Case study – Rehabilitation and Performance Enhancement

Hamstring injury in a professional football player - Management and return to play strategies.

Summary
Following a FA cup match, a 29 year old professional footballer reported significant discomfort in his left hamstring. The injury was sustained within the first 10 minutes of the match while attempting to hook the ball out of play. He reported a tightness develop in the posterior thigh but continued to play as he thought it was a cramp. Although he could perceive the discomfort especially during long kicking, he completed the match. The initial clinical assessment indicated some degree of upper lateral hamstring damage.

This case study will focus on the subsequent assessment, rehabilitation and the strategies allowing for the earliest return to play without re-injury and to be able to participate at the same or an improved level.

Introduction

Hamstring injuries occur frequently in sport (12% in football) and result in a significant loss of playing time (Woods, Hawkins, Maltby, Hulse, Thomas & Hodson, 2004). The hamstrings are important in speed production, hip extension, paradoxical knee extension in the stance phase, deceleration of the lower leg during the swing phase (Wiemann & Tidow, 1995), and aid in pelvic stability (Panayi, 2010). The most commonly injured region is the proximal myotendinous junction of the bicep femoris and is normally non-contact (Koulouris & Connell, 2003). A hook kick; hip flexion, adduction and internal rotation with knee extension was reported and seems to indicate a reasonable mechanism of injury.

It is reported that hamstring injuries have a high recurrence rate (Orchard & Seward, 2002) and there is strong evidence to suggest that muscle weakness (Proske, Morgan, Brockett & Percival, 2004), past hamstring injury and age (Arnason, Sigurdsson, Gudmundsson, Holme, Engebretsen & Bahr, 2004) are pre-disposing intrinsic factors for hamstring injury. The relevant information pertaining to this player’s susceptibility to injury includes his age as well as his quadriceps to hamstring strength ratio and his flexibility, measured in an earlier assessment, may have contributed to this injury. Although he has no history of hamstring problems in the past, it is important to consider as this may be a predisposing factor for future injuries. The type of warm-up (Junge, Rosch, Peterson, Graf-Baumann & Dvorak, 2002) and player fatigue (Woods, et al., 2004) may also increase the risk of injury and interestingly on this occasion the warm-up was shorter than normal due to the bus arriving late and five players reporting tiredness a day earlier following a tight grouping of games

It is important to determine the extent of the injury early as well as to discuss any differential diagnosis. The challenge is to distinguish between a low grade hamstring strain and other non-specific pathologies (Turl & George, 1998). Failing to identify the correct cause may result in prolonged rehabilitation time or premature return to play resulting in recurrent injury.  

Assessment

The initial 48 hours following the injury remained uneventful. The player was advised on the importance of ice and compression as well as early mobilization but avoiding stretching and pain (Orchard, Best, Mueller-Wohlfahrt, Hunter, Hamilton, Webborn, Jaques, Kenneally, Budgett, Phillips, Becker & Glasgow, 2008). Due to the limited evidence pertaining to the use of non steroidal anti inflammatory drugs (Petersen & Holmich, 2005) immediately in acute muscle injuries, a mild analgesic was prescribed to assist early mobilization.

The main aim at the initial assessment was to take a history and examination to determine the extent of the injury as well other potential factors contributing to this problem. The player presented with a hyperlordotic lumbar spine and an apparent anterior pelvic tilt. A bilateral reduced range of motion was observed in his hip flexors, as well as a locked left sided sacro-iliac joint. There was a palpable hypertonicity and sensitivity over the lateral portion of the muscle with reduced active and passive range of movement as well as mild reduction in strength (4/5) with some discomfort. However the most remarkable feature was the neural tensioning straight leg raise which was highly sensitive in the hamstring compared to the other side. All other test were found to be unremarkable.

Due to the sudden onset with moderate pain and marked tenderness, further investigation was recommended. Diagnostic ultrasound can be helpful but a MRI seems to be more sensitive and also allows for an estimated return to play time (Koulouris & Connell, 2003), which is very useful in a professional sports environment. Prior to the receiving the MRI results, the working diagnosis was an acute grade I strain with some neural tissue involvement with associated lumbar-pelvic issues. The results confirmed a grade II myotendinous junction injury of the long head of biceps femoris with fluid around the sciatic nerve (Appendix 1, 2 & 3). A plan for the rehabilitation was established with an estimated time frame of 4 – 6 weeks until return to training.

Intervention with Clinical Reasoning
Following the initial 48 hours early resumption of activities was initiated. The evidence suggests that initial loading in a controlled, protected range is important during the early repair and remodelling phase (Sherry & Best, 2004) as well as progressing to jogging as soon as possible (Heiderscheit, Sherry, Silder, Chumanov & Thelen, 2010). The criteria the author selected as ‘return to jogging’ markers included pain-free bridging and full active knee extension while Heiderscheit, et al., (2010) includes normal walking without pain and pain free isometric contractions against submaximal resistance as well. These were achieved at day five at which point a progressive jogging programme was started. Although the evidence regarding soft tissue work and stretching is varied, regular massage and stretching sessions were undertaken as part of the general rehabilitation programme. Manual therapy consisting of Maitland mobilization and MET were used to reduce the thoracolumbar and left sacro-iliac joint restrictions as well as to assist in reducing the anterior pelvic tilt (Panayi, 2010).  

A progressive running programme was implemented as soon as possible to allow for a graded return to fitness (Heiderscheit, et al., 2010). With clear guidelines, it provided the author with an objective measure of player development and allows the player to grade his progression based on similar yet slightly more difficult, incremental tasks. The player’s progression was unremarkable, if slightly slower than expected. Sherry & Best (2004) showed that progressive agility and trunk stabilization decreased the recovery time and significantly reduced the rate of injury recurrence. Early change of direction movement and progressive plyometric activities were included in the rehabilitation programme to fully load the injured tissue and assist in improving the neuromuscular coordination. While general strength training may assist in recovery, specific loading with a focus on eccentric muscle action seem to provide the greatest benefits (Brooks, Fuller, Kemp & Reddin, 2006). Eccentric activity in the late swing phase is considered highly vulnerable in high speed running. By using eccentric high load exercises, it effectively allows the hamstring to work at a higher torque. The player struggled with these activities and although an improvement was observed, he was significantly below expectation at six weeks.    

As would be expected, the injury would prevent the player from participating in regular training sessions and thus susceptible to detraining effects (Mujika & Padilla, 2000). Together with the fitness coach, a conditioning programme was developed around the limitations of the injury (Dooman & Jones, 2009). Upper body and single leg strength and power activities were selected as well as bike and pool based activities to work different energy systems, maintaining leg speed and general fitness. Core and flexibility sessions were undertaken in an attempt to improve on vulnerable areas in an attempt to offset future injuries and improve performance. The return to sport criteria, were attained at six weeks post injury. The limiting factor for an earlier return was the sensation of adverse neural tension likely associated with the fluid surrounding the sciatic nerve.

Outcome

The outcome of this case was fairly uneventful. The player participated in a reserve fixture on Tuesday, few days over six weeks post injury. He played particularly well in his normal position and only reported some general stiffness the following day. The player was selected to play the next first team fixture; however the game was postponed due to snow. The two weeks leading up to the following game were unremarkable and no further problems have been reported since.

Discussion

The available literature shows that hamstring injuries are common is sport however there are still best practice inconsistencies (Goldman & Jones, 2011). There seems to be correlation between the rehabilitation programme and recovery rate as well as recurrent injury rate (Heiderscheit, et al., 2010). Strong evidence links age and previous injury; however this case study indicated that a combination of risk factors may lead to hamstring strains.

The evidence suggests, early loading and mobility are key, however it is important to manage the pain especially in the early stages of the injury. Although it is important to return to normal loads as quick as possible this needs to be introduced over a reasonable time frame to allow for tissue adjustment. A progressive running programme, core, agility and specific strength training allow for a graded return from injury as well as developing the components to cope with the load sustained by the local and surrounding tissue during high level activity. While risk elimination is unreasonable to consider, longer rehabilitation significantly reduces the recurrence rate (Orchard & Best, 2002).

Conclusion

Hamstring injuries occur regularly within athletic populations and while some of the risk factors are unavoidable it is important for the therapist to consider all of these factors. The evidence seems to suggest that rehabilitation programmes may have a significant effect on the short and long term outcome. And while clear guidelines can assist in directing the process, therapist intuition is vital in minimizing the risk while still working within a reasonable time frame, especially in a sports environment.

References

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Brooks, J.H.M., Fuller, C.W., Kemp, S.P.T. & Reddin, D.B., (2006). Incidence, Risk, and Prevention of Hamstring Muscle Injuries in Professional Rugby Union. American Journal of Sports Medicine. 34, 1297-1306. doi:10.1177/0363546505286022. Accessed: 07/06/2011.

Dooman, C.S. & Jones, D., (2009). Down, but not out: In-season resistance training for the injured collegiate football player. Strength and conditioning journal. 31, 59-68.

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Heiderscheit, B.C., Sherry, M.A., Silder, A., Chumanov, E.S. & Thelen, D.G., (2010). Hamstring strain injuries: Recommendations for diagnosis, rehabilitation, and injury prevention. Journal of Orthopaedic & Sports Physical Therapy. 40, 67-81.

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Panayi, S., (2010). The need for lumbar-pelvic assessment in the resolution of chronic hamstring strain. Journal of Body work & Movement Therapies. 14, 294-298.

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Proske, U., Morgan, D.L., Brockett, C.L. & Percival, P., (2004). Identifying athletes at risk of hamstring strains and how to protect them. Proceedings of the Australian Physiological and Pharmacological Society. 34, 25-30.

Sherry, M.A. & Best, T.M., (2004). A comparison of 2 rehabilitation programs in the treatment of acute hamstring strains. Journal of Orthopaedic Sports Physical Therapy. 34, 116–125.

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Woods, C., Hawkins, R.D., Maltby, S., Hulse, M., Thomas, A. & Hodson, A., (2004). The Football Association Medical Research Programme: an audit of injuries in professional football—analysis of hamstring injuries. British journal of sports medicine. 38, 36-41. doi: 10.1136/bjsm.2002.002352. Accessed: 08/06/2011.