Tuite MJ, Hetzel SJ, Heiderscheit BC. Clinical and morpho logical changes following 2 rehabilitation programs for acute hamstring strain injuries: a ran domized clinical trial. Journal of Orthopaedic & Sports Physical Therapy. 2013 May;43(5):284- 99.  

8. Brockett CL, Morgan DL, Proske UW. Predicting hamstring strain injury in elite athletes. Medi cine & Science in Sports & Exercise. 2004 Mar 1;36(3):379-87.  

9. Wille CM, Stiffler-Joachim MR, Kliethermes SA, Sanfilippo JL, Tanaka CS, Heiderscheit BC. Pre season Eccentric Strength is Not Associated with Hamstring Strain Injury: A Prospective Study in  Collegiate Athletes. Medicine and Science in Sports and Exercise. 2022 Apr 13.  

10. Tyler TF, Schmitt BM, Nicholas SJ, McHugh MP. Rehabilitation after hamstring-strain injury em phasizing eccentric strengthening at long muscle lengths: results of long-term follow-up. Journal  of Sport Rehabilitation. 2017 Mar;26(2):131-40.  

11. Askling CM, Tengvar M, Thorstensson A. Acute hamstring injuries in Swedish elite football: a  prospective randomised controlled clinical trial comparing two rehabilitation protocols. Br J  Sports Med. 2013 Mar 26:bjsports-2013.  

12. Askling C, Karlsson J, Thorstensson A. Hamstring injury occurrence in elite soccer players after  preseason strength training with eccentric overload. Scandinavian Journal of Medicine & Sci ence in Sports. 2003 Aug;13(4):244-50.