THE SPORTING HAMSTRING PART 2: RETURN TO SPORT

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There is a lot involved in the decision making process around return to sport / play following any injury. However, injuries with high recurrence rates such as hamstring injuries require a little more care and consideration…

WHAT DOES THE EVIDENCE SAY?
  • Players returning to sport are at greater risk of re-injuring their hamstring during the first three weeks back from injury.
  • A player taking longer than 24 hours to achieve pain-free walking is four times more likely to need more than 3 weeks to return to competition compared to players walking pain-free within 24 hours of injury.
  • Players with a past history of a hamstring strain on the same leg in the preceding season and unable to walk pain free within twenty four hours, have a significant chance of taking four or more weeks to return to play.
  • Players with a lateral hamstring strain and a past history of a hamstring strain are at a greater risk of suffering a recurrence in the first three weeks of returning to competition
THE GRADING SYSTEM
Grade Recovery Symptoms
Grade 1          ~ 3 weeks
  • Overstretching without tearing of muscle or tendon fibres.
  • Symptoms may not present until activity is over.
  • Minimal loss of muscular strength
  • Reported tightness
  • A feeling of pain may be reported with sitting or while walking uphill or ascending stairs.
  • Generally can walk pain free but unable to run at full speed.
Grade 2 ~4-8 weeks
  • Partial tear in the muscle.
  • Muscular strength and flexibility in reduced.
  • Pain is more immediate and more severe than the pain of a Grade 1 strain.
  • Pain on stretch and contraction of the muscle, and is usually sore to touch.
  • Limping is likely during walking and occasional sudden twinges of pain during activity may occur.
  • Bending the knee against resistance will cause pain and there may be some difficulty in fully straightening the knee.
Grade 3 ~3 months
  • Severe or complete rupture of the muscle.  May be a large lump (of muscle tissue) above a depression where the tear is.
  • Sudden, sharp pain in the back of the thigh.
  • Walking is not possible without pain.
  • After a few days with Grade 2 and 3 injuries, a large bruise may appear below the injury site caused by bleeding within the tissues.
  • May require surgical repair.

 

RETURN TO SPORT CRITERIA

The rehabilitation process for hamstring injuries is highly individualised, with physiotherapists and injured athletes working together to address all modifiable risk factors, whilst ensuring their bodies are prepared with exercises that are both sport and conditions specific (eg. speed, agility, flexibility, endurance).

As a result, working on time frames alone is an inadequate measure of readiness for sport. But at what point is each individual safe to return to sport? How strong do they have to be? How flexible? How confident?

There is yet to be a clear consensus developed for a safe return to sport criteria, however testing should address the following:

 

Clinically
  • Strength: mixed ratio (eccentric hamstring strength to concentric quadriceps strength) criteria: <10% difference to uninjured side
  • Flexibility:
    • Active ballistic hamstring flexibility test (often referred to as the Askling-H test): criteria: no insecurity
    • Hamstring length criteria:  <10% compared to uninjured side
  • Palpation-criteria: no pain/ crepitus
  • Patient reported measures: criteria: no pain, discomfort, insecurity
Functionally
  • Single leg hamstring bridge test-greater than 30 repetitions is considered good.
  • Nordic hamstring curls- criteria: no insecurity or discomfort
  • Biomechanics of sports specific movements eg running, jumping, agility, lunging
    • Motor patterning
    • Symmetry
    • Control
Activity Simulation
  • Simulated:
    • Intensity
    • Speed
    • Fatigue
    • Load
    • Environment
  • Criteria: no discomfort or insecurity

 

SUMMARY

Although the grading system can give individuals a rough time frame for return to sport, physiotherapists need to:

  • Address the key factors that have contributed to their injury (see part 1),
  • Prepare athletes to a standard that meets clinical and functional criteria
  • Successfully simulate match/sport conditions
  • Carefully consider their injury history and the evidence available as predictors of re-injury

The high recurrence of hamstring injury indicates that there is a need for further research in this field, in particular, a clear set of return to sport criteria and rehab milestones that can guide therapists in their decision making, and set clear goals for the injured individual.

What the available literature does tell us, is that hamstring injuries and their rehabilitation are highly individualised. Individuals need to work closely with their physio to tailor their rehabilitation and return to sport requirements specifically to their needs.

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