Hamstring injuries and athletic running seem to go together. The injuries also tend to reoccur and become chronic. Often, the recovery rate becomes frustrating for the athlete as well as the practitioner. While the etiology remains controversial, the primary causes may be considered, in order to enhance recovery and prevent reinjury.
Some of the most common causes of hamstring muscle strains are:
- muscle fatigue
- muscle strength imbalances
- lack of hamstring flexibility
- insufficient warm-up
Hamstring muscle strain is a non-contact injury that presents in two ways: sudden onset with acute pain (runner pulls up and grabs his/her leg), or a more insidious onset of muscle tightness. Typically the biceps femoris, with or without the semitendinosus, is involved. The area most commonly inflamed is the proximal and lateral musculotendinous junction of the hamstring near the ischial tuberosity.
Acute Phase Treatment
During the acute, painful phase, the goal is to reduce inflammation. Ice works best; don’t use heat. As a general rule, use ice for twenty minutes, every two hours (during the hours the patient is awake), until the pain is gone. A light towel or face cloth should be used to protect the skin, even though it will dissipate some of the cooling effect. This treatment may be utilized from two days to two weeks.
The injured athlete should be advised to maintain a normal walking gait, even if it means walking with a cane or crutch on the opposite side (the toe of the cane or crutch should always be in line with the toe of the injured side). Most athletes aren’t happy with this advice, but to compromise the gait into a hobble will only prolong recovery.
Active knee extension and flexion without resistance should be performed as soon as tolerated by the patient. Some pain may be experienced during this motion, as long as it is not increased pain. When the athlete can perform knee extension and flexion with little to no pain it is usually safe to perform these two range-of-motion exercises against resistance with an at-home rehab system. Be particularly aware of pain. Initially, the range of motion and/or the amount of resistance may be limited. Set them to patient tolerance.
Do the uninvolved side first. An effective protocol is:
• 1 set to fatigue of knee extension (uninvolved side)
• 1 set to fatigue of knee extension (involved side)
• 1 set to fatigue of knee flexion (uninvolved side)
• 1 set to fatigue of knee flexion (involved side)
Repeat the sequence above two more times. This protocol should be done daily at first, and then progressed to twice daily as the patient recovers.
I recommend doing one extra set of knee extension exercises, because according to the hierarchy of strength in the body, the extensor should be slightly stronger than the flexor.
If any soreness develops, follow the rehab exercises with ice. Do not let your patients overwork themselves. Athletes have a tendency to do too much too soon and reinjury occurs. This type of protocol is designed to facilitate neurologic firing into the involved muscle(s) and initial strength gains. As muscles get stronger they will naturally be able to do more. Let pain be your guide. This type of exercise will also build up endurance levels over time.
Proper Stretching Activity
Stretching is important, but only if done correctly. Many people stretch their hamstrings by bending over a propped-up knee and curling their back to touch their forehead to their knee. This will not effectively stretch the upper portion of the hamstrings where the injury site is. Do that stretch, but arch the lower back to create anterior pelvic tilting and lean the body forward, keeping the head level.
Evaluation of Progress
To progress to activity, an athlete should be able to:
- walk without discomfort
- jog straight ahead without discomfort
- run straight ahead without discomfort
- run with change of directions without discomfort
- perform the tasks of his/her athletic activity without discomfort
As with any condition involving the lower extremity, thoroughly evaluate the sacroiliac joints and the spine. Subluxation complexes can create structural imbalances, and muscular imbalances may also be playing a role.
You must also look for involvement of the knee and/or foot/ankle complex. Remember that the most common painless biomechanical fault is excessive pronation. Excessive inward rotation of the mid-foot and rear-foot can set up a serial distortion, resulting in structural misalignment and muscle imbalances. Without stabilizing this area with custom-made, flexible orthotics, reinjury will always be a concern, even with the best rehab program. Consult with an established orthotics laboratory about specialized shoe inserts for athletes. TAC
Dr. John Danchik is the seventh inductee to the American Chiropractic Association Sports Hall of Fame. He is the current chairperson of the United States Olympic Committee’s Chiropractic Selection Program. He lectures extensively in the United States and abroad on current trends in sports chiropractic and rehabilitation. Dr. Danchik is associate editor to the Journal of the Neuromusculoskeletal System and the Journal of Chiropractic Sports Injuries and Rehabilitation. He has been in private practice in Massachusetts for 24 years. You may reach Dr. Danchik at (617) 489-1220 or e-mail [email protected].