The complete management
of a recurrent hamstring muscle
strain of a soccer player
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Abstract
This case study describes the complete management of a forty-year-old soccer player with a grade two hamstring muscle tear, who complained of similar pain six years ago. The management aimed at addressing the acute presentation of the patient and the prevention of any future incidents of similar nature. Thus rehabilitation was aimed at addressing muscle integrity, loading and neuromotor control while being sports specific to a soccer player. The final stage of the management dealt with addressing the believed cause of the injury and educating the client, thus preventing reoccurrence. The program consisted of five weeks in total with an ongoing home exercise program.
Other issues addressed are the functional biomechanics of the hamstring muscle, the believed contributing risk factors to such an injury, and the need for further diagnostic measures.
Introduction
Hamstring injuries are among the most common lower limb injuries in sport requiring bursts of speed or rapid acceleration (Sally et al; De Smet and Best 2000; Best and Garrett 1996; Taylor, Waring and Brashear 1995). These injuries often result in a long recovery time with consistent complaints after returning to the activity, a high incidence of reoccurrence, and the athlete having difficulty reaching their pre-injury standard of performance (Croisier et al 2002; Best and Garrett 1996). The mechanism of injury is often associated with a violent force (either stretch or contraction), or with repeated strain (Sutton 1984; Brandser et al 1995). When trying to determine the mechanism of a hamstring muscle injury, it is important to consider the functional biomechanics of the muscle.
The hamstring muscles are biarticular structures acting at the hip and knee joint. Due to this biarticular configuration, the muscles have no intrinsic mechanism to localise their contraction force to a particular joint. Conversely, they contract as a whole and thus depend on adequate stabilisation of one joint by the actions of other forces in order for movement to occur at the desired joint (Sutton 1984).
The biceps femoris muscle acts in extension of the hip joint and in flexion and lateral rotation of the tibia on the femur. The muscle is also active in lateral rotation of the extended hip, and resisted hip adduction and abduction (Sutton 1984). Significantly, biceps femoris plays an important role in force closure of the sacro-iliac joint (SIJ) by forming part of the deep longitudinal system, thus increasing tension in the thoracolumber fascia and increasing the compressive force through the SIJ. It is also important to increase sacral nutation during the gait cycle via its attachment to the sacrotuberous ligament (Sutton 1984; Lee and Vleeming 2000). The semimembranosus and semitendinosus muscles are active during hip extension, medial rotation and resisted abduction and adduction. They are also active during flexion of the knee and medial rotation of the tibia on the femur (Sutton 1984).
The hamstring muscle is loaded maximally during the late swing phase and at the initial contact stage of the gait cycle (Brukner and Khan 2002). At initial contact Mann (1981) found the hamstring to be maximally contracted as the foot strikes the ground. Lieber and Friden (1993) found hamstring injuries most common during the late swing phase as the muscle is often strained due to inadequate eccentric strength (Jonhagen, Nemeth, Eriksson 1994); which is required during this phase to decelerate the forward swinging leg (Sutton 1984; Mair et al 1996).
Other situations whereby there is increased incidence of injury due to abnormal loading of the muscle occurs when the athlete's foot is placed in front of their centre of gravity, or due to an unstable trunk resulting in unnecessary movement of the muscle's origin away from its insertion (Brukner and Khan 2002).
The most commonly injured site of the hamstring muscle is the proximal third of the biceps femoris muscle at the musculo-tendinous junction (Best and Garrett 1996; Sally et al 1996; De Smet and Best 2000) resulting in most of the pain being experienced approximately ten centimeters below the gluteal fold (De Smet and Best 2000).
There is no single factor that can be considered as a predisposing factor when trying to determine the main cause of a hamstring strain. One needs to consider muscle fatigue, poor technique/form or posture, inadequate warm-up, overuse, abnormal muscle contraction or conditioning, incorrect skill patterns, magnesium imbalance, and sepsis. Three other more commonly mentioned risk factors include poor flexibility, muscle tightness, strength imbalance, and history of previous injury (Sutton 1984; Best and Garrett 1997; Croisier et al 2002; Taylor, Waring and Brashear 1995; Orchard et al 1997).
It has been found that the most important risk factor for injury is a previous history of the same injury (Orchard 2001). It is also believed that the reason for re occurrence of a hamstring muscle strain is strongly related to inadequate rehabilitation of the initial injury (Croisier et al 2002; Jonhagen, Nemeth, Eriksson 1994). Thus one can assume that an athlete is at a high risk of injuring their hamstring if they have a previous history of the same injury with inadequate initial rehabilitation.
Although the above problem may easily be addressed, there has been no published literature to determine the most effective management of a recurrent hamstring muscle strain. Best and Garrett stated: "There is likewise no consensus on optimal rehabilitation following initial treatment, but functional rehabilitation that includes stretching and strengthening has been emphasized."
This case study aims to address the need of a complete management protocol for hamstring muscle strains. This will cover the acute management of the condition, stretching, soft tissue management, manual techniques, and rehabilitation of the patient. The goal of this protocol is to allow the patient to return to soccer pain free and to perform at his maximum potential in the shortest and safest possible time.
Assessment
A 45-year-old male soccer player attended physiotherapy complaining of right posterior thigh pain after playing a social game of soccer three days prior to the assessment. The pain was isolated to the upper third of the posterior lateral aspect of his right thigh (P1). He required treatment as the pain was affecting his work, activities of daily living, and social life with his soccer peers. There was no evidence of any yellow flags but he was very moody and irritable due to the injury and was hoping that physiotherapy could rid him of this discomfort and prevent reoccurrence.
P1 was stabbing, intermittent, deep and rated six out of ten on the visual analogue scale (VAS). There was no pain or discomfort in his back, hips, knees, or ankles. P1 was aggravated by walking up stairs or inclines, weight bearing on the right leg, moving from sitting to standing, accelerating while driving a car, or bending down with straight legs to pick something up. It was eased with ice, massage, and relaxing the leg with the knee slightly bent.
P1 was worse when returning home from work and lasted until he went to sleep. There was no night pain, but on awaking he experienced slight pain and stiffness which eased within half and hour of inactivity. There was no pain through out the day during which he was mainly sitting on a chair.
He did not perform any stretching or warming up prior to playing the game. Ten minutes into the game he tried to receive an aerial ball with his right leg by controlling it with forced knee and hip flexion. He felt a crack at the back of his right thigh and immediately begun to experience posterior thigh pain. He immediately stopped playing and applied ice to the area. He continued to apply ice for the next two days and massaged the leg with deep heat.
In 1996 he experienced a similar incident while playing soccer. He went to a physiotherapist and was told that he had a muscle imbalance between his quadriceps and hamstring muscles. He did not receive any further treatment and did not seek further advice.
He had been playing soccer since his school days and had never played at more than social level. He did not play soccer since the incident in 1996 as he felt that the hamstring muscle: ' did not feel right'. This was the first game he had played since the initial hamstring injury and he did not attend any training sessions in the interim. There were no changes in any of his old equipment, and he played in the mid field position. He was previously a striker and changed to midfield in 1996 prior to his initial injury. The only other sport that he has partaken in since 1996 was long distance walking during which he did not have any pain.
He is married, has one child and is a self-employed electronics engineer. He smokes approximately half a pack of cigarettes a day and drinks alcohol socially. There was no other relevant medical history and no history of any surgery. He was not taking any medication and did not have any investigative measures taken. There were no red flags and the only self-administered questionnaire was the VAS.
Physical Examination
The patient walked into the room unaided but apprehensive to weight bear on the right leg. When observed in standing, he had an anterior pelvic tilt, was apprehensive to weight bear on his right leg, and stood with his right knee in slight flexion. There was marked bruising around the posterior thigh concentrated mainly around the middle and lateral region.
Functional testing revealed no pain with walking, but marked discomfort with stride walking. Pain was also experienced when lunging forward on both sides, and when descending while performing a squat.
Movement tests revealed that the lumber spine was clear. The right hip was cleared of all active and passive movements. Resisted hip flexion was a grade 5 with mild pain at the beginning of the range of movement (ROM), and hip extension was grade 4 with P1 reproduced throughout the ROM. Active knee flexion was full range of movement with P1 at the end of ROM, while the passive movement was cleared. Resisted knee flexion was a grade 3 with P1 reproduced throughout the ROM. Both active and passive knee extension was cleared while resisted extension was grade 5 with mild pain at the end of ROM.
Isometric muscle testing revealed P1 with an isometric right knee flexion and right hip extension contraction. Muscle control testing revealed poor eccentric muscle control of knee extension while prone, and poor proximal stabilisation when performing a functional single leg squat, bridging and with single leg bridging. Muscle length tests revealed a limited straight leg raise (SLR) of 15 degrees compared to the left (which reached 90 degrees), and the Thomas test revealed a tight right rectus femoris muscle when compared to the left.
A neurological examination was performed. This consisted of comparing the left and right sides for any difference in a SLR, slump, myotomes, dermatomes, and reflexes. None of the above tests revealed any neurological difference between the two sides.
On palpation there was increased temperature over the proximal third of the lateral aspect of the posterior right thigh. There was increased tissue resistance and pain with a postero-anterior (PA) specific soft tissue mobilisation (SSTM) to the area described above. During the assessment of the lumber spine, Maitland PA and unilateral PA passive accessory intervertebral mobilisation (PAIVM) assessment techniques did not reproduce any posterior thigh pain, but increased resistance was evident (Maitland 1999).
After the physical examination it was decided to use the SLR, isometric resisted knee flexion contraction, and stride walking as comparable signs. The above were chosen in order to obtain both an objective and functional comparable sign.
Management
After performing the assessment and the physical examination, the patient was diagnosed as having a grade 2 hamstring (biceps femoris) tear. He was treated initially three times for the first week, and then twice a week for four weeks to follow. The main functional goal of the management was to rehabilitate the patient so that he can play soccer in the near future, and to prevent any future reoccurrences.
The initial treatment sessions were based on addressing the acute management of the patient. This stage was declared the lag (inflammatory) phase and the main aims of treatment were control and protection (Hunter 1994 and 1998). Techniques were used to limit the amount of oedema hoping to decrease the amount of future scar tissue formation (Hunter 1994). Thus ultrasound, gentle SSTM in a PA direction and ice with compression were utilised. The RICE (rest, ice, compress, and elevate) regime was also taught to the patient. The main result of this phase was the reduction in pain, tissue resistance and inflammation. The patient improved slightly with regards to the SLR position, but there was no significant change with regards to the other two comparable signs.
By the six-day post injury it was decided that the patient had entered the fibro-proliferation or regeneration phase, this is the period of greatest increase in tissue tensile strength (Hunter 1998). Techniques were now aimed at regaining the tensile strength of the tissue, decreasing tissue resistance, and functional proprioceptive rehabilitation. He was instructed that he can begin jogging, but must stop immediately if he felt any hamstring irritation. A home stretching and strengthening program was to be performed three times a day. The strengthening exercises were all closed kinetic chain exercises and were performed in a controlled and safe manner.
The SSTM were also gradually increased in terms of pressure, rhythm, and position of the patient. Initially, a PA pressure was applied to the muscle in a relaxed position. It was gradually increased to a stretched position, and then performed while the hamstring contracted statically. The main results of the above techniques were a decrease in tissue resistance, increased muscle strength, and increase in the tensile strength of the tissue. Psychologically, the patient responded well as there was decreased pain and increased function.
After three weeks following the injury the SLR had reached 85 degrees. He could now perform an isometric hamstring contraction with increased muscle strength and decreased pain. He could perform stride walking much easier than previously, but still with mild discomfort.
The final treatment sessions were aimed at addressing the cause of the problem, and progressively strengthening the muscle to the specific skill required by the patient. Grade 3 and 4 PAIVMs were performed to the lumber spine in a PA direction in order to mobilise the hypomobile segments (Maitland 1999). The SSTM were progressed once again in pressure, rhythm and rate; but also to a loaded hamstring contraction. The strengthening exercises were progressed to include peripheral muscles, open kinetic chain exercises, and eccentric and plyometric contractions. The main results of this stage was that of decreased tissue resistance with increased tissue tensile strength, mobilisation of the lumber spine, and increased strength of the hamstring muscle while maintaining core stability.
After five weeks since the injury the patient's right SLR was equal to that on the left. His muscle strength on the right was equal to that on the left and pain free. He could also perform stride walking with no pain or discomfort.
Patient adherence was excellent and at the beginning of each treatment session all exercises were checked and corrected if necessary.
Please refer to appendix A for the SSTM treatment, and appendix B for the exercises prescribed to the patient.
Outcomes
Reassessment after five weeks since the injury revealed that the patient presented with no pain on the VAS. Resisted hamstring muscle contraction was grade five, and functional activity was pain free. On palpation there was decreased tissue resistance, and when the SLR position was reassessed, the right side was equal to that on the left and was pain free.
Discharge criteria included being able to stride walk, sprint with ankles touching his buttocks, and rapid changing between walking and sprinting with no pain. Further investigation included right single leg bridging with the right leg resting on the therapist's shoulder in different degrees of hip and knee flexion, sprinting and changing direction, and kicking of a soccer ball. All of the above were pain free.
The patient was discharged and educated with regard to the warming up prior to playing sport, and cooling down after the sport. He was also advised that in the future he should first train prior to partaking in a sport that he has not played for an extended period of time.
A telephone call two months post treatment revealed that the patient continued to play soccer socially on weekends and was pain free.
Discussion
The outcome of this case study was based on the success of the applied techniques. Physiological stretching and SSTM were applied to elongate and increase the tensile strength of the tissue. This is important as following an injury; there is a drop in the tissue tensile strength and increase in tissue resistance. Manual tension was applied specifically to the biceps femoris muscle and functionally progressed while adhering to the principles used by Glen Hunter (Hunter 1994 and 1998).
SSTM are only successful if the tissue can function in the environment that matches the imposed functional demands (Hunter 1998, Norris 1995). Thus it must be implemented with sufficient rehabilitation in order to restore muscle control, proprioception and co-ordination (Hunter 1998). Closed chain exercises were implemented in order to achieve proprioception and co-contraction force (Brukner and Khan 2002) thus aiding in proximal stabilisation. Open chain exercises were implemented in order to achieve greater force (Brukner and Khan 2002). Plyometric exercises were applied in order to allow the patient to reach maximal strength in the shortest possible time (Baechle 1994). This achieved functional rehabilitation of the patient and was applied according to the skill required to the patient.
The cause of the injury was believed to be due to multiple factors. The initial injury in 1996 was not dealt with effectively, resulting in increased stiffness of the muscle and insufficient muscle strength. Other important factors include the fact that he did not warm up, and did not train since 1996. The main cause of the problem is believed to be due to a hypomobile lumber spine and insufficient proximal stabilisation, as both would result in abnormal stress to the hamstring muscle. The relation between poor proximal control and hamstring injuries has not been investigated.
The diagnosis of a grade two hamstring muscle strain was made on the basis of clinical experience. This could have been confirmed with a MRI scan performed in either the coronal or axial planes on T1 and T2 weighted images. This could also eliminate the chance of a complete muscle transection, or an avulsion fracture from the ischial tuberosity (Brandser et al 1995).
Further recommendations to future studies would be to include a biokinetic for final stage rehabilitation. Due to the importance of patient compliance, it may also be necessary to have the patient complete a daily diary sheet or attend more frequent treatment sessions.
This case study cannot be related to other articles as no other article has discussed the topic before. It has thus bridged this gap and stressed the importance for future research in this field.
Future research should address the use of manual therapy in the functional outcome of a soft tissue injury. Clearer guidelines with regard to the rate, rhythm, and depth of the applied tensile force need to be implemented and standardised. Research needs to consider the functional skill of each sports person considering his or her sport and position. This should be implemented into both the testing of various risk factors and the rehabilitation of the patient. The rehabilitation should be such that it acts as a guideline as to the return to sport and these guidelines should be further investigated and standardised.
This case study and future case studies would benefit greatly from a patient assessment half annually for two years following rehabilitation in order to determine the success of the rehabilitation.
Conclusion
The rehabilitation of this patient was satisfactory and efficient. The aim of physiotherapy was achieved as he returned to his sport pain free and at the same level prior to injury. Most importantly, the patient's aim needs to be considered. He was able to return to his sport and a follow up assessment will be performed as mentioned above in order to ensure that the cause of the problem was addressed, thus avoiding reoccurrence.
Reference List
- Baechle T (1994): Essentials of strength training and conditioning. Human Kinetics
- Best T, Garrett W (1996): Hamstring Strains: Expedition return to play. The Physician and sports medicine, 24, 8, 37-44
- Brandser E, Callaghan J (1995): Hamstring injuries: radiographic, conventional tomographic, CT, and MRI imaging characteristics. Radiology, 197, 1, 257-262
- Croisier J, Forthomme B, Namurosis M, Vanderthommen M, Crielaard J (2002): Hamstring muscle strain recurrence and strength performance disorders. The American journal of sports medicine, 30, 2, 199-203
- Hunter G (1994): Specific soft tissue mobilisation in the treatment of soft tissue lesions. Physiotherapy, 80, 15-21
- Hunter G (1998): Specific soft tissue mobilisation in the management of soft tissue dysfunction. Manual therapy, 3, 1, 2-11
- Jonhagen S, Nemeth G, Eriksson E (1994): Hamstring injuries in sprinters: The role of concentric and eccentric muscle strength and flexibility. The American journal of sports medicine, 22, 2, 262-266
- Lee D, Vleeming A (2000) International Federation of Orthopaedic Manipulative Therapists
- Lieber R, Friden J (1993): Muscle damage is not a function of muscle force but active muscle strain. Journal of applied physiology, 74, 2, 520-526
- Mann R (1981): Kinetic analysis of sprinting. Medicine and science in sports and exercise 13, 5, 325-328
- Mair S, Seaber A, Glisson R, Garrett W (1996): The role of fatigue in susceptibility to acute muscle strain injury The American journal of sports medicine, 24, 2, 137-143
- Maitland G (1999): Vertebral Manipulation. Butterworth Heinemann
- Orchard J (2001): Intrinsic and extrinsic risk factors for muscle strains in Australian Football. The American journal of sports medicine, 29, 3, 300-303
- Orchard J, Marsden J, Lord S, Garlick D (1997): Preseason hamstring muscle weakness associated with hamstring muscle injury in Australian footballers. The American journal of sports medicine, 25, 1, 81-85
- De Smet A, Best T (2000): MR imaging of the distribution and location of acute hamstring injuries in athletes. The American journal of roentgenology, 174, 393-399
- Sally P, Friedman R, Coagan P, Garrett W (1996): Hamstring muscle injuries among water skiers: functional outcome and prevention. The American journal of sports medicine, 24, 2, 130-136
- Sutton G (1984): Hamstrung by hamstring strains: A review of the literature. The journal of orthopaedic and sports physical therapy, 5, 4, 184-195
- Taylor B, Waring C, Brashear T (1995); The effects of therapeutic application of heat or cold followed by static stretch on hamstring muscle length. The journal of sports physical therapy, 21, 5, 283-286
Appendix A:
THE POSITIONAL PROGRESSION OF THE PA SSTM TO THE BICEPS FEMORIS MUSCLE
POSITION ONE: the patient was positioned prone with a pillow under his feet maintaining 45 degrees of knee flexion, thus keeping the hamstring in a relaxed position.
POSITION TWO: the patient was positioned prone with no pillow under the feet, thus applying more of a stretch to the hamstring muscle compared to position one.
POSITION THREE: the patient was positioned supine with his foot resting on the therapist's shoulder with the hip and knee both flexed at 90 degrees. The hip and knee were maintained in a neutral position.
POSITION FOUR: the patient was in the above position with the hip taken more into flexion, while the knee was extended.
POSITION FIVE: the patient was positioned as described in position three with the hip placed in adduction and medial rotation with the tibia medially rotated, thus isolating the biceps femoris.
POSITION SIX: the patient was positioned as in position five and asked to press his heel into the therapist's shoulder, thus loading the hamstring muscle isometrically isolating the biceps femoris.
POSITION SEVEN: the patient was positioned prone with a theraband attached to his ankle. He was then asked to perform knee flexion (hamstring curl) while the PA SSTM was applied.
Appendix B:
STRENGTHENING EXERCISES PRESCRIBED TO THE PATIENT
- ALL OF THE EXERCISES BELOW WERE TO BE PERFORMED SLOWLY, SMOOTHLY AND IN A CONTROLLED MANNER.
- ALL EXERCISES WERE TO BE PERFORMED WHILE MAINTAINING A NEUTRAL PELVIS AND WITH ABDOMINAL BRACING.
- ALL EXERCISES WERE TO BE PERFORMED FOR THREE SETS OF TEN, TWICE A DAY.
- WHEN APPLICABLE, ALL UNILATERAL EXERCISES ARE TO BE PERFORMED WITH BOTH THE RIGHT AND THE LEFT LEGS.
- IF ANY DISCOMFORT WERE TO BE EXPERIENCED DURING THE EXERCISES, THE EXERCISES SHOULD BE STOPPED IMMEDIATELY
WEEK ONE
EXERCISE ONE: the patient was asked to perform a bridge with his feet approximately forty centimeters away from his buttocks. He was also asked to perform hip adduction by squeezing his knees together on a ball.
EXERCISE TWO: the patient was asked to perform a wall squat that was a quarter range of movement of the full range of movement. He was asked to place his heels a hands breath away from the wall.
WEEK TWO
EXERCISE THREE: the patient was asked to perform the same exercise as described in exercise one, but with his feet placed approximately 15-20 centimeters further away from the position described above.
EXERCISE FOUR: the patient was asked to lie supine with his ankles and leg resting on a chair, making sure that his hips and knees are at right angles to each other and in a neutral position. He was then asked to perform an isometric hamstring contraction with a ten second hold.
EXERCISE FIVE: the patient was asked to perform step-ups and step-downs on a raised step that was 15 centimeters off the ground.
WEEK THREE
EXERCISE SIX: the patient was asked to perform the exercise as descried in exercise three, but to keep his knees in 40-50 degrees from full extension.
EXERCISE SEVEN: the patient was asked to perform a forward lunge.
EXERCISE EIGHT: the patient was asked to perform an unassisted squat in his available pain free range.
Stretching is one of the most under-utilized techniques for improving athletic performance, preventing sports injury and properly rehabilitating sprain and strain injury. Don't make the mistake of thinking that something as simple as stretching won't be effective.
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WEEK FOUR
EXERCISE ELEVEN: the patient was to adopt the same position as described in exercise four and perform a bridge.
EXERCISE TWELVE: the patient was asked to perform a bridge as described in exercises one and hold the position. He was then instructed to straighten his leg while maintaining a squeezing pressure on the ball. He was then asked to place the lifted leg back on the bed and repeat the movement to the other side.
EXERCISE THIRTEEN: the patient was instructed to lie prone with his left leg over his right leg. He was then instructed to perform a self-resisted concentric hamstring muscle contraction. When reaching the end of range of movement, he was instructed to perform an eccentric hamstring muscle contraction, and then to repeat on the opposite side.
EXERCISE FOURTEEN: the patient was instructed to perform a single leg squat.
WEEK FIVE
EXERCISE FIFTEEN: the patient was instructed to position himself in the starting position described in exercise four and straighten his left leg. He was then instructed to perform a single leg bridge.
EXERCISE SIXTEEN: the patient was instructed to kneel on a flat surface and to stabilise his feet with external support. He was instructed to lock his hips in the upright position and to slowly bring his body forward by unlocking at the knees to approximately 30 to 40 degrees, and then to return to the starting position. A chair was placed in front of the patient in case of the situation whereby he may uncontrollably fall forward.
EXERCISE EIGHTEEN: the patient was asked to stand behind a chair and hold onto the chair for support. He was then instructed to bend his right knee and slowly lower it to the ground until his toes touched the ground. At this point he was to quickly bend the knee back to the starting position, thus performing a plyometric hamstring curl.
SPORT SPECIFIC EXERCISES: the patient was asked to sprint forwards, sideways and to sprint while changing direction to the right and to the left. He was then asked to kick a soccer ball as he would during a match. He was asked to perform the above three times during the last week of treatment and to report back if any discomfort was experienced.
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Article by Darryn Lifson - BSc Physio (UCT).
You can contact Darryn at lifsons@new.co.za.
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