HAMSTRING STRAINS

INTRODUCTION Members of the sports medicine team for League 2 side Morecambe FC explain their approach to the prevention and treatment of hamstring injuries. They stress the importance of determining the possible underlying causes especially pelvic alignment and muscle imbalance with a subsequent effect on the sciatic nerve and its influence in the kinetic chain and the effects of differing playing surfaces. The importance of hydration and rest in maintaining maximal muscle function is stressed whilst acknowledging that the evidence base for most interventions is limited. In particular video gait analysis and measurement of possible leg length discrepancies are discussed with the prescription of orthotics if necessary. A more holistic approach is taken with the addition of an oriental medicine practitioner. Together this multi-disciplinary approach has substantially reduced the incidence of hamstring injury at the club.

By The Morecambe Football Club Medical Staff

Morecambe Football Club are in their first season in the Coca Cola Football League, but the club have been full time for a number of years and have a multi-discipline sports medicine team including a club doctor, a chartered physiotherapist/sports massage practitioner, podiatrist and oriental medicine practitioner. The club has been successful in reducing the amount of hamstring injuries over the last couple of seasons and the following article gives each member of the sports medicine team’s perspective.

THE MULTIDISCIPLINARY PERSPECTIVE A CLUB DOCTOR’S PERSPECTIVE The hamstring strain is a condition all people involved in sport can recognise. Such injuries are a major cause of time lost from sport. Hamstring injuries account for about 10% of injuries in football. Of these biceps femoris injury accounted for over half. Players are 2.5 times more likely to sustain a hamstring strain than a quadriceps strain during a game.

It is important when assessing an injury to take a history, watch a replay of the injury on video (if available) and examine the injury. If the hamstring pain came on gradually and was not a sudden sharp loss of function it is important to think of neural pain as a cause of the posterior thigh pain. It is easy to appreciate that an acute disc prolapsed at the L5/S1 level may present with hamstring and/or calf pain and limitations in flexibility, which may mimic a muscle strain. Many predisposing factors for hamstring strain have been suggested in the literature. The factors listed below are looking at a hamstring injury rather than referred posterior thigh pain: ■ Insufficient warm up ■ Poor flexibility ■ Muscle imbalances (quads to hamstring strength ratio of greater than 60%)

■ Muscle weakness ■ Neural tension ■ Fatigue (most hamstring injuries occur at the ends of the match/training sessions)

■ Dys-synergic contraction of muscle groups (separate innervations of short and long head of biceps femoris) ■ Previous injury (re-injury rate is 10%).

All of these factors need to be addressed if hamstring injuries are to be prevented. It is important at a football club that the

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coaches are aware of the role of a warm up in the preparation of the muscles for activity and that appropriate stretching also takes place. Hydration is very important in maintaining optimum functioning of muscles. In pre-season it is important to look at the day to day load of aerobic/anaerobic training so that muscles are appropriately loaded on a regular basis and that tiredness does not cause injury. Coaches need to understand the value and importance of rest days.

The evidence to substantiate these speculations is minimal and conflicting. The same holds true for the management and treatment of hamstring strains. There is no consensus on optimal rehabilitation, hence management

anecdotal evidence and experience rather than evidence based practice.

CHARTERED PHYSIOTHERAPIST/SPORTS MASSAGE PRACTITIONER PERSPECTIVE Physiotherapists working in football clubs often complain that one of the most common injuries they have to deal with is to the hamstrings. Pain often presents itself in the hamstrings due to a biomechanical load from another area that is not functioning cor- rectly. Even the worst scenario when a hamstring is injured dur- ing explosive sprinting during a game or training, the underlying cause may well be biomechanical, and unless that cause is addressed, the problem may become recurrent. Quite often, the precursor is a hamstring that feels tight or feels difficult to stretch; again the cause is usually biomechanical.

These biomechanical dysfunctions can either be skeletal or muscular, and as a physiotherapist in a football club working on a daily basis with players, these are two areas, which must be investigated and treated regularly to aid with the prevention of hamstring lesions.

Often these biomechanical causes are due to incorrect alignment of the pelvis, and if the pelvis has rotated the piriformis muscle may go into a protective spasm. This effectively prevents the hip joint from functioning correctly meaning that other areas have to compensate. It is also important to consider synergistic action of the gluteus maximus and adductor magnus and their role as powerful hip extensors. Weakness in either the adductor or gluteus maximus will result in an increased load on the

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