Hamstring Rehabilitation

Hamstring rehabilitation covers a broad spectrum of treatments from simple soft tissue techniques and stretching for the most minor hamstring strains, to prolonged graded rehabilitation for the more severe hamstring strains.  The American Journal of Sports Medicine (2006) published an article on the incidence of hamstring injuries in rugby union and concluded the following:

• Average time lost – 17 days.

• Average time lost in recurrent injuries – 25 days.

• Average time lost in new injuries – 14 days.

• Hamstring “kicking” injuries produced an average of 36 lost days.

• Hamstring running injuries constituted 68% of the mechanism of injury.

The key point here is the significance of previous injury and no doubt we can all recount cases of recurrent hamstring strains that proved a real challenge to rehabilitation.  There also appears to be a difference between athletes who breakdown in field sports activities as opposed to track athletes.  This may well have it’s origins in altered running mechanics between the two environments and anecdotally hamstring rehabilitation does appear harder in with the high intensity, straight running demands of a track athlete.  We have talked previously of the mechanisms of hamstring overload, which still remain speculative and are generally derived from the epidemiological data.

Causes of hamstring strain

Hamstring tightness

Hamstring weakness

Hamstring hyperactivity

Prime hip extensor weakness

Hamstring quadriceps coordination deficits

Rotary hip control deficits

Rotary lower limb control deficits

Weak quadriceps

Impaired core stability

Hamstring gastroc paradox

This spectrum of etiological possibilities represents a significant challenge for the clinician and opens up the spectrum of a wide possibility of rehabilitation exercises as part of the hamstring rehabilitation protocol.  It must also be said, that even testing these components only gives us a snap shot of what is required for functional movement, as it is virtually impossible to accurately analyse functional interaction at the speeds which hamstring injuries occur.

It is equally hard to ascertain information regarding precise patterns of co-ordination/inco-ordination which may precipitate hamstring failure in a sporting situation.  We also have the possibility that failure on one side may be as a result of weakness on the contralateral limb producing overload.  This raises the even broader spectrum of treating the opposite side to that of the breakdown as a rehabilitation goal.  Obviously to justify this type of intervention there would need to be a distinct lack of physical signs on the effected side to indicate a legitimate target for rehabilitation.

Hamstring Gluteal Synergy

Sometimes referred to as the extensor chain mechanism in the sports science literature, clinical differentiation here is between the function of the 1 & 2 joint hip extensors.  As far back as the 1950’s Janda classified what he considered the “optimal firing pattern” of hip extension, which should be gluteal dominant with secondary hamstring co-activation in synergy with proximal trunk stability.  This became known as the prone hip extension test and is an exceedingly useful measure in routine clinical practice.

My preference is to perform this test with the knee flexed to put the hamstring in a disadvantaged position (by virtue of the length/tension relationship) and then evaluate the efficiency of hip extension.  There are a number of observational faults which may be observed, most commonly hamstring dominance –  in which the predominant perception of effort is in the posterior thigh rather than the gluteal region.  This is frequently accompanied by cramping in this area.  I have always interpreted this as an important clinical sign of strong substitution of hamstrings even in this disadvantaged position.

Sometimes the firing pattern can be changed by pre-activating the gluteals i.e. the verbal instruction of strong buttock contraction prior to the initiation of hip extension.  We are looking here to shift the location of perception of effort.  There are also combination of compensatory trunk actions which can occur, most frequently increased lumbar lordosis coupled with paraspinal hyperactivity.  This requires us to evaluate the capacity of the anterior/anterolateral abdominal wall when observed.  The other trunk compensation is a rotary compensation, which is usually a dropping of the pelvis on the side of the lifting leg.

The one joint hip extensor load is relatively low in this position compared to the functional requirements of sprinting.

Hamstring Rehabilitation Protocol’s

Progression of Hamstring loading would incorporate some of the following exercises as sequential progressions

Prone lying on gym ball – hip extension

Single leg bridging

Single leg bridging with asymmetrical contra lateral limb loading

Upright kneeling with asymmetrical trunk load

Lunge kneeling with narrow base – asymmetrical trunk load

Squat with arms elevated overhead

Lunge

Lunge with arm elevation

Lunge matrix

Single leg squat

Rear foot elevated split squat (RFESS)

Evaluation of sprinting mechanics may require collaboration with a technical skills coach but we will discuss some of these aspects in our next look at Hamstring Rehabilitation.

Enjoy the clinical challenge
David

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