Lionel Pannunzio PT / SCS
Hamstring Injury Treatment has changed a lot in the last decade. Professional Soccer teams are putting a lot of emphasis on prevention and quicker recovery. There is good consensus now to safely accelerate the recovery process so player can return to play earlier and most important avoiding a re-injury
Rehabilitation Process - Grade II hamstring Injury
We will use a Grade II injury as an example (see picture above ) . As we mention in our previous posts about HSI, many patients with a hamstring start to feel better within a few days of the injury. However, there is an extremely high hamstring re-injury rate due to a poor rehabilitation process.
Hamstring strains are one injury that professional guidance is highly recommended for both an accurate diagnosis but also provide you with the best chance of avoiding re-injuries. Repeat hamstring injuries have sidelined soccer players for months.
In Physical Therapy the treatment we provide will follow these guidelines:
Reduce hamstring pain and inflammation.
Normalize your muscle range of motion and extensibility. Remember one of the causes of HSI is short and tight Hamstrings.
The hamstrings create Hip Extension and Knee flexion simultaneously . Even though that in the beginning we may concentrate in improving each movement in isolation at some point The rehabilitation should address both the knee flexion and hip extension roles of the hamstrings together. High Speed Running is ultimate expression of the hamstrings doing this double action.
Strengthen your knee muscles and hamstrings. A key factor in the recovery process is Eccentric Load of the Hamstrings. Regular exercises will not do it for this condition reason why we have developed a progressive and comprehensive Strengthening program with this in mind
Strengthen your lower limb muscles: calves, hip and pelvis muscles.
Normalize lumbo-pelvic control and stability - a co-factor in many hamstring strains. Another super important factor is your pelvic position. Almost every Hamstring Injury goes with excessive curvature in the lumbar spine called hyperlordosis and anterior pelvic tilt causing your hamstrings to be under tension constantly just from standing and even more tension during High Speed Running
Improve your game speed, proprioception, agility and balance. Remember most of the HSI are the result of High Speed Running so this should be part of your rehabilitation process but most of the time it does not happened. At White Bay Physical Therapy this HSR and running mechanics drills are mandatory before we release players to train and prevent a re-injury.
One note on Hamstring Stretching: Injured Hamstrings respond much better to strengthening exercises and movement than it does to vigorous stretching. Any tight muscle denotes some type of weakness, lack of movement control or postural deficit. In these situations the muscle gets “tight” to compensate for these other problems. So please, Stop stretching your hamstrings vigorously, it won’t get much softer. There is a type of contraction called Eccentric contraction where the muscle lengthens as it moves a weight ( own body weight or external weight). These types of exercises are the ones recommended for most of the muscular injuries because of this double benefit: strength + lengthening. We ,as therapist, know when to introduce these type of exercises in the rehabilitation process.
To summarize, Long and Strong Hamstrings are the goals of the rehabilitation process
Stage I - Acute Injury
In the Acute phase we focus on resolving the pain with Ice , Ultrasound , Electrical Stimulation for Pain and We initiate an early mobility routine to safely put stress in the muscle to promote healing.
Hamstring Extenders - Mobility Workout
Begin lying on your back with one leg straight and the other leg bent
Bring your knee toward your chest and grab the back of your thigh with both hands. Slowly straighten your knee until you feel a stretch in the back of your thigh and return to original position. Repeat 10 Times.
Make sure to keep your back flat on the floor during the stretch and the opposite heel pushing against the ground during the stretch.
Hamstring Isometrics Strengthening
Bridge on Heels - Isometric HS contraction
Begin lying on your back with your knees bent and your feet resting flat on the ground.
Keeping your heels on the ground, lift your toes up.
Engage your abdominals and slowly lift your hips off the floor into a bridge position. You will feel your hamstring muscles contracting.
Hold contraction for 5 seconds. Then, Lower back down to the ground and repeat. Be aware this exercise can make your hamstrings to cramp. If that happens.
Repeat a few more times exercise 1. Do this exercise in 3 different angles: 90, 45 and 10-15 degrees of Knee Flexion to target the whole muscle group
Make sure to keep your abdominals engaged and do not arch your back during the exercise.
Stage II - Strengthening Phase
In the strengthening phase we will load the muscle progressively to assure proper scar mobilization and remodeling of the muscle to sustain higher loads everyday. We progress from simple contractions like Hold and Relax, then typical Hamstring exercises like leg curls and more Function-related exercises like eccentric contractions which not only make the muscle stronger but also increase the length of it. Remember we mentioned before that Short Hamstrings are highly related with HSIs.
Begin bending forward with your back straight and feet hip width apart, holding a barbell that is resting on the ground with your hands placed slightly wider than your feet.
Keeping your back straight, stand up, engaging your back, buttock, and thigh muscles. Slowly reverse the movement and repeat. Allow body to move till you feel the workout in your hamstrings and Glutes. Mild discomfort at the injury site is ok .
Make sure to keep your abdominals tight, back straight, and do not shrug your shoulders during the exercise. Try to keep the barbell close to your body as you stand and bend over.
Single Leg RDLs
Begin in a standing upright position holding a landmine or dumbbell in one hand.
Lift the uninvolved leg off the ground and bend forward at your hips, lowering the weight toward the ground. Then return to an upright position and repeat.
Allow body to move till you feel the workout in your hamstrings and Glutes. Mild discomfort at the injury site is ok .
Make sure to keep your back straight during the exercise and try not to let your knee move forward as you lower the weight.
Stage III - Return to Play Phase
Finally in the third phase we simulate soccer activities to reproduce the demands of the game in a closed environment and assure the scar tissue will tolerate the activity. This includes some field drills by the end of the phase and right before allowing you to play.
Key factors in this recovery are restoring Eccentric strength of the Hamstrings, restoring hip and knee range on motion, restoring proper core strength, and finally restoring dynamic balance and control of the Lumbo - Pelvic - Hip area.
Once all these factor were addressed we expose the injured players to Running Mechanics and High Speed Running itself.
You can see that our rehabiliation process is comprehensive and it covers the gap between the Clinic / Gym and the fields to return to play safely with the only goal of preventing another HSI.
Hamstring Injuries (HSI) are the second most common muscular injury in soccer players (quadriceps is #1)
Grade I injuries recover quick, while Grade II and III will take long time to recover and have an unfortunate high risk of re-injury and becoming chronic ( Proximal Hamstring Tendinopathy)
Most of these injuries does not require expensive MRIs or Test. The clinical examination by a professional specialized in HSI is usually enough to make the diagnosis and treatment
Do you want to find out more about what you can do to get better from your Hamstring Strain?
Click the link below to get access to our PDF E-Book
where you'll find valuable information about Muscle Injuries in general
and Hamstring Injuries in Particular
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