The HOW and WHY of ‘Pulling’ your Hamstring again
I know it’s early but summer-time is ramping up, and with that you have committed to one or more of the following:
- Spending an extra (possibly dreaded) one-to-two hours with your co-workers per week playing beer-league softball
- Sweating-it-out with the TRIBE crew for the first time at RPM
- Unexpectedly chasing your children around the yard and park
- Watching your child chase around a soccer ball… give me a second to make sense of this one…
Whatever it may be, for some reason you, or your child, returns to your beloved activity and somehow manages to ‘pull’ that hamstring again. And no, it’s simply not because you are older (well, maybe it is a little bit) or less flexible. There are many reasons why, and many ways to avoid this common injury, so let’s get to it!
What is a recurrent hamstring injury and when does it happen?
It is exactly as it sounds, a hamstring muscle strain injury occurring greater than one time on the same leg and muscle. Hamstring injuries in general account for 12-15% of all sport-related injuries, with re-injury rates reported as up to 40%. Subsequent hamstring injuries often are associated with greater injury severity and recovery time in comparison to the first injury, meaning you miss out on more ‘fun’.
Common sports and activities that lend themselves to this type of injury include high-speed sports and those involving rapid acceleration and deceleration (think running to first base in softball, flag football, sprints). Additionally, jumping and kicking activities also put the athlete at higher risk (think soccer and track and field sports). Does your weekly fitness routine include any of these elements? Add that to the list.
What puts us at risk?
Please allow me to delve a bit into what current research tells us. There is no gold standard at this time to classify risk of injury, but the evidence does suggest the following:
– Previous hamstring injury increases risk of re-injury (within 2 years of the first injury) to 13- 63%.1 This is probably the most obvious risk factor but also most important to the clinician in developing a progressive program for the athlete to reduce the risk of future injury.
– Previous anterior cruciate ligament (ACL) reconstruction on the same leg as the initial hamstring injury increased re-injury risk (up to 66%).1 This would be more relevant in soccer players, and even-more-so female soccer players.
– Thigh muscle imbalance (quadriceps to hamstring strength ratio).2 Conflicting evidence here. The general idea is that our hamstrings (muscles in the back of the thigh) need to be able to decelerate the action of the quadriceps (muscles in the front of the thigh) efficiently, which requires both strength and muscle contraction timing.
– Age.1,2 Again, conflicting evidence here. If there is an increased risk it is not as relevant as the above factors… so don’t sweat it, age is just a number.
– Improper warm-up. I’ll be honest, I didn’t find this in my literature review, but anecdotally I have re-injured my hamstring when returning to the field ‘cold’.
So what would we be looking for?
Coming in for a detailed biomechanical assessment will bring you one step closer to avoiding re-injury. Special attention will be paid to the pelvis, hips, and knee given that the hamstring muscles directly affect these areas of the body. Additional evaluation of the foot and trunk is also relevant. Highlighting and resolving biomechanical and strength deficits is something that can’t be done by reading this blog, so please use our expertise appropriately.
And how would we treat this?
Most importantly, every rehab and prehab program is client specific and goal-directed. What we discover in the assessment, in conjunction with your goals, will mold the treatment plan. If there are clear limitations in strength or range of motion (i.e. at the hip, knee, pelvis, or lumbar spine) then these need to be addressed. If a warm-up wasn’t included (shame on me), then education around this is required.
But out of interest, what does the evidence suggest? Interestingly, more evidence is coming out that suggests that agility and stabilization training should be included in the treatment plan (with a reduction of re-injury to 7.7% from 70% when compared to a rehab protocol aimed at leg strength and flexibility).3 What does this mean? It means that we need our core muscles to work like core muscles (provide STABILITY and transfer POWER to our limbs), and we need our thigh muscles to fire in a coordinated fashion when we accelerate, decelerate, or change directions in sport. If we have a weak core, control of our hip and pelvis will rely more on muscles such as the hamstrings and quads (which were designed to MOVE our thigh and not stabilize our thigh).
Lastly, progressive return-to-sport is a critical conversation that needs to occur between the practitioner and you, the athlete. The athlete should be able to demonstrate all skills of their sport before returning to play, have returned to the appropriate level of conditioning to perform, and should likely be able to participate in a team scrimmage in sports such as soccer, symptom-free. It becomes more complex when there are financial incentives (i.e. paid gym membership, elite sport) or upcoming tournaments/games with organized sport.
Thanks for sticking it out! If you have any questions, please comment below.
Jordan is a graduate of the University of Toronto Physiotherapy program and has since been practicing in orthopaedic settings. He has developed an interest in sports physiotherapy through his many years as an athlete, participating in baseball, golf, snowboarding, and more recently rock-climbing, cycling, and strength training. He has worked with a variety of clientele including athletes from disciplines such as competitive dancing, running, rock-climbing, and mixed-martial arts, as well as non-athletes of a wide age range and ability. Regardless of activity level, he is dedicated to improving mobility, optimizing function, and strengthening to help achieve your goals through the use of manual therapy and individualized exercise prescription. He also has additional training in acupuncture and sports taping.
- de Visser HM, Reijman M, Heijboer MP, et al. Risk factors of recurrent hamstring injuries: a systematic review. Br J Sports Med 2012; 46: 124-130.
- Freckelton G, Pizzari T. Risk factors for hamstring muscle strain injury in sport: a systematic review and meta-analysis.Br J Sports Med 2013; 47: 351-358.
- Sherry MA, Best TM. A comparison of 2 rehabilitation programs in the treatment of acute hamstring strains. J Orthop Sports Phys Ther 2004;34:116–25.