1. Nick Mellows BSc (Hons) MCSP Stoke City FC Girls Centre of Excellence

2.  Aims  Anatomy review  Muscle strain  Prevalence  Risk factors  Screening  Diagnosis  Management

3.  By the end of the presentation, you should know: ◦ Relevant anatomy ◦ Risk factors ◦ Screening techniques ◦ Diagnostic techniques ◦ Evidence based management

4.  Bi-articular muscle group  Made up of SM, ST, and BF  Hip extension and knee flexion  Most taught in hip flexion and knee extension  Supplied by the tibial portion of the sciatic nerve ( L4-S3) http://www.pasaloa.com/Hamstring-Muscle-Tears

5.  Definition: A tearing of muscle fibres when they are not able to cope with mechanical demands placed on them  Graded in relation to the amount of muscle fibres affected ◦ Grade I ◦ Grade II ◦ Grade III

6.  The most common injury in football  In a team of 25 players: ◦ 5 HMI’s per season ◦ 80 days lost  Re-injury rates between 12-63% ( Morgan et al 2013)

7.  Most at risk when muscle is lengthening and absorbing load  End of stride/kick  Classified into two main mechanisms ◦ Sprinting ◦ Stretching

8.  H/Q ratio  Decreased hamstring flexibility  Poor pelvic control

9.  Toe touch  Muscle patterning  Pelvic rotation  Strength ◦ Manual ◦ Dynamometer ◦ Cybex

10.  MOI  Pain ◦ Location ◦ Intensity  Palpation  Strength  ROM  Neural

11.  Location ◦ Medial/lateral ◦ Proximal/distal  Gait pattern

12.  Immediate management  Evidence base? ◦ Sherry and Best (2004) ◦ Askling ( 2013) ◦ Heiderschiet (2010)

13.  PRICE  Pain control  Taping?

14.  Stretch  Strengthen  Eccentrics  Return to function

15.  RCT  Static vs Progressive agility and trunk ex’s  Significant differences in re injury at 2/52 and 1 year  No through year analysis  2006 follow on paper

16.  RCT  75 subjects  Lengthening vs conventional protocols ◦ 3 exs per protocol  Significant difference in RTP ◦ L=28 days C=51 days 1 re-injury C protocol H test?

17.  Systematic review  Collated evidence into comprehensive, evidence based rehab program  2 phases

18.  Neurodynamic element ◦ Sliders/gliders  Lumbar spine ◦ Maitland mobes (Szezlak 2011)  Motor patterning

19.  Strengthen ◦ Eccentric  Soft tissue quality ◦ Massage ◦ ART ◦ Stretch  Progressive agility ◦ Sagittal plane ◦ Early  Neurodynamics  Lumbar/pelvic control  VARIETY!!!

20.  Specific  Replicate game intensity  GPS tracking  Variety!!!

21.  Performed as a marker for RTP  Active hip flexion with knee extension  Graded VAS 0-100 for pain Insecurity ROM  Fail= 1-2 weeks further Rx Askling 2013 Askling 2010

22.  Lack of high level evidence base  Not always as simple as it seems  Do more than stretch and strengthen  No standardised, accepted Rx protocol ◦ Brukner et al

23. ?

24.  Schneider-Kolsky ME, Connell DA, Hoving JL, et al. 2006 A longitudinal study comparing sonographic and MR imaging assessment of acute and healing hamstring injuries. Am J Sports Med;34:1008–15.  Warren P, Gabbe BJ, Schneider-Kolsky M et al. (2010) Clinical predictors of time to return to competition and of recurrence following hamstring strain in elite Australian footballers. Br J Sports Med 44: 415-419  O'SullivanK, O'Ceallaigh B, O'Connell K and Khafat ( 2008) BMC The relationship between previous hamstring injury and the concentric isokinetic knee muscle strength of irish gaelic footballers Musculoskeletal Disorders, 9:30  Coombs R and Garbutt G (2002) DEVELOPMENTS IN THE USE OF THE HAMSTRING/ QUADRICEPS RATIO FOR THE ASSESSMENT OF MUSCLE BALANCE Journal of Sports Science and Medicine 1, 56-62  Heiderscheit, B Sherry, M Silder,A. Chumanov, E., Thelen, D. (2010 ) Hamstring Strain Injuries: Recommendations for Diagnosis, Rehabilitation, and Injury Prevention journal of orthopaedic & sports physical therapy 40:2  Askling CM, et al (2013) Acute hamstring injuries in Swedish elite football: a prospective randomised controlled clinical trial comparing two rehabilitation protocols. Br J Sports Med 2013;00:1–8. doi:10.1136/bjsports-2013- 092165

25.  Brukner P, et al. ( 2013) Recurrent hamstring muscle injury: applying the limited evidence in the professional football setting with a seven-point programme Br J Sports Med 2013;0:1–12. doi:10.1136/bjsports-2012-091400  Sherry, M., Best, T. (2004) A Comparison of 2 Rehabilitation Programs in the Treatment of Acute Hamstring Strains J Orthop Sports Phys Ther 34 :3  Askling, C., Nilsson, J., Thorstensson, A. A new hamstring test to complement the common clinical examination before return to sport after injury (2010) Sports Traumatol Arthrosc 18:1798–1803