Straining the friendship
Our families are often our best teachers when it comes to working through injuries and rehabilitation issues. My partner Michael’s most recent injury, providing me with an opportunity for growth, involved a grade 2 hamstring strain when surfing.
We’re going to explore two different types of Hamstring injuries. Working with the weekend warrior with active overstretch hamstring injuries and some of the passive overstretch injuries or tendinopathies that are commonly seen in dancers and martial artists.
Whenever you deal with an injury whether it be a hamstring, shoulder or neck it is important to understand:
a.) the individual muscles and joints and their functional role in whole-body movement.
b.) your clients desired activities and how they are affected by a specific movement or joint pattern is essential for the development of a movement plan.
The challenging part after an injury is how to grade the load and manage tolerance for movement.
The hamstring group of muscles are part of the deep longitudinal sling, and therefore support the tibialis anterior muscles as part of dorsi flexion and the erector spinae muscles as part of thoracic extension.
Hamstrings are needed for hip extension and knee flexion in various stages of gait. Accordingly your exercise choices are those that support walking, running and spinal extension. How you grade your clients program depends on the mechanism of injury and stage of the healing process, their particular goals and condition before the injury. Mutually respectful work with a physiotherapist is also essential.
Mechanism of hamstring injury
The mechanism for hamstring injuries are classified as trauma, active overstretch and passive overstretch. Each of these are more likely to affect one of the different hamstring muscle group.
A trauma muscle injury may be contact trauma, or surgery. It is not unusual to see cyclists and skiers who have had an avulsion fracture of the ischial tuberosity, resulting in the hamstring being torn. Once a hamstring has been damaged there is a vulnerability to future tears. Direct trauma can also happen as a result of surgeries, for example when an anterior cruciate ligament (ACL) is reconstructed and part of a hamstring tendon is removed to recreate the ligament.
An active overstretch is also known as a ‘deceleration’ injury, because the hamstring is actively slowing the movement of the leg. For example when the hamstring muscle is working eccentricly, but is overcome by the stretching force applied to it and forcibly lengthened. Think what happens when you are running fast and you are about to have a foot strike, that is the stage when the bicep femoris muscle is vulnerable to this sort of injury. It is usually accompanied by the sudden onset of pain and an inability to continue the activity. This is the type of injury Michael experienced when surfing, during a turn.
A passive overstretch occurs when a stretch force is applied to the hamstring muscle with an injury occurring at the limit of range. Commonly seen amongst footballers kicking, or dancers, and generally involves the free tendon of semimembranosus and amongst dancers was also noted to involve quadratus femoris. Even if the force is applied slowly (as in a dancer stretching), there may be a pop associated with the injury. Symptoms may not develop for some hours, or only slowly over time, and may not be more than mild discomfort and dysfunction.
The location of the hamstring strain
The active overstretch or running injury tends to be at the musculo-tendinous junction of the quite lengthy intramuscular Biceps Femoris tendon and adjacent muscle. This type of injury will be close to a good recovery by around 12 weeks.
The closer the injury is to the buttock, think close to the ischial tuberosity, the more likely the injury is to involve a tendon tissue and the slower the rehabilitation. This is more likely to be coming from a passive overstretch injury and can have a much longer recovery program; often around 30-76 weeks. I have worked with a few ballerinas and barre officenados who have struggled with this recovery process.
Remember it is very important that your physiotherapist clear other options – especially when there was not an obvious ‘mechanism’ of injury.
The healing stages
Stage one: Destruction phase, at the time of injury the myofibers and ultra-small blood vessels are torn. You’ll see the start of bruising and an inflammatory cell reaction lasting for the first few days following injury.
Pain management is essential as it can inhibit movement, especially walking. This can mean that both stretching and sitting need to be avoided in the early days. As a damaged muscle will impact on the tendon it is important to manage tensile and compression loads.
Stage two: Repair phase, begins a few days after injury and peaks around two weeks post-injury. It allows regeneration of the myofibers, and simultaneous production of a type of collagen for early scar tissue. This is when your client should be doing some small movements at home, under the guidance of their physiotherapist. It is good to get a list of their exercises from this stage, because you will see how they inform your exercise progressions when the client comes back to the studio.
If there is a ‘passive stretch’ injury, the function loss for the person will be in flexibility, then active rather than passive stretching is ideal. Active exercises would be those designed to increase the range of motion (hip flexion with different extension angles at the knee). For this type of injury, it’s recommended to consider foam roller or trigger point work rather than stretching as the latter places both a tensile and compression load on the tendon.
When working with hamstring injuries it is important to remember that the muscle attaches to the pelvis and therefore will impact lumbo-pelvic control/ stability. This means you will need to add lumbo pelvic focus to your class through low load and low speed and NOT in the same plane in which the hamstring injury occurred. Progression of this work would focus on speed, intensity, and into the sagittal plane. Gentle pain-free eccentrically focussed exercises, what pilates is famous for, to accelerate recovery (this is not quicker healing, but functioning at a higher level with less pain). It’s important to note that whilst the client might be feeling quite good at this stage, healing is still in the early days and is vulnerable to further injury.
For example at this stage the client will be doing things like:
Towel leg slides (we know this from our pre pilates work)
Ball supported leg slides and side to side
Standing towel leg extensions
Wall slide/ mini squats ( with a quad focus)
Some spinal mobility
You are not wanting to have load or resistance on the affected areas at this stage because the muscle fibres are not able to withstand forces, and could easily tear and prolong recovery.
Stage three: Remodelling phase, begins two to three weeks following injury and involves the production of scar tissue. Regenerated myofibers are maturing and scar tissue is re-organised and contracts, and the functional capacity of the muscle recovers.
The client should start walking without pain and add in some work on a stationary exercise bike, at around week three. At around week four and definitely by week six, your client will be coming back in a private or semi-private setting. It will probably be around week 12 when your client will be returning to sport, but I would still be taking it moderately carefully at this stage building up strength and endurance, particularly in your older clients, who in general will have slower healing times. With high-level athletes there is often a much faster return to sport, and they are managed by a team of health professionals.
Exercise choices in the first eight weeks include:
Starting at no resistance we progress to some very light resistance with mainly a quad focus at the start of any home program. This would include:
· Wall squats
Feet on a fit ball pressing the legs in and out, and towards the end of the eight weeks start with a modified shoulder bridge, foot on the ball
Seated press outs (sit on the Reformer carriage with feet on the floor and no springs progressing to seated on a long box and feet on the foot bar with a light to medium spring setting)
Seated on a Wunda chair at the end of a CoreAlign, feet slides progressing resistance.
Standing leg work (wall lunges with a ball pressing into a hip for stability)
Spinal rotation movements and
Ankle range of motion movements for example using the Makalu.
Stage 4: Sports or activity specific.
At this stage, you would be progressing your client in a way reflective of their goals.
In the case of ‘active overstretch’ injury the exercise program is gradually progressed to high-level agility and sport-specific drills, high-level eccentric work, possibly including Nordic curls. The recovery program also progresses to include high-speed eccentric conditioning (sprinting or jump board work), as well as emphasising varying trunk movements during running or on the CoreAlign (for example upright posture, forward flexed, forward flexed and rotated).
For the ‘passive stretch’ injury, return to activity will be slow, with a high risk of recurrence. It is important for your client to understand that gradual pacing will improve their recovery and reduction of reinjury. With this type of injury, tendon rehabilitation is likely to be part of the plan. Continued graduated increase in both tensile and compressive forces is essential for hamstring recovery.
As with any musculoskeletal injury respect the healing process of the injury, work collaboratively with the physiotherapist and use the opportunity to build your relationship with your client and their goals. And finally relish the learning opportunity.
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To learn more and see exercises and interesting progressions - the hamstring injury course can be found here. Carla is the co-director and co-owner of Body Organics and Body Organics Education. Find out more bodyorganicseducation.com/