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Recurrent hamstring muscle injury: applyingthe limited evidence in the professional footballsetting with a seven-point programmePeter Brukner,1 Andrew Nealon,1 Christopher Morgan,1 Darren Burgess,1

Andrew Dunn2

Additional material ispublished online only. To viewplease visit the journal online(http://dx.doi.org/10.1136/bjsports-2012-091400).1Departmernt of SportsMedicine and Sports Science,Liverpool Football Club,Liverpool, UK2North West MusculoskeletalImaging, Liverpool, UK

Correspondence toDr Peter Brukner, c/- 158 UnityBuilding, 3 Rumford Place,Liverpool L3 9BW, UK;[email protected]

Received 8 July 2012Revised 11 December 2012Accepted 17 December 2012

To cite: Brukner P,Nealon A, Morgan C, et al.Br J Sports Med PublishedOnline First: [Please includeDay Month Year]doi:10.1136/bjsports-2012-091400

ABSTRACTRecurrent hamstring injuries are a major problem insports such as football. The aim of this paper was to usea clinical example to describe a treatment strategy forthe management of recurrent hamstring injuries andexamine the evidence for each intervention. Aprofessional footballer sustained ve hamstring injuriesin a relatively short period of time. The injury wasmanaged successfully with a seven-point programmebiomechanical assessment and correction,neurodynamics, core stability, eccentric strengthening, anoverload running programme, injection therapies andstretching/relaxation. The evidence for each of thesetreatment options is reviewed. It is impossible to bedenite about which aspects of the programmecontributed to a successful outcome. Only limitedevidence is available in most cases; therefore, decisionsregarding the use of different treatment modalities mustbe made by using a combination of clinical experienceand research evidence.

INTRODUCTIONHamstring muscle injuries (HMIs) present one ofthe greatest challenges for those working withathletes and are known to be the most commoninjuries in sports that involve high-speed runningsuch as athletics,1 cricket2 and the various footballcodes.38 Recurrence levels are high, ranging from12% to 63%.46 912 The rst month after returnto play (RTP) is the highest risk time for recur-rence,4 13 though the risk remains elevated for atleast 12 months.9 14 15 Despite a rapidly expandingbody of the literature investigating HMI in recentdecades,16 there has been no signicant reductionin HMI rates in professional sport17 18 and recur-rences typically cost the athlete more playing timethan primary injury.10 17 19 HMIs are heteroge-neous, making their prognosis difcult to predict20

and there is no consensus on a single clinical orfunctional test or imaging investigation that pro-vides strict criteria for safe RTP.21

A recent systematic review of risk factors forrecurrent HMI determined that only ve prospect-ive studies fullled its inclusion criteria and con-cluded that no risk factor could be judged ashaving strong or moderate evidence (box 1).22

Evidence for addressing modiable risk factorsincludes hamstring muscle strengthening and effect-ing change in associated properties such as ham-string:quadriceps (H/Q) strength ratios andoptimum angle of peak torque36 for which reliabil-ity for the different measures varies.37 38

There is little evidence regarding the efcacy ofvarious treatments for HMI. Recent reviews of inter-ventions for acute hamstring injury39 40 includedonly three randomised studies that included time toRTP as an outcome. No paper studied the same inter-vention. Consequently, clinicians are obliged to con-sider the evidence that is available in conjunctionwith their own clinical experience and apply it to theindividual case in determining the particular treat-ment regime to be implemented.41

The aim of this paper was to use a clinicalexample to describe a treatment strategy for themanagement of recurrent hamstring injuries andexamine the evidence for each intervention.

CLINICAL PRESENTATIONA 26-year-old professional footballer rst sustainedan injury to his right hamstring when sprintingduring a match. Clinically42 and radiologically43 hepresented with a grade 2 biceps femoris musculo-tendinous junction strain (gure 1). Intermuscularhaemorrhage tracking around the sciatic nerve wasnoted.Past injuries included left adductor strain

18 months prior; left soleus strain 18 months prior;left proximal hamstring tendinopathy 17 monthsprior; right knee grade 3 medial collateral ligament(MCL) tear 16 months prior; right Achilles reactivetendinopathy onset 8 months prior and leftadductor strain 6 months prior.

Treatment includedRICE followed by soft tissue massage, stretching,core strengthening, progressive agility and neuro-muscular control exercises, a graded running pro-gramme and an isolated hamstring strengtheningprogramme with specic emphasis on eccentricexercises. He returned to full-team training (RTT)21 days postinjury, RTP 30 days postinjury andthen played the next three games without incident.Two days after his third game, when the player

was walking, he experienced a gradual onset of pos-terior thigh pain. Clinically, he presented with agrade 1 hamstring strain that was MRI negative. HeRTT 7 days postinjury and RTP 16 days postinjury,playing a full game without incident. The playerthen went on holiday for a month which involvedlong periods of travel, sustained sitting and minimalexercise.On returning to preseason training, he com-

plained of tightness in his right hamstring fromthe second day of training, worsening until day 5when he was withdrawn from training reporting

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more intense discomfort after kicking a ball in shooting forgoal. Clinically, he presented with a grade 1 hamstring injurythat was conrmed on MRI (gure 2) to be more medial,towards the epimysium and not continuous with the scar tissuefrom the initial injury.Given the players history of lower back pain, symptoms of

tightness on the right side and a feeling of general restrictionthroughout the lumbar spine, an epidural corticosteroid injec-tion was performed at L45 followed by 2 days of complete restfrom physical activity.Postinjection the player reported a general improvement in

his feeling of freedom on the right side and felt able to swinghis legs through fully into hip exion when running for the rsttime since the onset of hamstring stiffness on return to pre-season training. However, following a long drive (>3 h) 5 dayslater he reported a return of his posterior thigh and lumbarspine restriction. He was treated similarly to the initial injury,RTT 10 days postinjury and RTP 21 days postinjury, playing afull preseason friendly game without incident.

Five days later he started another pre-season game. After5 min, he sprinted with the ball and crossed the ball with awhipping action and immediately felt some tightness in his ham-string, without an associated feeling of tearing or pain, and wasthereafter unable to sprint with condence. He left the pitchand again presented clinically with a grade 1 injury. SubsequentMRI was reported as a small grade 2 injury (gure 3). Thisinjury was again within the long head of biceps femoris muscle,at a similar level, but not continuous with the site of any previ-ous injury.

Figure 2 Axial T2-weighted image with fat saturation showinginterfascicular oedema (arrows) centrally reecting grade 1 injury, inthe long head of biceps femoris.

Figure 3 Axial T2-weighted image with fat saturation showing smallregion of muscle bre disruption (arrows) reecting grade 2 injury,involving the long head of biceps femoris with myofascial oedema.

Figure 1 Axial T2-weighted image with fat saturation showing smallregion of muscle bre disruption (arrows) reecting grade 2 injury,involving aponeurosis of long head of biceps femoris.

Box 1 Risk factors for hamstring muscle injury

Primary injuryIncreasing age3 9 14 2328

EthnicityBlack African or Caribbean12 and Australianaboriginal27

Previous injurymajor knee injury (eg, ipsilateral anteriorcruciate ligament reconstruction, independent of graftselection27 29 and history of osteitis pubis27

Higher level of competition12 27

Later stages of football matches5 12 30

Hamstring muscle strength imbalance prole31

Recurrent injuryHistory of Hamstring muscle injury3 14 15 23 2628 32 33

Larger volume size of injury as measured on MRI34

Grade 1 injury10 35

2 Brukner P, et al. Br J Sports Med 2013;0:112. doi:10.1136/bjsports-2012-091400

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After this fourth episode the player underwent a more pro-longed and intensive rehabilitation which included progressionsbased on the percentage of normal running activity in a game(accelerations, repeated efforts, total distance and high-speeddistance). The strength programme had an even greater bias oneccentric hip and knee dominant hamstring strength exercises.He RTT 25 days postinjury and RTP 34 days postinjury as asubstitute coming on late in the game. Despite extensivelywarming up prior to joining the play, after 2 min he acceleratedat medium intensity and felt some hamstring pain. He playedthe few remaining minutes but was unable to sprint. Clinically,he presented with a grade 2 strain but MRI showed only a smallmyofascial tear (gure 4). The player had completed a fullweeks training prior to this game including repeated maximalsprinting and match play situations at full intensity.At this stage, the player had sustained ve hamstring injuries

in 5 months, none very severe clinically, all of which had under-gone a routine yet comprehensive rehabilitation and gradedRTP programme that had been successful with other players.Table 1 summarises the episodes of hamstring injury.

InvestigationsBetween the fth episode and RTP, a number of additionalinvestigations were performed, including a standard lumbar andposterior thigh MRI; an upright lumbar MRI with standing,sitting and lumbar exion views and nerve conduction studies,all of which were normal. Isokinetic assessment was conducted22 days after the nal episode using a Biodex 3. After familiar-isation, the player completed ve maximal efforts of concentricknee exion and extension from 0 to 90 knee exion at 60/s.The results demonstrated right hamstring strength>left(142 Nm vs 128 Nm, 10% asymmetry); right H/Q ratioleft (24 vs 23).

THE SEVEN-PART MANAGEMENT PLANThe clinical challenge was to identify and address any possiblefactors that may have contributed to the recurrences, and toreview and modify the rehabilitation programme accordingly.Potentially relevant risk factors and modiable hamstring muscleproperties are noted in table 2.It was decided early in this injury management to prolong the

rehabilitation period to enable a higher volume of interventionand loading. Given the lack of evidence on known univariaterisk factors, we investigated a range of other issues that theavailable evidence and our collective clinical experience sug-gested may be contributing to elevated risk of reinjury.

Biomechanical assessment and correctionA biomechanical assessment included review by a sports podia-trist. Signicant ndings included asymmetrical ankle jointdorsiexion (L=7.5 cm vs R=9 cm on dorsiexion lungetesting)45 46 and a positive Trendelenburg sign47 on the rightside with associated internal femoral rotation on treadmill gaitanalysis. Pelvic assessment was suggestive of a slight anteriorrotation of the right ilium with associated functional leg lengthdiscrepancy (left approximately 5 mm longer than right).The player was tted with custom-made semirigid orthotics

to address the 5 mm leg length discrepancy. They were worn inboth trainers and football boots from the start of the rehabilita-tion programme. Specic hip abductor and lateral trunkstrengthening exercises were increased into his programme.Osteopathic manual therapy was started aiming at achieving a

sustained resolution of the anterior tilt of the right ilium. Initialmanipulation of the ilium was performed by an osteopathic spe-cialist in Germany. Further sacroiliac joint (SIJ) manipulationwas undertaken on a weekly basis and combined with specicstretches of the posterior chain. Other manipulations performedincluded right anterior astragalum (anterior-external position),anterior bula head, internal hip, anterior iliacum and horizon-tal sacrum, T11-L2, T7-C1 level and rst rib (right side) andoccipital-C1-C2.

NeurodynamicsAlthough adverse neurodynamic signs were not objectively iden-tied clinically or radiologicallySLR and slump test had at alltimes been consistently equal and within normal ranges as wererepeated normal lumbar MRIsthe player continued to com-plain of symptoms consistent with a neural contribution to hispresentation. Relevant complaints included prolonged sitting,especially while driving, causing numbness and aching in theright buttock and posterior thigh. The player also complainedof a general restriction in the right side during swing phase ofhigh-speed running and kicking, and an asymmetrical feeling ofheaviness on the right side when fatigued. These symptomswere addressed in two ways.The rst epidural (L4/5) resulted in an immediate resolution

of these neural symptoms. However, the player felt that theeffect wore off after 45 days which coincided with a long carjourney in which the player had been sitting for 3 h. It isunclear whether the effect of the epidural had indeed worn offrapidly, or if it had been mechanically counteracted by sustain-ing the provocative sitting and exed position. Due to the initialsuccess of the epidural and unknown inuence of the prolongedsitting and exion on negating its effectiveness, a second epi-dural was performed between the fourth and fth episodes,with a more prolonged rest period followed by strict instruc-tions on avoiding any periods of prolonged sitting.The initial rehabilitations included mobilising the neural

structures within the posterior thigh via sliding techniques48

complemented by mobilising and releasing areas along thecourse of the sciatic nerve. This included passive accessorymobilisation and manipulation of lower lumbar segments,manual release and stretching of the hip rotators, intermuscularmobilisation of the hamstring muscle group and mobilisation ofthe proximal tibio-bular joint due to its close proximity to thecommon peroneal nerve.As these techniques were components of the previous failed

rehabilitations, a more aggressive neural mobilisation approachwas started incorporating an SLR-biased technique sensitised

Figure 4 Axial T2-weighted image showing interfascicular andmyofascial oedema (arrows) reecting grade 1 injury, involving the longand short heads of biceps femoris.


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Table 1 Summary of features of each hamstring injury episode

Clinical severity42 Imaging severity43 (and interventions)

Episode

Days untilnextepisode Onset In Mechanism

Clinicalgrade

AKEdeficit

Days towalkpainfree Grade Site

Distance fromischialtuberosity44

Daysto RTT

Daysto RTP

Eccentricstrengthsessionspre-RTP

Teamtrainingsessionspre-RTP

Gamesmissed

Gamesplayed tonextepisode

1 46 Sudden Match Sprint 2 15 2 2 Longhead

11.7 cm 21 30 6 5 3 3

2 49 Insidious Themepark

Walking-2 dayspostgame

1 0 1 0 N/A N/A 7 16 5 4 1 1

3 27 Suddenongradual

Training Kicking (shooting atgoal)

1 0 1 1 Longhead

23.6 cm 10 21 7 4 N/Apreseason

1

Day 1: epidural #1

4 35 Gradual Match After longhigh-speed run

1 0 1 2 Longhead

27.9 cm 25 34 11 7 4 0

Day 17: Epidural #25 Sudden Match Low speed run

2 min after 81 minon bench

1 0 2 Myo-fascial tear Shorthead

28 cm 28 38 12 7 5

Day 5: lumbar routine,sitting and upright MRIcommence aggressiveneural slidersDay 10: actovegininjections

4BruknerP,etal.BrJ

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with internal hip rotation, adduction and dorsiexion. This wasapplied daily with a dosage of 310 repetitions.

Core stability/neuromuscular control/lumbar spinestrengtheningThe players core stability programme was redesigned. The pro-gramme included a combination of global core type exercises;control exercises with an emphasis on transversus abdominisand internal oblique recruitment and reformer-based Pilatesexercises with the aim of combining lumbopelvic control withdynamic recruitment of the hip extensors and hamstringmuscles. The player continued to participate in the squad injuryprevention programme, a multistation session conducted twiceper week before training. These sessions comprise a circuit ofproprioceptive, neuromuscular control, core stability/strengthand a varied lower limb strength exercise.Core strengthening was supplemented using Document Based

Care (DBC; www.dbc-clinic.com) core strengthening machineswhich have been designed to isolate the specic musclesinvolved in trunk core stability through a series of specicloaded exercises incorporating the main global lumbar move-ments (extension, rotation, exion and side exion) while limit-ing movement and activity in the muscles around the hips andthoracic spine. Exercises on the DBC machines were completedevery other day from week 2 of the rehabilitation.

Increase strength in hamstrings with eccentric-biasedprogrammeEccentric strengthening should form an essential part of anyhamstring rehabilitation programme19 49 and the player wasexposed to this early in all the rehabilitations. Initially, this wasin the form of manual eccentric strengthening exercises com-pleted prone on the plinth in three sets of six repetitions with

maximal pain-free effort. From week 2, the player completed a1-in-3 day-strength programme which included both hip andknee dominant hamstring exercises. The programme includeddouble and single leg reverse dead lifts, Nordic hamstring exer-cises with variations of hip angle, high box step ups, YoYo y-wheel hamstring exercises50 and slide board hamstring curls in abridge position.In the nal failed rehabilitation, the player completed 11

strength sessions; in the latter rehabilitation the number ofstrength sessions was similar (12) with a similar volume of eccen-tric strength exercises. The signicant difference was an increase inthe number of exercises which focused on faster speed of contrac-tion at longer hamstring muscle lengths such as drop lunges (hipdominant) and single leg cable sprinter kick outs (knee dominant).

Overload running programmeHamstring rehabilitation protocols typically involve incrementalprogression of running speed with supplementary conditioningwhen appropriate. The total running and non-weight-bearingtraining load is usually progressed based on standard weeklytraining distances and high-speed running intensities. Duringthe players previous HMI, this type of running progression wasadministered, with the player RTT after completing variousobjective assessments.Running load was signicantly increased during this latter

rehabilitation. The programme was designed to overload theplayer with high-speed running to provide greater exposure toexcessive eccentric loads during this specic movement.51 Itcomprised eight sets of 3 day cycles with consecutive days ofrunning followed by a day of off legs conditioning (pool train-ing). The rst of the two running days was progressed over the24-day period based on both the maximum running speed andthe players individual training and match high-speed runningand accelerations/deceleration requirements.The second of the two running days was a submaximal

running session based on the players maximal aerobic speed(MAS).52 This session (48100 m at 120% MAS or 6 m/s)was, therefore, conducted eight times and this not onlyimproved the players aerobic running power but also served asa regular tness test. As the session was standardised, close heartrate (HR) and Heart Rate Variability (HRV) monitoring deter-mined the players adaptation to this standard protocol duringthe rehabilitation.Table 3 demonstrates the programme.The programme was monitored using GPS tracking which

provided data on variables including total distance, number ofhigh-speed efforts, high-speed metres and accelerations/decelera-tions during training sessions.53 In conjunction with video-basedtracking of matches (Prozone), this provides an objectivemeasure of each players standard week in terms of trainingand match loads. From this standard week incremental load per-centages can be calculated.

Table 3 Summary of the running overload programme

Cycle 1 2 3 4 5 6 7 8

Day 1 50%speed+match

60%speed+match

70%speed+match

80%speed+match

85%speed+match

90%speed+match

95%speed+match

100%speed+match

Day 2 MAS/assess MAS MAS MAS MAS MAS MAS MASDay 3 Bike Off Pool Off Bike Off Pool Off

MAS, maximal aerobic speed.

Table 2 Currently proposed risk factors after episode 5

Non-modifiable risk factorsHistory of HMI Yes: five episodes in 5 monthsAge>23/24 Yes: age 26Black African/Caribbeanethnicity

Yes

Past ACL/major knee injuryhistory

No: as per definition in study but Gd 3 MCL18 months prior

Past osteitis pubis No: as per definition in study but bilateralSportsmans hernia repair 8 years prior

Modifiable hamstring muscle propertiesBilateral hamstring strengthasymmetry>8% (REFS)

No (injured side strength>uninjured side)

Concentric H/Q ratio

Injection therapiesThe player consulted an international physician 5 days after thelast episode. The physician concluded that this HMI was notserious and that abnormalities in the lumbar region were con-tributing to the reinjuries. He injected a number of sites withlocal anaesthetic followed by a mixture of Traumeel andActovegin. Injections were performed in the lumbar regions cen-trally, over the facet joints and the iliolumbar ligaments bilat-erally and the right SIJ. Three similar injections wereadministered into and adjacent to the HMI site.

Stretching/yoga/relaxationThe player started regular sessions of yoga-based stretching andrelaxation with a qualied DRU yoga instructor. These consistedof DRU fascial warm-up techniques; intense hamstring and lowback stretches; guided DRU relaxations and DRU breath train-ing (techniques to improve lung capacity, stamina and to activatethe relaxation response through the body). Sessions were under-taken for 60 min twice per week. The player soon reported sub-jective improvement in his hamstring freedom.

OUTCOMEThe player RTT 33 days postinjury and was deemed availablefor selection in 39 days. He then RTP 42 days postinjury. Heplayed 33 out of a possible 42 games until the end of theseason. He missed seven games with a ruptured plantaris butdid not miss any due to hamstring problems. He continued thistreatment regime at maintenance level during this period.

DISCUSSIONHistory and recurrence riskThere are a number of possible causative links between theplayers previous injuries and this series of HMI. These includedright knee grade 3 MCL rupture 16 months prior. Managed con-servatively and despite causing no knee symptoms since RTP, per-sistent laxity may induce a subtle change in knee biomechanicsduring end-stage swing phase. It is possible that incompleterehabilitation from the players right adductor strain 18 monthsprior may increase load on the lateral hamstrings to compensatefor medial weakness. However, the player has not had anyadductor symptoms since the injury and his objective signs onpreseason screening54 55 were within normal ranges.54 55

Right Achilles tendinopathy pain earlier in the season mayhave resulted in altered running mechanics and reduced plantarexor power though this was not specically measured. Theplayer had proximal left hamstring pain 17 months prior report-ing a similar feeling of restriction during swing phase whenhigh-speed running. Investigations of the lumbar spine at thattime showed no abnormality and he was diagnosed with prox-imal hamstring tendinopathy. The symptoms of pain soonresolved, but a feeling of restriction persisted for approximately1 year.

SEVEN PART MANAGEMENT PLANSeven interventions were performed following the fth episodeof HMI. There are varying degrees of evidence for theseinterventions.

Biomechanical assessment and correctionA signicant association between functional leg length asymmet-ries of greater than 1.8 cm and approximately four times greaterrisk of HMI has been demonstrated in professional footbal-lers.56 Leg length asymmetries have also been associated with

innominate bone rotation, anteriorly on the side of the shor-tened and posteriorly on the side of the lengthened limb57. SIJdysfunction has also been reported to be associated with glutealhip extensor weakness in patients with lower back pain, com-pared with patients with lower back pain without SIJ dysfunc-tion.58 Elite sprinters who subsequently sustained HMI alsodemonstrated reduced concentric hip extensor strength relativeto uninjured sprinters.59 These ndings suggest that there maybe a relationship between SIJ dysfunction, gluteal hip extensorweakness and HMI.Despite treatment restoring the normal load transfer patterns

on dynamic pelvic girdle testing during active straight leg raise insupine60 and in weightbearing,61 62 the player consistentlydemonstrated a small leg length asymmetry. Despite this asym-metry being considerably less than 1.8 cm56 and within normalvariance and measurement error,63 64 given the circumstances ofthe players recurrent injury history, custom-made orthotics wereprescribed to correct this asymmetry. They were immediately welltolerated and remain a component of the players overall manage-ment regimen even though their specic effect is incalculable.The anatomical relationship between biceps femoris, which is

also the most commonly injured of the hamstring muscles,65 andSIJ stiffness has been demonstrated.6669 Several authors have alsodemonstrated the relationship between SIJ dysfunction and altera-tions in load transfer throughout the pelvis via leg asymmetriesduring walking,70 altered muscle activation timing and strengthincluding earlier hamstring activity onset during functional move-ments and compromised pelvic stability.58 71 72 Subjects recoveringfrom HMI have similarly been shown to demonstrate earlier ham-string activity onset when preparing for single leg stance,73 sug-gesting a common trend of altered neuromuscular control betweenpatients with SIJ dysfunction and hamstring injury.However, it appears that this relationship between SIJ dys-

function and the hamstrings relates to muscle activity onsettiming58 rather than the muscle length as was proposed.67 Thehamstring length has also been shown not to be associated withthe degree of lumbar lordosis or anterior pelvic tilt in severalstudies7477 despite excessive anterior pelvic tilt being suggestedto be associated with HMI.12 78

SIJ dysfunction has been reported in subjects with HMI7981

though the inter-rater reliability of many of the tests used isknown to be poor79 with almost all subjects including controls inthese studies identied as having some level of dysfunction.While Cibulka et al80 claimed that SIJ manipulation resulted inan increase in hamstring peak torque measured isokinetically, sig-nicant methodological aws undermine the interpretation ofthis outcome40 and further research is required to validate therole of SIJ manipulation in the treatment of the player withHMI.71 It is also important to differentiate between studies diag-nosing SIJ dysfunction and those based on identifying the SIJ as apain source using a combination of manual pain provocationtests.82

Asymmetries in hip joint ROM have also been associated withSIJ dysfunction in patients with lower back pain83 and pelvicinnominate tilt has been reported to alter following SIJ manipu-lation.83 Future research is proposed to investigate the effects ofa pelvic belt on injured hamstring function.84 Despite thecurrent lack of clarity in the evidence, the theoretical basis formanual therapy to treat clinically diagnosed SIJ dysfunction jus-ties consideration in the management of the player with HMI.

NeurodynamicsNeural tension has been shown not to be a risk factor forHMI28 in two prospective studies in Australian Rules


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football.14 25 However, its relationship with hamstring exibil-ity48 85 suggests that such sub-threshold risk factors maycombine to increase the recurrence risk. Neural tension hasbeen shown to limit movement and increase stretch resistancewhen compared to hamstring exibility measures without addedneural tension with this attributed to the extensibility of theneural tissues.85

Adverse neural tension, dened as a positive slump test86

reproducing the players posterior thigh pain, subsequentlyreduced by cervical extension, was present in over half of asample of rugby union players with a history of two or more clin-ically diagnosed grade 1 HMI in the past 2 years. This contrastedwith no positive tests in age, gender and rugby position-matchedcontrol subjects.87 Despite this there was no difference in ham-string exibility between groups. The authors suggested that theproximity of the sciatic nerve to the hamstrings implicates scar-ring potentially compromising the normal mobility and nutritionof the sciatic nerve. This suggests that clinical signs of adverseneural tension, or more aptly neurodynamics as proposed byShacklock,88 can persist beyond functional recovery.Research has shown that including slump stretching in the

rehabilitation of AFL players with clinically diagnosed grade 1HMI and a positive slump test resulted in fewer missed matchesprior to RTP.89 Sciatic nerve slider exercises have also beenshown to immediately increase lumbar exion and slump testROM in comparison to hamstring muscle stretching in isolationin a small pilot study of young footballers.48

Shacklock88 suggests that the primary mechanical fault in thesubject with positive neurodynamic tests may be one of reducedsliding (neural sliding dysfunction) which implies a lack ofmobility rather than excessive tension. Despite the player con-sistently demonstrating clinically acceptable symmetrical rangesand absence of symptoms on SLR and slump testing, his historyand symptom of a lack of freedom when running at high speedsuggested a neural component to his presentation. Following themost recent HMI more aggressive and frequent neural mobilisa-tion techniques were included in the players managementregimen, particularly immediately prior to training and playing.The rate of MRI-negative scans for clinically diagnosed HMI

ranges from 14% to 45%.12 17 27 35 65 9092 This relativelycommon clinical presentation implies a referred posterior thighpain subgroup of HMI.27 The origin of the neural supply to thehamstring and posterior thigh implicates the lumbar spine andits neurodynamics to the lower limb as a potential source ofpain referral and injury risk.Orchard93 proposed that subtle extraforaminal lumbosacral

canal impingement of the L5 nerve root may be associated withthe increasing age predisposition trend of hamstring and calf injur-ies in AFL players although injury rates of muscle groups suppliedby nerve roots L1-4 show no propensity to increasing age.94

Several interventions attempted to address any possible con-tribution from the lumbar spine. Positive clinical experienceshave been reported with imaging-guided corticosteroid injec-tions to the region of the lumbosacral canal in athletes withrecurrent hamstring problems, both as treatment for acute painand a prophylactic intervention for high-risk players.93 Epiduralsteroid injections have also been shown to be effective in achiev-ing and sustaining rapid RTP in American footballers with acutelumbar disc herniation shown on MRI.95

While the effectiveness of such injections seems greatest inathletes with MRI-negative hamstring or lower limb muscleinjury presentations, the frequency and minimal clinical andradiological grade of the HMI sustained by the player, in ouropinion, warranted management with lumbar epidural steroid

injection. This was undertaken following his third injury. Onreturning to running 4 days postinjection, during which time hehad rested from all physical activity and avoided any sustainedsitting, the player reported immediate and complete relief of hissymptom of lack of freedom during swing phase of running.However, an unavoidable long drive the following day corre-sponded to a return of his posterior thigh ache when sitting andduring his next running session the day after he reported hislack of freedom again. This sequence further indicated a mech-anical relationship between his lumbar spine and running symp-toms and hence the epidural injection was repeated at the nextavailable opportunity.Unilateral lumbar spine zygapophyseal joint mobilisations have

been shown to immediately improve SLR ROM96 which is a validmeasure of lower limb mechanosensitivity.97 Ankle dorsiexioninduces a different and earlier pattern of muscle activation andalso signicantly reduces SLR ROM.97 Oscillatory unilaterallumbar spine mobilisation at L4-5 has also been shown to induceimmediate side-specic changes in lower limb sympathetic nervoussystem (SNS) activity, specically a sympatho-excitatoryresponse.98

Although the optimal dose, grade and vertebral levels oflumbar manual therapy require further investigation and themechanisms by which the increase in SLR ROM96 and SNSstimulation98 are unknown, this evidence suggests that benecialeffects from this intervention are possible. Such manual therapyhas been an integral component of the players pretraining andmatch routine throughout and since his rehabilitation and isreported to provide improved freedom of lumbar and lowerlimb mobility.

Core stability/neuromuscular control/lumbar spinestrengtheningA progressive agility and trunk stabilisation programme signi-cantly reduced the HMI recurrence rate at both 2 weeks and12 months following RTP when compared with a stretching andisolated progressive hamstring strengthening programme.99

Cameron et al100 also showed that AFL players with poorerswing leg movement discrimination were more likely to subse-quently suffer HMI and that a running technique programmeachieved improvements in the same neuromuscular controlmeasure.101 Hamstring muscle stiffness, as measured by thepassive knee extension test, was signicantly reduced by a 4-weekprogramme of two specic exercises performed twice perweek.102 A soccer-specic balance training programme resultedin a signicant reduction in HMI rates in a professional womensfootball team.103

Such research ndings suggest that improvements in lumbo-pelvic control can reduce demands on the hamstrings, especiallybiceps femoris, and subsequently, injury. The players ongoingprogramme incorporated all components of the programmessuggested to be effective in preventing reinjury and minimisingdemands on the hamstrings.A localised approach to core strengthening with the utilisation

of DBC machines104 105 complemented this programme. In con-junction with functional exercise, isolated strengthening of thetrunk muscles was also undertaken with the goal of optimisingthe rate and gain in core strength.

Increase strength in hamstrings with eccentric-biasedprogrammeEccentric exercise is the most researched means of achievingchanges in hamstring muscle properties and reductions in HMIrates. While the 2010 Cochrane Collaboration systematic review


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on hamstring injury prevention106 concluded that there wasinsufcient evidence to draw conclusions on the efcacy ofinterventions used for preventing hamstring injury in football,its inclusion criteria is perhaps too strict to dismiss the ndingsof excluded research from clinical practice. Several studies haveinvestigated the effect of various forms of eccentric exercise onHMI rates in sport,4 14 50 107111 strength50 110 and optimumangle measured on isokinetic equipment.36 112115 The vastmajority reported signicant effects on their respective outcomemeasures.Previous HMI has been associated with reduced eccentric

hamstring strength and biceps femoris EMG activation towardsfull knee extension in athletes who have returned to training fortheir sport.116 It has also been associated with shifting optimumangle towards greater angles of knee exion compared with theuninjured leg,113 117 which is the opposite effect to eccentrictraining.36 112115 Given that previous HMI is a strong riskfactor for future injury,3 14 15 23 2628 32 33 altered muscle prop-erties such as these may contribute to this risk.Contrastingly, previous HMI has been shown to not signi-

cantly affect peak torque113 116 117 or H/Q ratios.113 117

Similarly, eccentric exercise programmes have been shown notto signicantly affect peak torque112 113 115 or H/Qratios,112 113 perhaps questioning their validity as risk factorsfor reinjury. Fatigue induced by a soccer-specic treadmill proto-col and repeated eccentric isokinetic testing was shown to resultin decreasing eccentric torque output, especially at highertesting speeds.30 This suggests that the effects of previous injury,eccentric exercise and fatigue on hamstring muscle performanceare contraction type, knee angle and parameter specic and itmay be critical to work the muscle accordingly in rehabilitation.The weight of evidence indicates that the terminal swing phaserepresents the highest risk phase of the gait cycle during high-speed running118122 when it is known that the hamstrings aremost active119 and eccentrically as the knee is extending123

while also at peak length.123 This suggests that eccentric train-ing, ideally at lengthened ranges, is the most indicated form ofexercise in the rehabilitation and prevention of HMI.19 49

Croisier31 demonstrated in a large prospective study of pro-fessional footballers that preseason normalisation of strictstrength imbalance criteria that included bilateral asymmetryand various H/Q ratios reduced injury rates to that of non-imbalanced players. The discriminatory benets of eccentrictesting were also demonstrated with over 30% of players identi-ed as imbalanced exclusively on this basis. Unfortunately, theoptimum angle was not included in this study. Similarly, the nor-malisation of isokinetically determined strength decits in 17 of18 athletes with recurrent HMI was associated with a zerorecurrence rate in the subsequent 12 months.124 These ndingsindicate that isokinetically determined imbalance criteria canprospectively identify players at higher risk of subsequent ham-string injury and that the normalisation of such criteria, irre-spective of the form of exercise undertaken to achieve this, cansignicantly reduce hamstring injury rates.Isokinetic testing was conducted after the completion of six

strengthening sessions, 22 days post the latter injury and 8 and16 days prior to RTT and RTP, respectively. While eccentrictesting and mixed speed and contraction H/Q ratios have beenreported to be more sensitive in detecting imbalances,31 there isa low risk of discomfort31 and injury.125 In our setting, this riskwas not justiable. Concentric peak exion torque was 10%greater in the injured leg though average eccentric peak torquereduction in athletes with a similar history of HMI has beenshown to be more than double the concentric reduction.124

Optimum angles were almost symmetrical and preferable tothose reported in uninjured subjects,117 immediately after high-dose eccentric exercises36 and after a preseason programme inuninjured footballers.112 They were comparable to a similarlyrecurrently injured AFL player following an extensive eccentric-based rehabilitation programme.113 However, the optimumangle has only been studied prospectively once thus far andthere was no difference between the injured and uninjuredgroups of sprinters.126

Concentric H/Q ratios would indicate that the player remainspredisposed to injury according to the thresholds reported in somestudies,100 126 127 but not others.31 Based on the parameters thatwere measured and Crosiers criteria dening preseason muscleimbalance, the player would not be classed as imbalanced thoughhe would have failed to meet the more strict normalisation criteriaand was not subjected to eccentric testing.31 124

Following the isokinetic test, the player completed a furthersix strengthening sessions, two high-speed running sessions andsix team training sessions prior to RTP. While isokinetic testingwas not repeated immediately prior to RTP, it is reasonable toexpect that his isokinetic prole would have continued toimprove as a result of this training. Continued optimisation ofsuch factors remains a focus of the players management inden-itely beyond his RTP.Recent incontrovertible49 evidence demonstrated spectacu-

larly good49 results in reducing both injury and recurrence ratesin footballers with an eccentric Nordic hamstring exercise pro-gramme. New injuries and recurrences were reduced by 60%and 85%, respectively. The number needed to treat to preventone injury (new or recurrent) was only 13 and to prevent onerecurrence was only 3. No injuries were sustained during theexercise and there was no increase in the injury rate duringthe intervention period. The lack of signicant decrease in theinjury rate during the intervention period indicates that a criticalvolume of exercise needs to be reached before its effects are rea-lised. However, once this volume is reached the effects werehighly substantial. The authors suggest that the shift in optimumlength, previously shown to be achieved by eccentric exerciseand this particular exercise,36 may be the mechanism by whichsuch favourable effects were achieved.The Nordic hamstring exercise also has its criticisms including

being bilateral and thus potentially promoting existing asymmet-ries and that it is a single joint exercise, whereas biceps femoriswhich is the most commonly injured hamstring muscle65 is biar-ticular.128 It is also typically performed at slow velocity4 36 109 115

and at relatively short muscle lengths until subjects haveimproved sufciently to be able to lower themselves to theground. However, it has been shown to signicantly and imme-diately shift optimum length36 112 113 117 and when performedin sufcient volume also dramatically reduce injury rates.109

Unfortunately, the scheduling within a 6-week English PremierLeague preseason renders the application of this volume109 ofexercise very difcult to implement.The need for eccentric training to be the foundation of

muscle injury rehabilitation has already been outlined. However,it is important to note that in the elite sports setting, both interms of striving to prevent HMI en masse, and within thecontext of injury rehabilitation, administering sufcient load tothe hamstrings is a major challenge. In the context of an HMIrehabilitation which commonly average 34 weeks8 the schedul-ing of optimal exercises and prescription of optimal dose areparamount. While most evidence for changing muscle propertiesrevolves around the Nordic hamstring exercise, its limitations asoutlined above demand that other exercises be prescribed for


Original article


the player with acute unilateral injury. The programme shouldbe progressed not just in terms of resistance and volume butalso in velocity, muscle length at contraction and multiple jointmotion. A range of such exercises have been outlined in previ-ous studies112 113 128 and include manual eccentrics in variouspositions, forward deceleration steps, box drops landing insquat or lunge, eccentric forward pulls, eccentric single and stiffleg dead lifts. Other exercises with similar goals include slide-board leg curls, hamstring catapults, sprinter eccentric leg curlsand loaded hip bridges.Pain and acute injury healing may contraindicate resistance

exercise for the rst 35 days and the player should also returnto training and playing not in a fatigued state thus requiringrecovery time. This can leave time for as few as 57 intensivestrengthening sessions if conducted every other day should theplayer RTP on 3 weeks.This player completed 11 strengthening sessions prior to the

latter injury. Following this episode, he completed 12 sessionsprior to RTP. While a similar number of sessions, the mechan-ism of injury and clinical presentation of this episode were lesssevere, enabling a more rapid progression to more functional,multijoint, higher speed and greater length at contraction exer-cises, such as the hip dominant drop lunges and knee dominantsprinter eccentric leg curls in single leg standing.The player consistently produced greater force on the injured

leg with isometric testing measured by a dynamometer in supineat 90 of hip and knee exion129 and in prone at 15 knee exionduring the latter stages of the latter rehabilitation.15 71 Asklingsballistic SLR test130 was also devoid of pain and insecurity.Several imaging studies44 65 131 132 have demonstrated patho-

logical signs and biceps femoris atrophy and increased strain ina signicant proportion of subjects up to 2 years beyond RTP.Given that recurrence risk remains elevated for up to a year andthat the effects of eccentric exercise have also been shown to betemporary,36 114 it is imperative that the player continues hiscustomised, varied eccentric programme indenitely.

Overload running programmePeak hamstring force has been shown to signicantly increasewith increasing running speed from 80% to 100% effort118 andso running at high speed is an essential and the most functionalcomponent of late stage rehabilitation. By contrast, peak ham-string stretch does not change signicantly with increases inspeed from 80% to 100%123 so a player should only increasespeed above this level once full ROM has been restored. Theplayer will only overcome their anxieties and fear of reinjuryhaving successfully completed a sufcient volume of this uniquetask which is an inherent demand of most sports. AFL playersdemonstrated relatively poor performance in their rst matchon RTP133 and it is reasonable to postulate this is associatedwith a lack of condence with sprinting especially given therelationship between sprint distance and repetitions in successfulfootball matches.134 Sprinters have reported taking a median of16, and up to 50 weeks, to feel that they have returned to

preinjury levels of performance.44 While in-house data trendsand research135 suggests that there is some risk in players com-pleting high volumes of high-speed running, the risk in not per-forming a sufcient volume of such training contributing toreinjury upon returning to play may be even higher. Thus fol-lowing the latter injury an overload approach was applied to therunning component of the rehabilitation programme for threereasons:1. High-speed running provides functional eccentric loading.19 51

2. Expose the player and his hamstrings to substantially morerunning load than is required during a typical week thentaper just prior to RTT. This was administered to achievephysiological and psychological benets while recognisingthat the match situation and its associated sympatheticresponses and injury risk being 15 times greater than train-ing11 cannot be readily simulated.

3. The players physical condition required improvement afterrepeated disruptions to training in recent months. Theplayers HR and HRV scores had been disproportionatelyhigh relative to his training load. Extra conditioning hadbeen prescribed during this period however the player wasstill required to play matches and therefore the volume ofconditioning had to be adjusted. A period of overload train-ing provided an ideal opportunity to address this.The results of this programme can be seen in table 4. The

high-speed running volume was 49.8% higher in the overloadrehabilitation programme than the previous rehabilitation pro-grammes despite a moderate 16.8% increase in training timebetween the protocols.The player was also not selected to play by the management

when he was rst declared available and so may have benetedfrom an extra week of team training prior to RTP.

Injection therapiesActovegin and Traumeel injections for treating muscle injuriesare routine practice in German sports medicine. Actovegin isreported136 to promote acceleration of muscle bre synthesis indamaged muscle and de-toning of the hypertonic musclebundle. Traumeel S, a homeopathic formulation, is alleged137 tosuppress the release of inammatory mediators and stimulatethe release of anti-inammatory cytokines. There have been nocontrolled trials138 into either substance for the treatment ofHMI. Reduced HMI time to RTP was reportedly associatedwith Actovegin injections in professional footballers139 thoughmethodological aws compromise the interpretation of out-comes of this pilot study.However, there is not likely to be any harm in administering

either substance.140 While striving for the most comprehensiveintervention and rehabilitation programme possible, the playerconsulted an acclaimed sports medicine physician and under-went a series of such injections. At the very least this had thepsychological effect of ensuring the player felt he was providedwith all interventions for which expert opinion suggests anybenet.

Table 4 Total training loads of the players final overload hamstring rehabilitation protocol compared with the previous standard protocol

SessionsDuration(min)

Dist(m)

Average distanceper minute

High-speeddistance (m)

Average high speeddistance per minute

High-speedentries

Average HR(bpm)

Training load(RPEmin)

Standard 22 1130 83541 95.7 8950 8.94 996 136 5905Overload 29 1320 106225 107.7 13409 14.5 1388 141 7245


Original article


Stretching/yoga/relaxationWhile evidence regarding hamstring exibility as a risk factorfor HMI remains ambiguous.3 14 23 25 32 126 127 141143 higherstretching frequency during rehabilitation was associated withearlier restoration of AKE ROM and reduced time to RTP.144

Soft tissue healing theory145 also advocates stretching within thetreatment regime to maximise scar extensibility.Maximum hamstring muscle lengths are reached during ter-

minal swing phase of high-speed running with increasing speedbeyond 80% only affecting the moment and speed at which itoccurs.123 146 Given that the moment of maximum length coin-cides with the highest risk phase of the gait cycle118120 122 andthat prior HMI increases mechanical strain at the proximalbiceps MTJ even at relatively low eccentric loads,132 it is essen-tial that optimal tissue extensibility is restored.Reduced exibility into hip extension has also been impli-

cated as a risk factor for HMI.14 Given that the activation levelof iliopsoas in the stance leg greatly increases the stretch of thehamstrings of the swing leg118 and that it was during thismoment in the running stride that our player complained of hislack of freedom of his injured hamstring, several manual tech-niques were employed to optimise hip extension ROM on hiscontralateral leg. However, ROM on modied Thomas Test147

was not signicantly limited or asymmetrical at any stage duringhis various rehabilitations. Currently, we continue to stretch theplayers hamstrings regularly, including from Thomas test pos-ition with the contralateral hip concurrently stretched into hipextension. However, we note that static hamstring stretchingwith the ankle held in plantar grade has been shown not toachieve a change in SLR ROM or neurodynamics.48 96

Dru Yoga is shown to be effective in the treatment and manage-ment of low back pain and stress.148 149 Whether the relaxationor stretching is contributing the most benet remains unknown.

CONCLUSIONWe have presented a seven part intervention strategy for the man-agement of recurrent HMI in one player. Whether any one ofthese interventions was the key factor in the success of thisrehabilitation is impossible to determine. There are varying levelsof evidence for every individual component of this treatmentregimen. This gap between the evidence base and the reality ofclinical practice and its variable outcomes intensies the pressureon clinicians working in professional sport and invites the tempta-tion of speculative interventions. The clinician is obliged to deliverinterventions based on the evidence that is available in its varyinglevels and forms. This is true for the management of many injuriesencountered in sports medicine and medicine generally. Our pro-fession must acknowledge this inadequacy and pursue the evidenceessential to overcome it.

What are the new ndings?

A new rehabilitation protocol is proposed for themanagement of recurrent hamstring injuries.

How might it impact on clinical practice in the near future?

This paper will help clinicians in determining therehabilitation protocol for a recurrent hamstring injury.

Contributors PB coordinated the treatment programme and with AN was the mainauthor of the paper. CM and DB were involved in the management of the patientand contributed to appropriate sections of the paper. AD was the radiologistinvolved in the management of the patient and provided the images.

Competing interests None.

Provenance and peer review Not commissioned; externally peer reviewed.

Open Access This is an Open Access article distributed in accordance with theCreative Commons Attribution Non Commercial (CC BY-NC 3.0) license, whichpermits others to distribute, remix, adapt, build upon this work non-commercially,and license their derivative works on different terms, provided the original work isproperly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/3.0/

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doi: 10.1136/bjsports-2012-091400 published online January 15, 2013Br J Sports Med

Peter Brukner, Andrew Nealon, Christopher Morgan, et al.

seven-point programmeprofessional football setting with aapplying the limited evidence in the Recurrent hamstring muscle injury:

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