Expert Interviews Hamstring Strain
Neal Reynolds has worked as physiotherapist to Premiership and England International teams. Here he discusses how a full time professional team might approach the treatment of achilles tendon injuries.
Susan Findlay teaches sports massage at the North London School of Sports Massage. She explains how massage can aid in the recovery of achilles tendonitis.
Recovery times and prevention
Things are written all the time about recovery times, especially for hamstring strains. I tend to think about anything up to 3 weeks for a grade 1, anything from between 2 and 8 weeks for a grade 2 hamstring strain and you are looking at pretty much 12 weeks for a grade 3. It can be anything within that. I have had someone come back from a grade 2 hamstring strain within three an a half weeks and I have also had players who take eight weeks to recover from a hamstring strain.
With a grade 1, some of them can only take a couple of days then others will take a little bit longer so it varies considerably. There are a lot of things that can influence it but I do say if you can get that initial stage of treatment right this can have a large influence on the rehab time you are looking at.
I think it is important that they carry on doing continued maintenance work. That is where I would bring strengthening in but you want to strengthen both hamstrings together and you get them so the right is equal strength to the left so there is symmetry. So they would carry on and carry on strengthening when they are back to full training.
It is very easy when you go back to playing sport and you think that's it and the injury is over but it is well known that it takes up to 12 months if not more than that for a scar to be completely remodeled so it acts like it did in the past. However, it is never going to be the same. If you get a moderate hamstring strain that is never going to be exactly as it was before. It is going to act like it but it is never going to be the same so it is quite important that you keep educating that scar and keep putting different stresses through it for months and months afterwards and maybe even years.
It is a good habit to get into that if you get an injury you work and continue to work that muscle afterwards. Nordic curls is an exercise we would use for continued maintenance. That is the exercise that tends to have the most evidence in terms of injury prevention and post injury.
Early stage treatment
All muscles trains are much the same in the early stages. First thing is to get an idea of how severe the injury is. The initial stages are much the same whatever the severity, but more severe injuries will require longer periods of treatment. Ice and compression should be applied straight away.
Neal believes that compression is just as, if not more, important than ice. This should be for 20 minutes as soon as the injury occurs to stop the bleeding as soon as possible. Another aim is to get into the inflammation stage and out the outer side as far as possible. After this the injury is assessed to determine the severity.
Electrotherapy can work best if applied in the earlier stages. After the first 24 hours, Neal would use ultrasound, or pulsed short wave therapy and then laser. This would continue for the first week. Ice would also continue for the first week, and then be changed to using hot and cold alternating.
Neal recommends not applying sports massage too early in the injury as there is bleeding so you don't want to make this worse and also it can be pretty sore to touch. After 4-5 days, he may do is very light effleurage to try to take some of the waste products away and break up the forming blood clot. Gradually the amount of massage and the pressure used is increased. This helps to develop a good quality scar - modeled into the right shape and form so that it acts like a muscle later on.
Stretching and strengthening for hamstring strains
Stretching we would bring in fairly early but completely pain free. So probably at the end of the first week I would start to stretch the hamstring muscle to get a little bit of elasticity into the muscle. Scar tissue forms within 2 or 3 days so you have to try and get a little bit of elasticity into the scar and to the muscle so it doesn't contract.
In terms of hamstring strengthening exercises I tend to focus more on what I call load. Reason being I think if you have a grade 1 injury so a very mild hamstring strain what I am looking to do is slowly put more and more load through that muscle and through the scar. So all all you are trying to do is get some tensile strength going through that scar so it becomes stronger and stronger so eventually it can withstand the load when you are doing normal sporting activities.
I would start doing isometric strengthening to start with. I would still follow the pattern of isometric, isotonic then isokinetic then get into eccentric strengthening exercises. I also use eccentric exercises earlier but at a much more gentle lower level. All the time I am thinking about getting a better quality scar. I am not really thinking about strengthening the muscle. I am thinking of getting the tensile strength within the scar.
We would start off doing a little bit of strengthening early on, probably 5 or 6 days following injury. This is the very early stages and everything must be pain free. Although eccentrics usually comes in at the end I would include a little bit early on for example manual eccentrics where the therapist provides the resistance with the athlete lying on their front resisting the hamstring down from flexion to extension. This is done though at a very low level.
Sports massage can help in treating hamstring strains. It helps to lengthen the muscles if they need to be lengthened out. In some cases this is not necessary. Sports massage can rectify compromises or dysfunction by flushing out the tissue, lengthening it, making it softer to prevent tears.
The hamstring is an area which tends to need regular maintenance. When the injury is in an acute state, RICE is applied and either immobilisation or active rest. Sports massage isn't usually applied until there is no pain on touching the area. At this point, the massage therapist can go in and flush out waste products, address any adhesions in the muscle or realign tissues and look at the muscle balances.
Massage does benefit this injury. Regular maintenance can help prevent the injury returning. Often people ignore a minor injury, it gets better so they continue and then it tears worse. It's better to address the initial injury.