- Email: [email protected]
Chiropractic management
Vaughn/Reed blue areas extending from the posterior upper portion of her left thigh, down to just above the back of her knee. She was stiff and the muscle soreness had increased. When she attempted to fully extend her left leg, the tightness in the thigh caused moderate pain and discomfort. Consequently she kept the knee slightly bent when standing or walking, and when sitting used wellpadded chairs because pressure, from sitting on the hamstring muscles, produced mild cramping sensations along with some mild 'pins and needles' tingling sensations around the area. JF decided to take a NSAID for her pain and discomfort - she chose ibuprofen (2 x 200 mg tablets per the manufacturers recommendation). JF has been running on a regular basis for 3 years. It began first as a
weight loss activity and later became the primary focus of stress reduction and social activities. Her running is an important component of her social identity within her community. She is very serious about rnnning and is very consistent with the activity. It makes her feel healthy and well at the start of her day and sustains her throughout the stress of being a personnel manager. JF has a strong desire to return to her running as soon as possible. Eight days after initially sustaining the hamstring injury, JF still has black and blue discolouration along the left posterior thigh. Although the stiffness has lessened in the thigh, the tenderness to touch is still present and she found that holding her leg in a slightly flexed position still provided relief. She
discontinued the NSAIDS after 5 days and has not used an ice bag on the area since the first day of the injury. She continues to walk while at work performing her duties and finds that walking makes her leg feel much better, especially after a long bout of sitting. She desperately wants to return to running and is beginning to feel frustrated and apprehensive that her injury is not improving. She is now self-treating with analgesic balms to provide feelings of relief as she considers when to begin running again.
REFERENCES Kulund D 1988 The injured athlete, 2nd edn. JB Lippincott, Philadelphia, pp. 431-432 Sutton G 1984 Hamstrung by hamstring strains. Journal of Orthopedic and Sports Physical Therapy 5 (4): 184-195
Chiropractic management M. P. Reed
Michael P. Reed, DC, DACBSP, CSCS Los Angeles College of Chiropractic, 16200 E. Amber Valley Drive, Whittier, CA 90607, and 192 North 1lth Street, Grover Beach, CA 93433, USA. Correspondence to: M.P. Reed, Fax: ++1 805 481
52817 Received April 1996 Revised May 1996 Accepted August 1996
Journal of Bodywork and Movement Therapies (1996) 1(1), 10-15 © Pearson Professional I_td 1996
The hamstring strain is a common and complex injury in the realm of athletics. It can be a frustrating injury for both the athlete and the clinician. This is evidenced by JF; she has indicated that she feels frustrated and apprehensive about her injury not improving. Realistically it has been only 8 days since the onset of her injury - which was severe enough to cause a large haematoma. An injury of this nature may be time consuming in relation to time off from the sport the athlete is training in. Treatment of this athlete will need to be aimed at maintaining her current level of aerobic conditioning, and essentially entertaining her. In all reality she will not be able to return to running 5000 metres per day within the very near future. With this in mind the clinician must develop a programme which is enjoyable for the athlete. A hamstring rehabilitation programme should be
based on current understanding of the aetiological factors contributing to the injury, the aspects of tissue healing, biomechanics of the hamstrings and the structures they affect, and the exercise physiology related to the sport the athlete will return to.
Anatomy The hamstrings consist of three muscles. . The biceps femoris is composed of the long head which originates from the ischial tuberosity and the short head which originates from the lateral lip of the linea asperum. Both heads insert into the head of the fibula. The function of the biceps femoris is to extend the hip, when the lower leg is fixed, flex the lower leg and rotate it externally. o The semitendinosus originates from the ischial tuberosity and on the
Q J O U R N A L OF B O D Y W O R K A N D M O V E M E N T T H E R A P I E S
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Hamstring strain: chiropractic management medial aspect of the tibia in the pes anserinus. • The semimembranosus originates from the ischial tnberosity and inserts at the medial condyle of the tibia. The semimembranosus functions in the same way as the semitendinosus, but is considered a more powerful muscle (Worrell 1994). These muscles all have the potential to exert forces on the lumbopelvic region because of their pelvic and sacral attachments. The force of the muscle contraction is readily transmitted to the pelvis when the femur or foot becomes fixed and a closed kinetic chain is established (Podesta & Podesta 1994). Additionally, these muscles influence the deceleration of the foot during the swing phase of gait. Furthermore, the hamstring muscles influence sagittal plane mechanics by exerting posterior torsion on the ilium/pelvis. This can lead to symptomproducing stress at the sacroiliac joints (Weineck 1990, Porterfield & DeRosa 1991, Podesta & Podesta 1994).
Aetiology There are many factors to consider when treating a hamstring injury. Is it a new injury? Is there scar tissue present? Is a long-term weakness or muscle imbalance present? Is there sufficient flexibility? Predisposing factors which have been identified are fatigue, muscle imbalance between the quadriceps and hamstring strength (normally 3:2) and tightness (Cantu & Micheli 1991, Tidball 1991, De Carlo et al 1992). A deficit in hamstring strength appears to be predictive of hamstring injury. It has been demonstrated that hamstring muscles are subjected to high forces during both open and closed kinetic chain activities of sprinting. Thus, a stronger hamstring can absorb greater forces (De Carlo et al 1992). The mechanics of the injury frequently
JOURNAL
involve a quick explosive contraction of hamstrings while the hip is in flexion and the knee extended. Additionally, certain situations will generate the forces necessary to produce injury to the sacroiliac ligaments; sudden violent contraction of the hamstrings is one of these forces (Tidball 1991). The kinetic chain concept allows us to view the actions of the total lower extremity and pelvis as a functional relationship. A tight medial hamstring can cause excessive internal thigh rotation with a toeing-in gait that results in sub-talar joint pronafion (Weineck 1990). With pelvic involvement, a posterior ileum, the resulting change in limb length will trigger a compensatory dysfunction in the foot or a change in the total extremity position (toe-ont, toe-in). Weakness of the hamstrings can cause an anterior innominate (Weineck 1990, Porterfield & DeRosa 1991), which can also trigger changes in the lower extremity mechanical balance. Macintyre (1994) indicated that untreated dysfunction at one site of the kinetic chain may lead to compensatory dysfunction at others. Thus, in dancers undergoing rehabilitation, the identification and treatment of kinetic chain dysfunction is important.
Injury Besides keeping in mind the standard grading of muscle strains (I, II and HI), it is important in hamstring strains to determine the site of injury. Tidball (1991) indicated that myotendinous junctions are sites of clinically observed muscle tears. The myotendinous junctions are a primary site of lesion in many muscle tears. It is important to bear in mind that hamstring strains frequently occur at the belly of the muscle. Recognition of this injury is as follows:
Grade I • Sore hamstring muscles • Minimal pain on palpation • Gait normal
OF BODYWORK AND MOVEMENT THERAPIES
• Hip flexion normal to slight limitation • Tight feeling to mild pain during resistive knee flexion • May not miss competition.
Grade II • Athlete may have heard a pop • Abnormal gait: lacks heel strike, unwilling to fully extend knee • Palpation produces moderate to severe pain • Defect in muscle belly may be evident • Swelling • Resistive knee flexion and hip extension reproduces moderate to severe pain • Passive hip flexion with knee extended produces moderate to severe pain. Grade III • May be unable to ambulate without crutches • Usually felt a pop, may have heard it • Swelling with ecchymosis • Severe pain on palpation • Noticeable defect in muscle belly • Poor resistive strength • Passive hip flexion with knee extended may not be tolerated • Passive hip flexion with knee flexed may be severely limited. Examination The physical examination of the athlete with an injured hamstring starts with a postural screening. Examination of the patient should begin with the observation of the patient's posture, standing, sitting and lying down. Observing the patient's movement from sitting to standing or other alterations of position is important (Porterfield & DeRosa 1991).
Posterior aspect of the body: • Foot inversion or eversion • Any abnormal muscle contractures of the legs • Level of the iliac crests
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• Rotation of the entire pelvis in relation to the trunk • Lateral flaring of one iliac crest more than the other • Greater trochanters on palpation: determine if one femur is more laterally or medially rotated than the opposite • Lumbar curve, increase or decrease • Genu varum or valgus.
Lateral aspect of the body: • Anterior or posterior rotation of the pelvis • Increase or decrease of lumbar lordotic curve • Position of knees (hyperextension or flexed) • Abdominal protrusion. Fixations occur in varying degrees and the joint may be fixated in its normal resting place, the extreme limit of movement, or any area in between (Porterfield & DeRosa 1991).
Posterior ilia (signs): • High anterior superioiliac spine (ASIS) on side of fixation • Short leg on same side (Note: a short leg may be caused by numerous conditions) • Sacrum may palpate anterior in relation to the ilia in the supine position. Postero ischium (signs): • Low ASIS • Long leg on same side • Wider PSIS - sacral spine distance. Medial ischium: • A narrowing of the ischial tuberosities: this produces a strain on the superior sacro-iliac ligamental structure and the associated soft tissues. Examination of the hamstring includes placing the athlete in a supine position and performing a straight leg raise, noting the position of pain or painful arc. This should be performed bilaterally. While the athlete is still supine, the hip should be flexed to 90 ° with the knee flexed. The knee is then
extended with the foot in the neutral position to the point of pain. This test is repeated with both internal and external tibial rotation. Internal tibial rotation wilt place more stretch on the biceps femoris. External tibial rotation will place a greater stretch on the semimembranosus and semitendinosus. Once again, there should be a bilateral comparison. The area of pain should be noted and followed by palpation of the area. Palpation of the area of complaint is extremely important to determine if there are any defects in the muscle. Palpation should be performed with the athlete's thigh in a position of comfort and during the tests described above. The thigh should be observed for haematoma. This may not present initially, but may take several days. It is important to remember that aspirin and other non-steroidal antiinflammatory drugs may increase bleeding if administered early (Sullivan et al 1992).
Treatment/rehabilitation The success of rehabilitation is directly related to the ability of the clinician and the patient to work together toward a common good. Basic principles that contribute to success include the following (Birrer & Brecker 1987): • Avoid overstressing the healing tissue • Prevent deleterious effects of immobilization • Identify specific criteria to fulfill as the patient moves through the stages of rehabilitation • Adapt the programme to each patient's specific goals • Base the protocol on current clinical and scientific research • Accelerated treatment or premature return of injured athletes to competition may result in repetitive microtrauma and re-injury that will prolong disability.
For rehabilitation of the injured athlete it is important that the phases of rehabilitation are addressed. Because hamstring injuries vary greatly in severity the length of each phase will be dependent upon the injury itself.
• Phase I (maximum protection): Treat the inflammation, achieve primary tissue healing, maintain function, control range of motion. • Phase II (moderate protection): Tissue maturation, strengthening, endurance, protective development. • Phase III (minimum protection): Determination of time segment needed for tissue maturation and/or reorientation, light functional activity, skill acquisition. • Phase IV (advanced rehabilitation): Functional programme, sport-specific skills, return to demanding environment. • PhaseV(maintenance). Please note that during all phases of rehabilitation the athlete is evaluated from a chiropractic standpoint and osseous and soft tissue manipulation are utilized along the kinetic chain as indicated. Worrell (1994) has described several exercises to be performed during rehabilitation.
Acute phase (phase 1) Ice should be applied for 20-45 minutes 2-4 times a day to reduce inflammation until pain and limitation of daily activities function are resolved. After application of ice for 20-45 minutes, gentle active knee extension and flexion can be performed while the athlete is seated for another 5-25 minutes. We utilize a slide board and have the athlete perform as many directions/patterns as they can tolerate (Figs 1 and 2). The athlete is also started on a wobble board in the seated position to help train proprioception (Fig 3). Additionally, the athlete should wear spandex shorts to help support the musculature and provide compression.
J O U R N A L OF B O D Y W O R K A N D M O V E M E N T T H E R A P I E S OCTOBER 1996
Hamstring strain: chiropractic management
Fig. 1 Seated slide board, knee and hip flexion and extension.
Sub-acute phase (phase 2) Once signs of inflammation have subsided and the athlete achieves full extension without pain, resistance exercises can begin. These should include multiple angle submaximal hamstring isometric exercises with 5second contractions, two sets, 15-20 degree increments (Figs 4-7). Stationary bicycle riding can also begin. EMG studies indicate that the semitendinosus, the biceps femoris and the semimembranosus are among the prime movers imparting energy to the bicycle (Gajdosik et al 1994). Swimming pool exercises - including walking, progressive jogging with a wet vest and kicking on the side or the use of a kick board - can be included.
Fig. 2 Seated slide board, knee and hip flexion and extension.
Fig. 3 Utilizing the balance wobble board to start early limited movement in seated
position. present with excessive haemorrhage and a palpable defect in the muscle. This type of injury will usually require a minimum of 3 weeks healing time.
Re-injury is common; this can lead to additional haemorrhage and may result in myositis ossificans (bony deposits in the muscle).
Fig. 4 Multiple angle submaximal
hamstring isometric exercise(knee flexion) 90°.
Fig. 5 Multiple angle submaximal hamstring isometric exercise(knee flexion 120°.
Fig. 6 Multiple angle submaximal hamstring isometric exercise (knee flexion) 170°.
Fig. 7 Multiple angle submaximal hamstring isometric exercise training (hip extension).
Remodelling phase (phase 3) During this phase, tissue healing time is determined. Mild contusions or strains may cause only slight damage to the capillaries. There may be bleeding, but it is not the result of derangement of the muscle fibre. This type of injury requires minimal healing time, the athlete may be able to continue play or return to play within a couple of days. If the trauma is more severe, as in the case of JF the injured runner, tissue fibres are destroyed and will need to heal. Additionally, therapists must be aware of the separation of the tissues that occurs during a severe strain. This would
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Once multiple angle hamstring isometrics can be performed at 100% effort, prone hamstring strengthening begins; this starts unilaterally with ankle weights. The strengthening programme initially consists of high repetitions and low resistance. During this phase light stretching is started and is a crucial part of rehabilitation. Stretching should be static and the target should be plastic changes in the connective tissue. If the muscle is able to return to its former length after a stretch it is considered elastic. Plastic rather than elastic changes cause more permanent changes in tissue length (Worrell & Perrin 1992) through partial reorganization of the structure of the tissues. It should be emphasized that whenever plastic changes are induced in tissue this causes a weakening of the tissue. However, the goal is to stress and stimulate the tissue to adapt; provided that the stress is not too great, the weakening will be short term. The athlete can progress to eccentric exercises, this is especially important in the open chain position, due to the fact that the hamstrings act as decelerators during gait.
weight-bearing more closely than open kinetic chain exercise in patients requiring rehabilitation of the lower extremity (Gould & Davies 1985). This is followed by a jog-sprint programme.
Sport-specific phase (phase 5) At this point in time the athlete starts sport-specific drills related to their
Fig. 8 Usingthe slideboard for concentric cocontraction exercise, comprising agonistantagonist sets. The athlete does these for time or reps.
Functional progression phase (phase 4) Once normal gait is achieved, walking progression begins, helped by pool activities. When the athlete can walk for 20 minutes without pain a walk and jog programme can begin. It is important to increase the intensity of closed chain exercises at this point in time. Kinetic chain exercise should concentrate on concentric cocontraction exercises comprising of agonist-antagonist sets (Figs 8 and 9). This type of exercise has the mechanical effect of making the joint stiffer (Won'ell & Perrin 1992). The goal is to have the athlete concentrate on cocontracting the entire thigh musculature. Exercises which will accomplish this are using a slide board in the athletic, breakdown, position, squats and lunges (Figs 10 and 11). Stair-stepping simulates functional
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Fig. 10 Walking lunges: side view.
OF BODYWORK AND MOVEMENT THERAPIES
particular sport. It is important to train the specific energy pathways related to the sport the athlete is competing in. The athlete should continue to perform cocontraction exercises, especially in specific athletic positions. The athlete should start playing racquetball at this point in time, this will assist in developing agility and quickness. Finally, the athlete should be evaluated
Fig. 9 Squats with stick to work cocontraction to thigh muscles.
Fig. 11 Walking lunges utilizing cocontraction exercises, comprising agonist-antagonist sets.
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Hamstring strain: chiropractic management athlete can return to their normal training schedule.
REFERENCES
Fig. 12 Utilizing the balance board to redevelop proprioception: using both legs prior to one leg.
Fig. 13 Utilizing balance board to redevelop proprioception.
for return to play. The American College of Sports Medicine (Sonzoghi & Gross 1993) has put forward the following guidelines for return to play following a hamstring strain. • Symmetric flexibility of hamstrings • Minimal tenderness to palpation • Minimal pain on range of motion against resistance • Functional progression Hop on one foot Duck walk (the patient is in a full squat position and walks) Run and cut at half speed, then full speed to right and left Run backwards Run functional figure-of-eights.
certain pelvic and trunk postures may be useful when developing therapeutic interventions (Gregor et al 1991). The hamstring muscles not only contribute to motion but also to postural stability. It is important to realize the forces that are placed on the kinetic chain when an injury occurs to this muscle group, and be able to recognize the need to care for fixations of osseous or soft tissue. Additional education of the athlete regarding the aetiology of their injury is important. In the case of JF, her injury occurred during the middle of her workout, there was no sudden overextending of the musculature. This leads me to believe that there was muscle cramping secondary to dehydration, causing the sudden muscle tear. My recommendation for this athlete is to concentrate on drinking approximately 3 litres of water a day to stay well hydrated. Finally, we must remember that the athlete frequently feels that they are not an athlete if they are not competing or training. This holds true for JF, her running programme provided essential stress relief. As clinicians we must strive to apply alternative training methods until the
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Maintenance phase It is important that the athlete maintains the level of conditioning both during competition and out of competition. This is achieved by continuing to perform closed chain exercises and maintain flexibility (Figs 12 and 13).
Summary An understanding of the relationship between the hamstring muscles and
J O U R N A L OF B O D Y W O R K AND M O V E M E N T THERAPIES
Birrer RB, Brecker DB 1987 Common sports injuries in youngsters. Medical Economic Books Cantu RC, Micheli LJ 1991 ACSM's Guidelines for the team physician. Lea and Febiger, Philidelphia, PA De Carlo M et al 1992 Electromyographic and cinematographic analysis of the lower extremity during closed and open kinetic chain exercise. Isokinetics Exer Sci 2:24-29 Emoka RM 1988 Neuromechanical basis of kinesiology. Human Kinetics, Champaign, IL Gajdosik RL et al 1994 Influence of hamstring length on the standing position and flexion range of motion of the pelvic angle, lumbar angle, and thoracic angle. Physical Journal of Orthopedic and Sports Therapy 20: 213-219 Gould JA, Davies GJ 1985 Orthopaedic and sports physical therapy. Mosby, St Louis Gregor RJ et al 1991 Exercise and sport sciences reviews: the biomechanics of cycling. Williams and Wilkins, Baltimore Logan AL 1977 Clinical application of chiropractic: low back and pelvis. West-Print, Westminster Macintyre J 1994 Kinetic chain dysfunction in ballet injuries. Med Probl Perform Art 9: 39-42 Podesta I, Podesta G 1994 Rehabilitation of the anterior cruciate ligament. Journal of Musculoskeletal Medicine 1: 54-64 Porterfield JA, DeRosa C 1991 Mechanical low back pain: perspectives in functional anatomy. W B Saunders, Philidelphia Sonzoghi JJ, Gross ML 1993 Hip and pelvic injuries in the young, Part 1 of 2: Biomechanics and soft-tissue insults. Emergency Medicine 25 (7): 74-94 Sullivan MK et al 1992 Effects of pelvic position and stretching method on hamstring muscle flexibility. Medicine and Science in Sports and Exercise 24:1383-1389 Tidball JG 1991 Exercise and sport sciences reviews: myotendinous junction injury in relation to junction structure and molecular composition. Williams and Wilkins, Baltimore Weineck J 1990 Functional anatomy in sports. Mosby, St Louis Worrell TW, Perrin DH 1992 Hamstring muscle injury: the influence of strength, flexibility, warm-up, and fatigue. Journal of Orthopedic and Sports Physical Therapy 16:12-18 Worrell TW 1994 Factors associated with hamstring injuries: an approach to treatment and preventative measures. Sports Medicine 17:338-345
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weight loss activity and later became the primary focus of stress reduction and social activities. Her running is an important component of her social identity within her community. She is very serious about rnnning and is very consistent with the activity. It makes her feel healthy and well at the start of her day and sustains her throughout the stress of being a personnel manager. JF has a strong desire to return to her running as soon as possible. Eight days after initially sustaining the hamstring injury, JF still has black and blue discolouration along the left posterior thigh. Although the stiffness has lessened in the thigh, the tenderness to touch is still present and she found that holding her leg in a slightly flexed position still provided relief. She
discontinued the NSAIDS after 5 days and has not used an ice bag on the area since the first day of the injury. She continues to walk while at work performing her duties and finds that walking makes her leg feel much better, especially after a long bout of sitting. She desperately wants to return to running and is beginning to feel frustrated and apprehensive that her injury is not improving. She is now self-treating with analgesic balms to provide feelings of relief as she considers when to begin running again.
REFERENCES Kulund D 1988 The injured athlete, 2nd edn. JB Lippincott, Philadelphia, pp. 431-432 Sutton G 1984 Hamstrung by hamstring strains. Journal of Orthopedic and Sports Physical Therapy 5 (4): 184-195
Chiropractic management M. P. Reed
Michael P. Reed, DC, DACBSP, CSCS Los Angeles College of Chiropractic, 16200 E. Amber Valley Drive, Whittier, CA 90607, and 192 North 1lth Street, Grover Beach, CA 93433, USA. Correspondence to: M.P. Reed, Fax: ++1 805 481
52817 Received April 1996 Revised May 1996 Accepted August 1996
Journal of Bodywork and Movement Therapies (1996) 1(1), 10-15 © Pearson Professional I_td 1996
The hamstring strain is a common and complex injury in the realm of athletics. It can be a frustrating injury for both the athlete and the clinician. This is evidenced by JF; she has indicated that she feels frustrated and apprehensive about her injury not improving. Realistically it has been only 8 days since the onset of her injury - which was severe enough to cause a large haematoma. An injury of this nature may be time consuming in relation to time off from the sport the athlete is training in. Treatment of this athlete will need to be aimed at maintaining her current level of aerobic conditioning, and essentially entertaining her. In all reality she will not be able to return to running 5000 metres per day within the very near future. With this in mind the clinician must develop a programme which is enjoyable for the athlete. A hamstring rehabilitation programme should be
based on current understanding of the aetiological factors contributing to the injury, the aspects of tissue healing, biomechanics of the hamstrings and the structures they affect, and the exercise physiology related to the sport the athlete will return to.
Anatomy The hamstrings consist of three muscles. . The biceps femoris is composed of the long head which originates from the ischial tuberosity and the short head which originates from the lateral lip of the linea asperum. Both heads insert into the head of the fibula. The function of the biceps femoris is to extend the hip, when the lower leg is fixed, flex the lower leg and rotate it externally. o The semitendinosus originates from the ischial tuberosity and on the
Q J O U R N A L OF B O D Y W O R K A N D M O V E M E N T T H E R A P I E S
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1996
Hamstring strain: chiropractic management medial aspect of the tibia in the pes anserinus. • The semimembranosus originates from the ischial tnberosity and inserts at the medial condyle of the tibia. The semimembranosus functions in the same way as the semitendinosus, but is considered a more powerful muscle (Worrell 1994). These muscles all have the potential to exert forces on the lumbopelvic region because of their pelvic and sacral attachments. The force of the muscle contraction is readily transmitted to the pelvis when the femur or foot becomes fixed and a closed kinetic chain is established (Podesta & Podesta 1994). Additionally, these muscles influence the deceleration of the foot during the swing phase of gait. Furthermore, the hamstring muscles influence sagittal plane mechanics by exerting posterior torsion on the ilium/pelvis. This can lead to symptomproducing stress at the sacroiliac joints (Weineck 1990, Porterfield & DeRosa 1991, Podesta & Podesta 1994).
Aetiology There are many factors to consider when treating a hamstring injury. Is it a new injury? Is there scar tissue present? Is a long-term weakness or muscle imbalance present? Is there sufficient flexibility? Predisposing factors which have been identified are fatigue, muscle imbalance between the quadriceps and hamstring strength (normally 3:2) and tightness (Cantu & Micheli 1991, Tidball 1991, De Carlo et al 1992). A deficit in hamstring strength appears to be predictive of hamstring injury. It has been demonstrated that hamstring muscles are subjected to high forces during both open and closed kinetic chain activities of sprinting. Thus, a stronger hamstring can absorb greater forces (De Carlo et al 1992). The mechanics of the injury frequently
JOURNAL
involve a quick explosive contraction of hamstrings while the hip is in flexion and the knee extended. Additionally, certain situations will generate the forces necessary to produce injury to the sacroiliac ligaments; sudden violent contraction of the hamstrings is one of these forces (Tidball 1991). The kinetic chain concept allows us to view the actions of the total lower extremity and pelvis as a functional relationship. A tight medial hamstring can cause excessive internal thigh rotation with a toeing-in gait that results in sub-talar joint pronafion (Weineck 1990). With pelvic involvement, a posterior ileum, the resulting change in limb length will trigger a compensatory dysfunction in the foot or a change in the total extremity position (toe-ont, toe-in). Weakness of the hamstrings can cause an anterior innominate (Weineck 1990, Porterfield & DeRosa 1991), which can also trigger changes in the lower extremity mechanical balance. Macintyre (1994) indicated that untreated dysfunction at one site of the kinetic chain may lead to compensatory dysfunction at others. Thus, in dancers undergoing rehabilitation, the identification and treatment of kinetic chain dysfunction is important.
Injury Besides keeping in mind the standard grading of muscle strains (I, II and HI), it is important in hamstring strains to determine the site of injury. Tidball (1991) indicated that myotendinous junctions are sites of clinically observed muscle tears. The myotendinous junctions are a primary site of lesion in many muscle tears. It is important to bear in mind that hamstring strains frequently occur at the belly of the muscle. Recognition of this injury is as follows:
Grade I • Sore hamstring muscles • Minimal pain on palpation • Gait normal
OF BODYWORK AND MOVEMENT THERAPIES
• Hip flexion normal to slight limitation • Tight feeling to mild pain during resistive knee flexion • May not miss competition.
Grade II • Athlete may have heard a pop • Abnormal gait: lacks heel strike, unwilling to fully extend knee • Palpation produces moderate to severe pain • Defect in muscle belly may be evident • Swelling • Resistive knee flexion and hip extension reproduces moderate to severe pain • Passive hip flexion with knee extended produces moderate to severe pain. Grade III • May be unable to ambulate without crutches • Usually felt a pop, may have heard it • Swelling with ecchymosis • Severe pain on palpation • Noticeable defect in muscle belly • Poor resistive strength • Passive hip flexion with knee extended may not be tolerated • Passive hip flexion with knee flexed may be severely limited. Examination The physical examination of the athlete with an injured hamstring starts with a postural screening. Examination of the patient should begin with the observation of the patient's posture, standing, sitting and lying down. Observing the patient's movement from sitting to standing or other alterations of position is important (Porterfield & DeRosa 1991).
Posterior aspect of the body: • Foot inversion or eversion • Any abnormal muscle contractures of the legs • Level of the iliac crests
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Reed
• Rotation of the entire pelvis in relation to the trunk • Lateral flaring of one iliac crest more than the other • Greater trochanters on palpation: determine if one femur is more laterally or medially rotated than the opposite • Lumbar curve, increase or decrease • Genu varum or valgus.
Lateral aspect of the body: • Anterior or posterior rotation of the pelvis • Increase or decrease of lumbar lordotic curve • Position of knees (hyperextension or flexed) • Abdominal protrusion. Fixations occur in varying degrees and the joint may be fixated in its normal resting place, the extreme limit of movement, or any area in between (Porterfield & DeRosa 1991).
Posterior ilia (signs): • High anterior superioiliac spine (ASIS) on side of fixation • Short leg on same side (Note: a short leg may be caused by numerous conditions) • Sacrum may palpate anterior in relation to the ilia in the supine position. Postero ischium (signs): • Low ASIS • Long leg on same side • Wider PSIS - sacral spine distance. Medial ischium: • A narrowing of the ischial tuberosities: this produces a strain on the superior sacro-iliac ligamental structure and the associated soft tissues. Examination of the hamstring includes placing the athlete in a supine position and performing a straight leg raise, noting the position of pain or painful arc. This should be performed bilaterally. While the athlete is still supine, the hip should be flexed to 90 ° with the knee flexed. The knee is then
extended with the foot in the neutral position to the point of pain. This test is repeated with both internal and external tibial rotation. Internal tibial rotation wilt place more stretch on the biceps femoris. External tibial rotation will place a greater stretch on the semimembranosus and semitendinosus. Once again, there should be a bilateral comparison. The area of pain should be noted and followed by palpation of the area. Palpation of the area of complaint is extremely important to determine if there are any defects in the muscle. Palpation should be performed with the athlete's thigh in a position of comfort and during the tests described above. The thigh should be observed for haematoma. This may not present initially, but may take several days. It is important to remember that aspirin and other non-steroidal antiinflammatory drugs may increase bleeding if administered early (Sullivan et al 1992).
Treatment/rehabilitation The success of rehabilitation is directly related to the ability of the clinician and the patient to work together toward a common good. Basic principles that contribute to success include the following (Birrer & Brecker 1987): • Avoid overstressing the healing tissue • Prevent deleterious effects of immobilization • Identify specific criteria to fulfill as the patient moves through the stages of rehabilitation • Adapt the programme to each patient's specific goals • Base the protocol on current clinical and scientific research • Accelerated treatment or premature return of injured athletes to competition may result in repetitive microtrauma and re-injury that will prolong disability.
For rehabilitation of the injured athlete it is important that the phases of rehabilitation are addressed. Because hamstring injuries vary greatly in severity the length of each phase will be dependent upon the injury itself.
• Phase I (maximum protection): Treat the inflammation, achieve primary tissue healing, maintain function, control range of motion. • Phase II (moderate protection): Tissue maturation, strengthening, endurance, protective development. • Phase III (minimum protection): Determination of time segment needed for tissue maturation and/or reorientation, light functional activity, skill acquisition. • Phase IV (advanced rehabilitation): Functional programme, sport-specific skills, return to demanding environment. • PhaseV(maintenance). Please note that during all phases of rehabilitation the athlete is evaluated from a chiropractic standpoint and osseous and soft tissue manipulation are utilized along the kinetic chain as indicated. Worrell (1994) has described several exercises to be performed during rehabilitation.
Acute phase (phase 1) Ice should be applied for 20-45 minutes 2-4 times a day to reduce inflammation until pain and limitation of daily activities function are resolved. After application of ice for 20-45 minutes, gentle active knee extension and flexion can be performed while the athlete is seated for another 5-25 minutes. We utilize a slide board and have the athlete perform as many directions/patterns as they can tolerate (Figs 1 and 2). The athlete is also started on a wobble board in the seated position to help train proprioception (Fig 3). Additionally, the athlete should wear spandex shorts to help support the musculature and provide compression.
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Hamstring strain: chiropractic management
Fig. 1 Seated slide board, knee and hip flexion and extension.
Sub-acute phase (phase 2) Once signs of inflammation have subsided and the athlete achieves full extension without pain, resistance exercises can begin. These should include multiple angle submaximal hamstring isometric exercises with 5second contractions, two sets, 15-20 degree increments (Figs 4-7). Stationary bicycle riding can also begin. EMG studies indicate that the semitendinosus, the biceps femoris and the semimembranosus are among the prime movers imparting energy to the bicycle (Gajdosik et al 1994). Swimming pool exercises - including walking, progressive jogging with a wet vest and kicking on the side or the use of a kick board - can be included.
Fig. 2 Seated slide board, knee and hip flexion and extension.
Fig. 3 Utilizing the balance wobble board to start early limited movement in seated
position. present with excessive haemorrhage and a palpable defect in the muscle. This type of injury will usually require a minimum of 3 weeks healing time.
Re-injury is common; this can lead to additional haemorrhage and may result in myositis ossificans (bony deposits in the muscle).
Fig. 4 Multiple angle submaximal
hamstring isometric exercise(knee flexion) 90°.
Fig. 5 Multiple angle submaximal hamstring isometric exercise(knee flexion 120°.
Fig. 6 Multiple angle submaximal hamstring isometric exercise (knee flexion) 170°.
Fig. 7 Multiple angle submaximal hamstring isometric exercise training (hip extension).
Remodelling phase (phase 3) During this phase, tissue healing time is determined. Mild contusions or strains may cause only slight damage to the capillaries. There may be bleeding, but it is not the result of derangement of the muscle fibre. This type of injury requires minimal healing time, the athlete may be able to continue play or return to play within a couple of days. If the trauma is more severe, as in the case of JF the injured runner, tissue fibres are destroyed and will need to heal. Additionally, therapists must be aware of the separation of the tissues that occurs during a severe strain. This would
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Once multiple angle hamstring isometrics can be performed at 100% effort, prone hamstring strengthening begins; this starts unilaterally with ankle weights. The strengthening programme initially consists of high repetitions and low resistance. During this phase light stretching is started and is a crucial part of rehabilitation. Stretching should be static and the target should be plastic changes in the connective tissue. If the muscle is able to return to its former length after a stretch it is considered elastic. Plastic rather than elastic changes cause more permanent changes in tissue length (Worrell & Perrin 1992) through partial reorganization of the structure of the tissues. It should be emphasized that whenever plastic changes are induced in tissue this causes a weakening of the tissue. However, the goal is to stress and stimulate the tissue to adapt; provided that the stress is not too great, the weakening will be short term. The athlete can progress to eccentric exercises, this is especially important in the open chain position, due to the fact that the hamstrings act as decelerators during gait.
weight-bearing more closely than open kinetic chain exercise in patients requiring rehabilitation of the lower extremity (Gould & Davies 1985). This is followed by a jog-sprint programme.
Sport-specific phase (phase 5) At this point in time the athlete starts sport-specific drills related to their
Fig. 8 Usingthe slideboard for concentric cocontraction exercise, comprising agonistantagonist sets. The athlete does these for time or reps.
Functional progression phase (phase 4) Once normal gait is achieved, walking progression begins, helped by pool activities. When the athlete can walk for 20 minutes without pain a walk and jog programme can begin. It is important to increase the intensity of closed chain exercises at this point in time. Kinetic chain exercise should concentrate on concentric cocontraction exercises comprising of agonist-antagonist sets (Figs 8 and 9). This type of exercise has the mechanical effect of making the joint stiffer (Won'ell & Perrin 1992). The goal is to have the athlete concentrate on cocontracting the entire thigh musculature. Exercises which will accomplish this are using a slide board in the athletic, breakdown, position, squats and lunges (Figs 10 and 11). Stair-stepping simulates functional
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Fig. 10 Walking lunges: side view.
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particular sport. It is important to train the specific energy pathways related to the sport the athlete is competing in. The athlete should continue to perform cocontraction exercises, especially in specific athletic positions. The athlete should start playing racquetball at this point in time, this will assist in developing agility and quickness. Finally, the athlete should be evaluated
Fig. 9 Squats with stick to work cocontraction to thigh muscles.
Fig. 11 Walking lunges utilizing cocontraction exercises, comprising agonist-antagonist sets.
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Hamstring strain: chiropractic management athlete can return to their normal training schedule.
REFERENCES
Fig. 12 Utilizing the balance board to redevelop proprioception: using both legs prior to one leg.
Fig. 13 Utilizing balance board to redevelop proprioception.
for return to play. The American College of Sports Medicine (Sonzoghi & Gross 1993) has put forward the following guidelines for return to play following a hamstring strain. • Symmetric flexibility of hamstrings • Minimal tenderness to palpation • Minimal pain on range of motion against resistance • Functional progression Hop on one foot Duck walk (the patient is in a full squat position and walks) Run and cut at half speed, then full speed to right and left Run backwards Run functional figure-of-eights.
certain pelvic and trunk postures may be useful when developing therapeutic interventions (Gregor et al 1991). The hamstring muscles not only contribute to motion but also to postural stability. It is important to realize the forces that are placed on the kinetic chain when an injury occurs to this muscle group, and be able to recognize the need to care for fixations of osseous or soft tissue. Additional education of the athlete regarding the aetiology of their injury is important. In the case of JF, her injury occurred during the middle of her workout, there was no sudden overextending of the musculature. This leads me to believe that there was muscle cramping secondary to dehydration, causing the sudden muscle tear. My recommendation for this athlete is to concentrate on drinking approximately 3 litres of water a day to stay well hydrated. Finally, we must remember that the athlete frequently feels that they are not an athlete if they are not competing or training. This holds true for JF, her running programme provided essential stress relief. As clinicians we must strive to apply alternative training methods until the
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Maintenance phase It is important that the athlete maintains the level of conditioning both during competition and out of competition. This is achieved by continuing to perform closed chain exercises and maintain flexibility (Figs 12 and 13).
Summary An understanding of the relationship between the hamstring muscles and
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Birrer RB, Brecker DB 1987 Common sports injuries in youngsters. Medical Economic Books Cantu RC, Micheli LJ 1991 ACSM's Guidelines for the team physician. Lea and Febiger, Philidelphia, PA De Carlo M et al 1992 Electromyographic and cinematographic analysis of the lower extremity during closed and open kinetic chain exercise. Isokinetics Exer Sci 2:24-29 Emoka RM 1988 Neuromechanical basis of kinesiology. Human Kinetics, Champaign, IL Gajdosik RL et al 1994 Influence of hamstring length on the standing position and flexion range of motion of the pelvic angle, lumbar angle, and thoracic angle. Physical Journal of Orthopedic and Sports Therapy 20: 213-219 Gould JA, Davies GJ 1985 Orthopaedic and sports physical therapy. Mosby, St Louis Gregor RJ et al 1991 Exercise and sport sciences reviews: the biomechanics of cycling. Williams and Wilkins, Baltimore Logan AL 1977 Clinical application of chiropractic: low back and pelvis. West-Print, Westminster Macintyre J 1994 Kinetic chain dysfunction in ballet injuries. Med Probl Perform Art 9: 39-42 Podesta I, Podesta G 1994 Rehabilitation of the anterior cruciate ligament. Journal of Musculoskeletal Medicine 1: 54-64 Porterfield JA, DeRosa C 1991 Mechanical low back pain: perspectives in functional anatomy. W B Saunders, Philidelphia Sonzoghi JJ, Gross ML 1993 Hip and pelvic injuries in the young, Part 1 of 2: Biomechanics and soft-tissue insults. Emergency Medicine 25 (7): 74-94 Sullivan MK et al 1992 Effects of pelvic position and stretching method on hamstring muscle flexibility. Medicine and Science in Sports and Exercise 24:1383-1389 Tidball JG 1991 Exercise and sport sciences reviews: myotendinous junction injury in relation to junction structure and molecular composition. Williams and Wilkins, Baltimore Weineck J 1990 Functional anatomy in sports. Mosby, St Louis Worrell TW, Perrin DH 1992 Hamstring muscle injury: the influence of strength, flexibility, warm-up, and fatigue. Journal of Orthopedic and Sports Physical Therapy 16:12-18 Worrell TW 1994 Factors associated with hamstring injuries: an approach to treatment and preventative measures. Sports Medicine 17:338-345
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