BANG! “Like a golf hitting my thigh”, “I thought the opposition player had kicked me”, “ It was like being shot!”
Just a few of the descriptions that are presented to us when someone has torn their hamstring.
Anecdotally recurrent and career ending in athletes from the recreational to the elite if not rehabilitated appropriately and even then can be tenuous.
Hamstring injuries have plagued the careers of top athletes such as; Cyril Rioli, Harry Kewell, Dante Exum and Darius Boyd. Why are these structures so difficult to rehabilitate, how has technology played a part in their rehabilitation and when is it just too early to return to running?
That is what we will cover in FootNotes Publishing newest article.
The hamstrings act upon 2 joints being the knee and hips. The semimembranosus and semitendinosus extend the hip during trunk flexion in addition to flexing and medial rotating the lower leg when the knee is bent.
The biceps Femoris extends the hip during the initiation of walking as well as flexing the knee and laterally rotating the lower when the knee is bent.
Below is a table breaking down the functions of the hamstring group:
| Muscle | Origin | Insertion | Action | Innovation |
| Semimembranosus | Ischial tuberosity | Medial Condyle of tibia | Extension of the hip and flexion of the knee | Sciatic n. |
| Semitendinosus | Ischial tuberosity | Pes anserinus (tibia) | Extension of the hip and flexion of the knee | Sciatic n. |
| Bicep Femoris | Ischial tuberosity and linea aspera (femur) | Head of the fibula and lateral tibial condyle | Extension of the hip, flexion and lateral rotation of the knee | Sciatic n. |
| Adductor Magnus | Pubis, Ischial tuberosity | Linea aspera and adductor tubercle of the femur | Adduction of the hip and extension of the hip | Sciatic n. and Obturator n. |
The Intramuscular tendon is an aponeurotic structure continuous of the tendon that extends within the muscle belly. The Intramuscular tendon acts as a supportive strut of which the muscle fibres attach. They are different from the free tendon as they function in the effective transmission of contractile force where as free tendons work in the storage and release of energy.
Identification, clinical relevance and the difference in prognosis of a muscle strain associated with the IMT have only recently been understood. For one, the rehabilitation of an IMT is less predictable than that of a free tendon. It is associated with a delayed
return to training and return to sport, this is commonly due to assessment not being able to reproduce the tensile and elastic demands required for sport leading to an over confidence in the tendon’s rate of healing.
When assessing or re-assessing a suspected hamstring IMT injury a number of tasks to be used to put the tendon through its expected requirements to see if healing and regained strength and function have returned.
The following exercises should be completed with specific assessment for focal pain or cramping, pain during these exercises should not be accepted, however, tightness can be.
- Supine Bridges –advance to a “drop and catch “ progression.
- Straight Leg or Bent Leg Raise – Increase speed of execution
- Palpation of the Intramuscular tendon to assess for tenderness
The presence of cramping can be catastrophic or trivial however, does correlate with the presence of an IMT injury with focal cramping at the site a common occurrence and an indication of potential re-current injury.
Goals of Rehabilitations
The first step is gathering as much information as you can from the athlete and the coaching staff about how the injury took place. The second is figuring out exactly which tissues have been affected and the physiological time frames around their ability to heal after a state of trauma. The third step is sitting down with the player, the coach and the allied health group to put a time return to performance time frame in place to which rehabilitation periodization can be attributed too.
Step One:
Who was involved? (Single person, teammate, opposition player)
What was the mechanism of injury? (Moment in play, build up, A:C workload)
When did the injury occur? (Game, training, gym/ start, mid, end, finals season)
Where is the site of injury? (Specific of the injury, IMT, tendon, muscle belly)
Why did the injury occur? (Not prepared, over worked, contact, moment in time)
How long do we prevent it in the future? (S&C, footwear, orthotics, position)
Step Two:
Developing clear guideline around the tissue, which has been damaged, and the physiological timeline of which that tissue needs to heal. This may be anywhere from 1 – 85+ days dependant on the severity of the injury and the tissues involved. Furthermore, it should be stressed that this is just for physiological repair of the tissues not inclusive of return to performance.
Step Three:
Developing realistic goals with the required rehabilitation participants including; the player, the coaching staff, strength and conditioning team and the medical staff. Taking all the previous information into consideration helps to realise the time frame required for return to play. Return to performance may be reached at the same time, however, variables such as minutes played; game readiness and mental preparation play a 
significant part.
Each person within the athlete’s support community will have their own specific goals or wish list of what the want to achieve in the athletes rehabilitation process – however everyone’s joint goal is getting the athlete back to a pre-injury state.
- For the medical/allied health team it is primarily about regaining body function, comfort and basic strength as well as putting in place extrinsic interventions for the prevention of future injury.
- For the strength and conditioning team it is about building and preparing the athlete for the worst possible scenario affiliated with the chosen sport.
- For the coach it may be ensuring the athlete is prepared for a specific game or event that has been scheduled.
- For the athlete it may be about returning to full performance as fast as possible.
Once all has been established it is time to work backwards!
When is our planned return to play date and how long do we have to work toward the end goal of being prepared for the worst-case scenario?
What is the requirement of not only the injured tissue but also the surrounding tissues which all work in conjunction to achieve high performance?
Knowing the requirements how then do we train them to get to the state of event readiness?
When preparing an injured athlete for return to performance it is important to understand what is required from the athlete in a game, the role of the targeted tissue in that game and how your chosen training modalities work in preparing the tissue for that role. The following components need to be trained in a relation to the hamstring for rehabilitation purposes:
- Tissue Capacity: Tissue capacity refers to a tissue’s ability to express tissue load through exercise, movement, or posture.
- Neuromuscular Control: Neuromuscular control is defined as the unconscious trained response of a muscle to a signal regarding dynamic joint stability.
- Strength: The ability of a muscle to produce maximum amount of force.
- Speed: The rate of which an object or athlete moves.
- Power: Is the ability to produce maximum force at a fast rate.
- Agility: The ability to change the body’s direction efficiently.
- Endurance: Ability of a muscle to produce force continually over a period of time.
Knowing these components and how they interact and relate to the athlete’s performance on field is important when structuring them into a rehabilitation program. In many cases one component may progress while others progress then regress as the athlete continues their rehabilitation.
It is important to be aggressive with rehabilitation programs especially while being performed in a controlled environment such as the gym or indoor training centre so the athlete is prepared for the inclusion of more environmental variables to their program as early as possible in their rehab process.
Strength training is important for the improvement of tendon maturation. It contributes to increased collagen thickness, improved cross-links and the orientation of collagen parallel to stress.
Programming:
The structure of a rehabilitation program can be just as important as the exercises prescribed and how they are coached. Taking advantage of physiological and physical adaptions to training principles can be the small difference in returning a client back to performance weeks or days earlier than expected.
Ensuring that activities that benefit from significant neurological input are not performed under fatigue is vital for the development of movement patterns and habitual actions when under fatigued in game day situation.
Tendon rehabilitation specialist and researcher Jill Cook recently tweeted an image demonstrating the steps of rehabilitation before return to play.
Demonstrated were the following training methods:
- Isometric Loading
- Strength Development
- Function Strength
- Plyometric
- Return to Play
The image shows a step-by-step process in a progression toward an end goal. Absolutely this is what we wish to achieve, however, as mentioned previously these individual principles can be both progressive and regressive in their time of rehabilitation. All four primary principles can be trained at the same time with individual goals being set for each – the end goal being return to play.
When developing a short time periodised rehabilitation program, the easiest place to begin is at the end.
What activity/exercise do you expect the athlete to be able to complete before their return to training where variables are more in number and less controlled?
What progressions do they need to complete to get to that point?
And at what point do you introduce running to their program?
Until Next Time
Jackson McCosker
Chief Editor/ Director
FootNotes Publishing 