Hamstring Injury: The Role of Strength Training

http://www.amazon.com/StrengthHamstring-Muscular-FunctionsInjuries/dp/1616681756

Kieran OSullivan SMISCP

Aims
1. Reflect on what we do 2. Provoke discussion..100% agreement? NO recipes!

You?
Flexibility / Stretch Strength Core Functional rehab / FMS / SAQ PRICE (POLICE?) More?

Hype v Science
Hamstring injury is like hip fracture!

Contributing factors for hip # ?

What constitutes evidence?

Cryotherapy baths / chambers DOMS v pain / injury! Hyperbaric oxygen? Electrotherapy? always a new one! Decompression chambers? Platelet-rich Plasma / Autologous Blood Injections better than nothing.no better than useful treatment Arnica?

Sound familiar?

ASK: Compared to? no treatment / ineffective treatment? Cant do any harm? As an adjunct maybe?

1. The promising report 2. Professional adoption 3. Public acceptance 4. Standard practice 5. Randomised clinical trials 6. Professional denunciation 7. Extinction

Today; What happened?

Discriminate between; What is known What is likely What is debatable What is highly unlikely

Mechanism of Injury
Poor control of eccentric action Usually late-swing early stance Was ms at end-range when injuredso what happened?

The big non-modifiable factors

Previous injury
2-6 times more likely to recur Most re-injure within 8/52 (not all) 1 year post-injury still 3 times as likely Minor injury doubles the risk of having a more severe injury within two months

Age
>23 years!! Cant change but consider when screening!

Diagnosis + prognosis
Diagnosis NOT complex!

Prognosis re RTS (once injured)

Previous injury Age BF injury Area of injury (prox free tendon?) Pain at time of injury is NB predictor (> our estimate!) If cant walk pain-free (not necessarily normally) within 24 hours, 4 times more likely to need > 3/52 for RTS If this combined with prev hams injury 93% chance of not returning to competitive action in < 3/52 >200 deficit in AKE ROM > 3/52 ...OR >300=6/52 OFF!! Amount of damage (MRI)?

Prognosis depends on; 1.Degree of muscle damage (affects time until

return and recurrence in severe cases)

2.Area of the muscle affected (worse if BF injury

or close to ischial tuberosity (esp prox free tendon)

So MRI?

High-tech??????

Contributing factors
Non-strength factors briefly

Flexibility & Stretching

Athletes with injury history less flexible Flexibility usually does NOT predict injury SS V DS: Flexibility/ST v performance Flexibility & performance v injury limited evidence stretching helps injury mgt ?? adjunct treatment, but not an alternative to (eccentric) strengthening based on the evidence Are there other ways to address feelings of tightness?

Core / trunk muscle dysfunction

Hams injury altered activation / strength of hip & trunk ms Sherry & Best: PATS training better than VERY BASIC rehab programme Control group had 70% recurrence! Did not analyse trunk stability pre/post what changed? Not yet compared to helpful treatments NB: performance v injury! Prior et al 2009 (SR): functional testing . poor association with hamstring injury..

Functional Rehab
FMS Neuromuscular control Movement discrimination Proprioception

Meaning? Are the best treatments functional.are functional treatments necessarily good?

Functional Movement Screening (FMS)

7 tests (scored /21) Overall assessment of strength & n-musc control Good reliability Related to risk of overall injury in sports & firefighters Justifiable > passive assessments++ Assesses ability to load Functional for everyone? Knee / ankle v hamstring?

Balance training: Kraemer & Knobloch 2009

Benefit related to number of training hours - ? Transient?

The 11

Functional Rehab: Summary

Altered motor control / proprioception may be a predictor Helps reduce risk of (overall) lower limb injuries Improves N-musc control and performance No evidence of superiority over established strengthening programmes Adv: done through-season Disadv: load too low for hamstrings? Compliance low like most programmes.

11 simple exercises (10-15 mins) Done everyday in training Reduced injury rate (esp non-contact) Not effective for all Link coaching (p)rehab Compliance related to success

Multi-dimensional programmes
Verrall et al Combination of anaerobic interval training, sports-specific training drills, and stretching when fatigued signif reduced hams injury v previous seasons Which part actually helped? ? Indicates role of fatigue & flexibility Work in trunk flexion long length rehab+ for hams BUT..effectiveness of this approach has not been compared to (eccentric) strengthening protocol Ethnicity

Other factors
Hip strength (Sugiura et al)
Anaerobic fitness (Verrall) Lumbar / pelvic dysfunction Warm-up: performance v injury Fatigue: More injured at the end of each half / late in training session (load?) Many more proposed

Hamstring Strength
Terminology: PT PT ratios PTAng

Strength after injury

PT might be altered PT ratios might be altered

PTAng (almost) always different !

Hams AngPT: Brockett et al

UL

Signif for ecc only (sample size / ecc more sensitive) No other sig differences (besides AngPT)

Can we see trouble coming?

Strength as a predictor
Not a great predictor either! (some yes / some no) No studies of PTAng as predictor Most have only studied PT, and done this pre-season (too early?)

Or is it just bad luck?

Schache et al 2010

Effects of strength training

Does it reduce the risk of injury? Same for all strength training modes? What is it changing is it increasing strength (PT), altering AngPT or what?

Still playing / training pre-injury ?subtle damage ?inhibition? ?RPE

After damaging strength exercise

EIMD 2nd shift in PTAng = sarcomerogenesis (animal studies, US in humans, L-T curve) protective effect against future 2nd shift in PTAng damage Damage related to poor load tolerance, and progressive damaging exercise reduces future damage Protection greatest if; Eccentric Longer muscle lengths Longer contraction times

This damage is good for us!

Inflammatory / healing response.. is this something we want to stop? Mechanical stress adaptation v failure (similar for bone / tendon / muscle) Adaptation - cellular +/- structural

Does strength training reduce the risk of injury?

Gabbe et al
2 seasons Severe programme season 1 (effective, very poor compliance) More gradual programme season 2 (ineffective, better compliance) Not continued through season either time

UNTIL THIS YEAR

moderately effective rate of injury lower after (demanding) hamstring strengthening incorporated, than in other seasons Adding strength training to existing programme (e.g. stretching) reduces injury RCT results mixed But Compliance poor / pre-season only

Petersen et al 2011
Best outcomes of all studies so far Key? through-season & compliance 50 Danish soccer teams (942 players) Control usual training (& some eccentric) Intervention through season! Less injuries (52 v 15) with eccentrics NNT to prevent 1 new injury is 25 NNT to prevent 1 recurrent injury is 3

Is it only eccentric that can help?

NO, but eccentric probably most helpful Concentric (or mixed conc/ecc) also helps Esp at longer lengths ROM NB - not just the mode of ex! Continue until values normalised Avoid conc exercise at short lengths (harm!)

Non-injury effects of eccentrics

improved LL strength & performance increase in 30m running speed Increased flexibility, without reducing intramuscular stiffness (stiffness = good)

Mechanism ??? - Shifting PTAng most likely?

Flexibility & PTAng

Traditional Nordic

Nordic
most common, and evidence they help BUT non-functional position relatively short hams length / FROM hard+ bilateral - ? dominance bias / ? side-side asymmetry not good predictor poor reliability LBP?

Other eccentric options

Razor curls Watch labelling of exercises Plenty more . Video clips Find one that matches demands!

Lunch demo!

Strength
Not great at predicting injury (even nordic) ?strength testing 1/52 in advance? ?monitor PTAng (or PT at length) > PT Aim increase tensile load capacity. adaptation in response to load (bone, muscle, tendon)

Practical Training Considerations

DOMS+ compliance (in prof athletes!) Appropriate baseline & progression Start on strength asap (isometric, duration, strength at length) Part of training / MUST damage muscle a bit! Progress to painfree dynamic Strength fxnal strength SAQ & function Include some eccentrics at long ms lengths FITT early v late (increased injury risk during ecc rehab) Loading schedule during week (heavy / medium / light
training monotony!)

Transient

ongoing eccentric load (Coach NB)

Conclusion
Eccentric strengthening can 1.reduce the rate of hamstring injury 2.improve performance 3.improve hamstring strength / flexibility / PTAng Best programme? in-season & compliance Incorporate functional tasks SAQ

Osteoporosis: Hip #
Principles: e.g. osteopenic hip Increase load tolerance vitamin d, calcium, WB ex, smoking, caffeine Reduce risk of sudden, unexpected high load balance, medications, hip protectors Related Risk factor: Load

Load
Most injured in pre-season or early season ? return to activity (even if different injury) Psych rest v tissue unloading??

Load: monitoring
Player and coach education NB Excess load (e.g. volume / rate of increase) assoc with illness, reduced performance and msk injury

Methods External load e.g. reps/sets/miles ran Internal load e.g. HR / lactate RPE (e.g. simple 0-10) 1. Training load = RPE per session x duration 2. Training monotony = avg load / SD load (high/mod/low) 3. Training stress = weekly load x monotony

Schache et al 2010 how was load being managed?

Load
Not only external load how does body absorb load? Posture / mvt / technique

Still playing / training pre-injury ?RPE ?subtle damage ?inhibition?

Hamstring tendinopathy
History & pain location differ to hams strain S&S typical of LL tendinopathy Pain & function (hams strain painful?) Pathology disordered tendon structure Treatment normalise tendon structure How?....wait for it to settle?....or increase load capacity?

Acute injury management

PRICE / POLICE
Intuitive Cold yes Analgesia yes Quicker return ?? Less recurrence??

Acute management
Remember the most relevant factors;
Realistic timeframe NB+ (Prognosis) Prevent further damage Normal load / movement asap (rel R & exercise) Inflammation is good (usually) NSAIDs? I/C/E debatable (in my opinion ) e.g. EIMD inflamm healing protective response adaptation resistance to injury!

Acute injury management

Manual therapy ? Electrotherapy? Cryotherapy baths / chambers Hyperbaric oxygen PRP / ABI Always a new cure electro / exercise / lotion / potion Evidence?

Summary
Restore ability to tolerate load! Strength.at longer lengths Anything that helps that is a bonus Any (modifiable) contributing factors? e.g. training load (pre-season / return to sport) multi-disciplinary role

Consider again!
What is known What is likely What is debatable What is highly unlikely

The End!
ACKNOWLEDGEMENTS

UL Physiotherapy dept Research collaborators HRB References & Courses: http://advancedmusculoskeletalsolutions.blo gspot.com/

10

Questions?
Kieran OSullivan
SMISCP, MISOM, M Manip Ther, B Physio Glenstal Physiotherapy Clinic, Murroe, Co. Limerick 087 4179050 Physiotherapy Department, University of Limerick. 061 234119 Email: kieran.osullivan@ul.ie

Extra slides on strengthening exercises

Eccentric curls
http://www.youtube.com/watch?v=XJIq4cvzjDg Nordic (early): - ? Static http://www.youtube.com/watch?v=atq9WerCXs4 Mid nordic: http://www.youtube.com/watch?v=PsLmEdum2x M&NR=1 Slower nordic: http://www.youtube.com/watch?v=GBfHwWX6la k&NR=1 http://www.youtube.com/watch?v=JlMCDT4Ksg M

Eccentric options

Razor curl http://www.youtube.com/watch?v=nB6RzVvflIY Modified razor curl http://www.youtube.com/watch?v=WUJyOo-hAzU ?the more functional position of the razor curl does, indeed, achieve activation of not only the hamstring muscle group but also the gluteus medius and maximus (Oliver & Dougherty 2009) ? partial body-weight support (early and late-stage)

Mimic OKC? (function, load?)

Strength training: Physio tools?

Supine conc/ecc http://www.youtube.com/watch?v=8PwOB0kEOHg Romanian dead lift (tx spine?) http://www.youtube.com/watch?v=PnBREGM7pE0 Single-leg dead lift http://www.youtube.com/watch?v=7eACTTzeh-E lx-pelvic control?

11

Other recommendations: Heiderscheit et al 2010

Types of contractile load

Speed of movement? External load Conc / ecc / isom SSC / plyometrics?

All needed? One most relevant?

Ecc box-drops Box lunge-drops Weighted lunge-drops Towel-pulls Resisted pushes HEP v incorporating into training? Consider SSC!

12