STRENGTH and CONDITIONING PROGRAMMING after HAMSTRING INJURY . Disclaimer If you have injured a hamstring or suspect an injury, you must see a qualified medical person to get an accurate diagnosis immediately. Any programs and phases in this book must to be assessed as suitable by a qualified practitioner after they have diagnosed an injury. This information is provided to give you more information on how to plan strength and conditioning programs after hamstring injury but the process and duration must be decided upon by qualified medical people. I will not be discussing treatment and specific rehabilitation processes in this document. That is for the clinician Also this manual will not cover back related hamstring problems or gluteal ( piriformis) problems and tendinopathies. Back problems ( example dics prolapses at L4/L5 and/or L5/S1) are often likely reasons to cause hamstring issues and scans ( MRI Scans) can show muscle strains as a result of the back problem or no strains but ongoing hamstring signs . Every hamstring is different. The approach is multifactorial and requires individual assessment and programming. Is the inner core or “transverse abdominus” dysfunctioning? Is there a problem with how the athlete runs? Is there a muscle balance problem? The list is endless and no cookbook will ever exist. The fitness guru can be a real worry when trying weird and wonderful exercises or reading the internet and looking for the magic exercise. Another concern is often the masseur or “magic healer” who lives around the corner and lurks in the shadows with “cure alls” for everything. Even clinicians can be a problem, given sometimes they know little about rehabilitation, running and strength and conditioning. And the biggest hurdle is often the athlete who wants to get back the moment that hamstring feels pain free. That is the reality of managing a hamstring rehabilitation. HAMSTRING RECURRENCE RATES IN SPORT SOCCER STUDY DONE OVER 2 YEARS ( PREMIER LEAGUE ENGLAND) What % of injuries were hamstrings? 12% What was the re-injury rate? 12% What muscle group was most involved Biceps Femoris 53% How many hamstrings per club per season 5 How many matches missed per season 15 When did they occur more often In matches and second half Old players, premiership players, Who got them? outfield players and black ethnic players The Football Association Medical Research Programme: an audit of injuries in professional.football.. Woods et al. Br J Sports Med. 2004; 38: 36-41 Monday, 24 September, 2001 Owen 'distraught' after hamstring blow Michael Owen has been ruled out of England's final World Cup game against Greece with a torn hamstring. The Liverpool striker, a hat-trick hero against Germany, would have been a definite starter for England's last group match at Old Trafford on 6 October. Liverpool manager Gerard Houllier revealed that Owen was inconsolable after sustaining the injury against Tottenham on Saturday. "I thought we had seen the last of these problems with Michael, and he is distraught at the moment," said Houllier. AUSTRALIAN RULES FOOTBALL AFL Injury Report: : Season 2006 Dr John Orchard, Dr Hugh Seward, AFLMOA . May 2, 2007 Recurrence rates for hamstrings were over 30% in the late 1990’s. This was 16% in 2006 which was the lowest on record. The average recurrence rate is still in the high 20’s. WHY LESS RECURRENCES IN 2006 IN THE AUSTRALIAN STUDY? Longer rehab? The decrease in recurrences in Australian Rules Football has been paralleled by longer rehabilitation periods in the past few years ( more towards 28 days) and more time for healing and rehabilitation. The table below shows that in Australian Rules you are have a real odds of injuring a hamstring again after rehabilitation, and the odds show that in this study, 12.6% recurred the week back and that 30.6% recurred in that season. WEEKS AFTER RETURN 858 Hamstring Injuries FROM INITIAL INJURY AFL 1992 to 1998 1 12.6 2 8.1 3 6.8 4-5 4.7 6-8 3.1 9-14 2.7 15-22 1.4 Risk of recurrence 30.6% This is part of a table adapted from: The Management of Muscle Strain Injuries: An Early Return Versus the Risk of Recurrence Clinical Journal of Sport Medicine, 12:3–5 Best and Orchard Professional Rugby Union Hamstring Statistics Am J Sports Med. 2006 Aug; 34(8):1297-306. Incidence, risk, and prevention of hamstring muscle injuries in professional rugby union Average Time Lost 17 days Average time lost in recurrent injuries 25 days Average time lost in new injuries 14 days Hamstrings ( Running Injuries) 68% Hamstrings ( Kicking Injuries) 36 days lost TAKE HOME MESSAGE: ADD A WEEK TO RECURRENCES Simply this study suggests that a week must be added if there is a recurrence in games or even training. IS IT WORTH FAST TRACKING REHABILITATION? An OZ study suggests maybe yes, because it all averages out in the end as games lost! “In numerical terms, it is preferable to have the average hamstring strain in a football player return at 3 weeks with a 90% success rate (in the first match back) than for the average injury to take 8 weeks to recover with a 95% to 100% success rate”. Return to Play Following Muscle Strains. Orchard, Best & Verrall . (Clin J Sport Med Volume 15, Number 6, November 2005) Maybe in a team sport one can gamble with players using the above statistics which even out in the end. But for an athlete in with an individual sport, having one hamstring is bad enough, but having a recurrence means you may be heading towards a hamstring history. And the best predictor of getting an injury is having had it before, so beware. Get the first one fixed properly. TAKE HOME MESSAGE: As an individual don’t gamble! HEALING My opinion also is that almost the most important phase of a rehabilitation is the healing phase. Compromise this and you may pay later if nature deals you a bad hand. Adding a day or 2 to the acute ( immobilization) phase and one or two days to the sub acute ( or mobilization) phase might make all the difference. And more importantly don’t go out on the pitch and try it out at day 5. TAKE HOME MESSAGE: Let the thing heal! IS FITNESS TESTING A HAMSTRING DANGEROUS? Functional testing is often discussed when relating to criteria or reasons for return to sport, and I believe testing can sometimes lead to recurrences in games and training if done too early or too fast. So if one tests at 100% with a maximal speed test on Day 17 of a 21 day hamstring program, there is every chance that on Day 21, the player might go into the game in a stage of adaptation to the stress of eccentric exercise as described. ( or read tired hammies ) Q1: Can you safely go 100% speed at Day 17 of a rehab.? Q2: With 3 extra days would that player have improved and be able to go 100%? TAKE HOME MESSAGE: Don’t’ risk everything in a fitness test. EDUCATED JUDGEMENTS and HAMSTRINGS With short rehabilitations ( 14 to 28 days maybe I short? ) I believe educated judgements have to be made at 90/95% of maximal speed and then at least 48 hour rest if possible is needed from those sub-maximal tests. Obviously if one gets time in a rehab, a 100% test is invaluable from a re-assurance point of view and also a specific conditioning perspective. But adaptation and recovery can take up to 7 days for maximal eccentric ( or fast explosive) exercise as many studies have shown. Possible Game Days The game is either the blue dot or the red dot. The blue dot is 6 days after the test Fitness Test and the red dot is 4 days after.You fitness 95/100 % test the athlete at 95/100 % on the training day. Maybe 8 fast strides and 2 agilities and then 30 mins of sports specific training at 90%. Accelerated recovery means you get all your treatment and training and eat well and so on. So if you do that you will be ok for the blue dot. But if the game was the red dot then you would be in big risk of recurrence TAKE HOME MESSAGE: Make sure you have adapted to training sessions before going 100%. DIFFICULT FOOTBALL REHABS: Personal Case Studies. After a recurrence we decided to do a 5 week ( 35 day) program. At day 27 I did maximal speed and agility tests on an athletics track for flying 20m and the player had DOMS ( Delayed Onset Muscle Soreness) for 4 days. He played 8 days later ( Day 35). He may have survived if he had played at day 28, but would have been sore ( DOMS) for days after the game, or he might have recurred due to fatigue from repeating maximum sprints in a game. Who knows! I remember another player who kept running 90% for a speed test and insisted his hamstring was ok. I knew his maximum time. Thus he was operating at 90% of his maximum speed and he was ruled out even though he looked ok to the media and staff and said he was ok. He then admitted later he still had some minor awareness! That’s how fine this is at the elite levels. ANATOMY BICEPS FEMORIS SEMI TENDINOSUS SEMI MEMBRANOSUS From Ischial Tuberosity From Ischial Tuberosity Long Head Biceps To medial side tibia To postero medial side tibia From Ischial Tuberosity Extends the Hips Extends the Hips Flexes the knee and extends the knee Flexes the Knee Flexes the Knee Rotates the tibia inwards & Rotates the tibia inwards & Short Head Biceps more when the knee is more when the knee is From femur flexed.