Management of Hamstring Injuries by Physiotherapy



Posted: Monday, March 22, 2010

by Jonathan Blood Smyth

The accurate diagnosis of the injury and the degree of its severity is the crucial factor to be decided initially as this indicates how the injury is to be expected to improve and how long it will be until the patient has functionally recovered. The mainstay of treatment is physiotherapy and the physio has to decide the how to progress the treatment according to the level of tissue injury and the time which has elapsed since the event. There is no effective scientific evidence for managing this kind of injury and the physiotherapist will design the rehabilitation programme individually to suit the particular and variable requirements.

There are three initial phases which hamstring injuries can be classified into: the acute phase, the sub-acute phase and the remodelling phase. There is a different treatment plan and strategy for each phase and the time elapsed since injury. The acute stage can last up to the end of the week since injury and the main aims are to reduce the levels of inflammation, pain and swelling secondary to the tissue damage. Treatment normally follows the PRICE system: protection; rest; ice; compression; elevation. Protection is aimed at eliminating any significantly harmful stresses to the damaged tissues, with the treatment options of using crutches to limit the amount of weight on the leg or bracing the knee in flexion.

Rest has an important protective function to limit the stresses through the injury and this is often difficult to impress on injured athletes. Ice is a first line treatment for tissue injury to give pain relief, applied for around twenty minutes to the area providing the skin remains healthy. Inflammation may also be reduced as the cold decreases the local metabolism of thereby the tendency to deliver more circulatory swelling. Compression is useful to control tissue swelling and may be more useful than the cooling effects of ice which physios often use. Wrapping the limb with elasticated bandages can give the required effect.

Elevation is a very useful technique for many injuries and if the part is raised above the level of the heart then the collection of tissue fluid in the part will be reduced. In the hamstrings this is difficult to achieve due to the location of the injury and may in many cases just not be necessary. Once the pain and inflammation have been brought under control the physiotherapist can start doing gently movements either passively or assisting the active movements of the patient. No stretching is attempted at this stage. If someone has a relatively minor injury and begins to feel much better over a few days they should still be carefully managed.

Six weeks is the typical healing time for soft tissue injuries even if they are minor, so athletes who begin to feel better should be advised to start back to activity in a limited way and progress slowly into range of motion, strength work, balance and stretches to forestall the likelihood of an injury recurrence. The sub-acute phase lasts up to around three weeks from the time of injury and the pain and inflammation should be settling well. Physiotherapists can now progress treatment to active exercises for range of movement and then start to work on muscle strengthening.

Hydrotherapy exercises may be useful in this phase as they allow hamstring exercise without the weight bearing stresses being fully applied to the limb. Patients can take up aerobic training for cardiovascular fitness and upper limb training whilst performing sub-maximal exercises for the injured area. The remodelling phase is indicated as taking the patient forward to the six week point and they should be able to manage isometric contractions at full effort without pain. Now the exercises can be progressed to isotonic (through range), with low weights and higher numbers of repetitions.

The patient starts this process in prone with light ankle weights, progressing to heavier and heavier resistance provided the pain in the injured area is not provoked. The progression of weights should be conservative as too rapid an increase may lead to relapse and a more long term problem. Once the patient has achieved good strengthening with the muscle shortening (concentric contraction) they should be progresses to strengthening with the muscle lengthening (eccentric contraction).

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapist, back pain, orthopaedic conditions, neck pain, injury management and Physiotherapist Leeds. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.
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