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Ins and Outs of the Hamstring A couple of Questions that I asked myself: What can I do better to prevent hamstring strains What can I do better or different to prevent a recurrence ? Ins and Outs of the Hamstring Goals of this Talk Anatomy of the Muscles Research of Hamstring Injuries. Intrinsic/Extrinsic factors of Hamstring Injuries. Hamstring healing phase’s Hamstring Rehabilitation Ins and Outs of the Hamstring Biceps Femoris Muscle - Short Head: Origin: Distal linea aspera and lateral supracondylar ridge of femur Insertion: Head of fibula and lateral condyle of tibia Actions on the leg Flexes the leg at the knee: laterally rotates leg when the knee is flexed. Biceps Femoris Muscle - Long head: Origin: Ischial tuberosity of os coxa Insertion: Head of the fibula and lateral condyle of tibia. Actions: on the thigh: Extends the thigh at the hip ( it also flexes leg at knee and laterally rotates leg if knee is flexed ) Ins and Outs of the Hamstring Semitendinosus Origin: It arises from the lower and medial impression on the tuberosity of the ischium, Insertion: into the upper part of the medial surface of the body of the tibia, nearly as far forward as its anterior crest. Action: Flexes and medially rotates the knee joint. Extends and assists in medial rotation of the hip joint Ins and Outs of the Hamstring Semimembranosus Origin: is the ischial tuberosity Insertion: medial condyle and nearby margin of tibia; intercondylar line and lateral condyle of femur; and the ligament of popliteal region. Action: Flexes and medially rotate the knee joint. Extends and assist in medial rotation of the hip joint. Ins and Outs of the Hamstring Marc A. Sherry, DPT, CSCS,1 Thomas M. Best, MD, Amy Silder, PhD Darryl G. Thelen, PhD,and Bryan C. Heiderscheit, PhD. MECHANISM OF HAMSTRING INJURY Most hamstring strain injuries happen while running. In the terminal swing phase of the gait cycle. During the second half of the swing, the hamstrings undergo an eccentric contraction and absorb energy from the swing limb before foot contact. Thus, the hamstrings are stretched while subjected to load(eccentric contraction), with the biceps femoris incurring the greatest amount. Ins and Outs of the Hamstring A historical perspective. 1902- first mention of muscle injuries 1906- management of muscle tears conservative immobilization, cool water. 1930- first research increased interest in understanding the histopathology . 1936- RTP to soon was discovered at this time 1950-1960 Cortizone injections were popular Ins and Outs of the Hamstring 1954- till present practice and principle of tx“…treatment must be designed to minimize the haemorrhage and inflammatory reaction so that there will be as little granulation (scar) tissue formed as possible…” Delarue NC 1960 -introduction NSAID 1970-1980 introduction physiotherapy Last 20 years seen explosion of research understanding of epidemiology, etiology, pathophysiology Ins and Outs of the Hamstring Research into Hamstring Injuries. Lot of research is done in conjunction with ACL reconstructions. Some research has pointed to how many hamstring injuries will cost a team in lost time. Some research has tried to look at intrinsic and extrinsic factors. Ins and Outs of the Hamstring Feeley at all reported that Muscle strains account for 46% of practice injuries Hamstring strains were the second most common preseason injury 1.79 per 1000 athletes exposures for practices 4.07 per 1000 athletes exposures for games Ins and Outs of the Hamstring Marcus C. C W. Elliot MD, Bertram Zarins, John Powell, Phd, ATC, Charles D Kenyon 10 year review Professional NFL players This study was done from 1989-1998 10 years 1716 hamstring strains 1129 different athletes. Mean of totally lost days was 2222 in the 10 years. About 47.3 % was during games About 52.7 % was during practice preseason most 16.5 % of re-injuries practices/22% during games Offensive more injuries than defense. Wide recievers/runningbacks Secondary has the highest rate of injury. Ins and Outs of the Hamstring Ekstrand J, Hägglund M, Waldén M 51 football teams, 2299 players, were followed during the years 2001 to 2009. 2908 muscle injuries were registered. 92% of all muscle injuries affected the 4 major muscle groups of the lower limbs: hamstrings (37%), adductors (23%), quadriceps (19%), and calf muscles (13%). 16% of the muscle injuries were re-injuries. Re-injuries caused significantly longer absences than did first time The incidence of muscle injury increased with age. When separated into different muscle groups, however, an increased incidence with age was found only for calf muscle injuries Ins and Outs of the Hamstring What can we conclude from this research Hamstring strain cost a lot of time of the field . Hamstring strains have a high recurrent rate. Hamstring strains cost a team valuable assets that are not able to perform. Is there anything we can do? Some research on intrinsic/extrinsic factors Ins and Outs of the Hamstring Burkett Lee 1970 Causative Factor in hamstring strains. 12 hamstring strain subjects/18 track athletes 32 football athletes/ 6 were predicted to strain hamstring Strength imbalance between knee flexors of both legs Strength imbalance between knee extensors of both legs Flexion-extension ratio Bilateral muscle strength Sit and reach test. Results: Strongly indicated that reduction of strength imbalance between limbs will be useful in the prevention of hamstring strains. Ins and Outs of the Hamstring Jean-Louis Croisier,* PhD, BenedicteForthomme, PT, MarieHelene Namurois, PT, Marc Vanderthommen, PhD, and JeanMichel Crielaard, MD, PhD. 2002 26 athletes w/ recurrent hamstring strains. Concentric/Eccentric isokinetic testing. Aim was to see if normalization of the differences in hamstring/quadriceps ratio would decrease recurrence of hamstring 18 athletes had strength deficits, as determined by statistically selected cutoffs of peak torque, bilateral differences, and the flexors/quadriceps ratio. Ins and Outs of the Hamstring Continued Showed a eccentric peak torque deficit and a significant reduction of the mixed eccentric/concentric quadriceps ratio. athletes with muscle imbalances followed a rehabilitation program individually adapted from their strength profile emphasizing eccentric training 10-30 sessions which resulted in normalization of the isokinetic strength testing. After 12 months of following the athletes none sustained an recurrent injury Ins and Outs of the Hamstring Fousekis, Tsepis,Poulmedis, Athanasopoulos, Vagenas. Nov 2010 Prospective cohort study 100 soccer players intrinsic factors. Soccer players 19.4-27.8 old Looked at composite effects in asymmetry muscle strength flexibility, proprioception, physical characters, knee joint stability previous history of strains. Study looked at several different variables together Ins and Outs of the Hamstring Results Cont’d: Three significant predictors for Hamstring strains when put together are: Functional leg length asymmetry Excessive isokinetic asymmetry Previous hamstring strain Other intrinsic factors such as age, cross sectional periphery, muscle flexibility, functional knee strength ratio, knee joint laxity and proprioceptive traits proved to be irrelevant Ins and Outs of the Hamstring Marc A. Sherry, Thomas M. Best, MD, Amy Silder, Darryl G. Thelen, PhD and Bryan C. Heiderscheit, PhD, June 2011 To decrease the recurrent rate this research proposes to incorporate into the rehabilitation process: Dynamic warm-up Integrating Neuromuscular control Trunk stabilization Functional eccentric strengthening. Ins and Outs of the Hamstring Brukner, Nealon, Morgan, Burgessand Dunn Dec 2012 Casestudy. Recurrent Hamstring injuries 12-63 % 1 month highest risk to reinjure. 7 point program to reduce recurrent injury 26 year athlete ® 5 hamstring injuries in 5 months Prior injuries included ® MCL strain,® Achilles tendinopathy , (l) Add strain Neurodynamics ( SLR and slump test) Biomechanical assesment Core stability/lumbar strengthening Increase strength thru eccentric Overload running program Injection therapy Stretching/yoga/relaxation. Ins and Outs of the Hamstring More Intrinsic factors to keep in mind associated with Hamstring Injuries are : Lumbo-pelvic status Muscle flexibility Strength training Running mechanics Ins and Outs of the Hamstring Lumbo-Pelvic Status: pre-existing lumbar spine pathology pelvic muscle imbalance – pelvic muscle tone 80% population will have right TFL, Illiacus, Psoas stronger then the left gluteal medius stability and joint control. Ins and Outs of the Hamstring Muscle flexibility. Studies have not definitively concluded that hamstring strains are due to inflexibility. Increase flexibility gradually . Look for tightness in the hip flexors for both legs. Ins and Outs of the Hamstring Include in your Strength program Quad strength vs Hamstring strength Maximum strength and fatigue tolerance Eccentric strength. Running Mechanics Over striding. Excessive force on the hamstring leading to fatigue and possible strain Ins and Outs of the Hamstring So where does this leave us athletic trainers. Athletes with previous Hamstring strains are higher likely to pull again. Strength deficits in the hamstring/quad ratio might be something to keep in mind. Leg length differences might be something to look at. 1st month after strain high incidence of re tear Rehab an athlete with neuromuscular, eccentric strengthening, core, and go slow. All points to keep in mind. Ins and Outs of the Hamstring 4 basic stages of healing The time of Injury Inflammatory phase Fibroblastic phase Remodeling phase Ins and Outs of the Hamstring Time of Injury Protect the injury Immobilization The more severe the longer it takes. Ins and Outs of the Hamstring The Inflammatory phase: Last approx. 4-6 days Bleeding- (inflammatory cells to injury) Delicate framework Scaffolding Prevent moving muscle. Clinically : Rest/immobilization Decrease inflammation via ice, rest compression, ultrasound, avoid stretching or exercises Ins and Outs of the Hamstring Repair/Regeneration phase 5 days to10-12 weeks Increased tensile strength in scar Stop immobilization. Clinically: Start rehab to increase strength, stretching, soft tissue mobilizations starting slowly. Ins and Outs of the Hamstring Remodeling phase Start 21 days continues 6-12 months Scar strength increases and becomes smaller. Clinically: Stretching to optimal length Rehabilitation vigorous enough to keep up with demands of sports (functional) Ins and Outs of the Hamstring Rehabilitation Old and New Bridge Hamstring curls Lunges SLRDL Slide board SLB Ins and Outs of the Hamstring Ins and Outs of the Hamstring Eccentric forward pull Ins and Outs of the Hamstring Ins and Outs of the Hamstring http://www.youtube.com/watch?feature=player_detailpage&v=AS9eqB_hZqo#t =50s Ins and Outs of the Hamstring Ins and Outs of the Hamstring Manual eccentric/concentric strengthening Ins and Outs of the Hamstring Leg dropping gently move the leg around and suddenly drop the leg tell the athlete to stop the leg Bridge on smaller ball Ins and Outs of the Hamstring Pogo butt kicks Below is Hamstring curls with feet stable on rolling cart Ins and Outs of the Hamstring Heel Toss with Med ball Hamstring injury’s CONCLUSION. QUESTION