MasterclassHamstring injury management—Part 2: Treatment
Introduction
The management and treatment of hamstring injuries has evolved through empiricism rather than through objective outcomes-based research. As many aspects of manual therapy are now under the spotlight of evidence-based practice ideals and outcomes, so too will the management of common sporting injuries. This is indicated by the fact that recurrent hamstring injuries commonly occur and anecdotally, tend to be more severe and disabling than the initial injury (Fried and Lloyd, 1992). On average, one in three Australian Rules football players will re-injure their hamstring on return to competition (Orchard and Seward, 2003). Risk of recurrence persists for 3 months after return to play, with the cumulative risk for the remainder of the season being 30.6% (Orchard and Best, 2002). In soccer, the re-injury rate is between 12% (Woods et al., 2004) and 14% (Dadebo et al., 2004). A previous or recent hamstring injury is the most recognized risk factor for future injury (Verrall et al., 2001; Orchard and Seward, 2002a). Given the high recurrence rates, hamstring injuries provide a significant challenge to the treating clinician. Knowledge surrounding optimal treatment and preventative measures is therefore critical.
This article will use the current available evidence to document the methods of hamstring injury treatment, rehabilitation and prevention. It will identify and speculate on potential local and non-local factors, which may be important in hamstring injury risk that may be addressed through the application of manual therapy. In doing so, it will provide a reflective essay on the status of hamstring injury management and propose some different directions for the management of hamstring injuries in the future. It will not focus heavily on diagnosis, or individual treatment or rehabilitation protocols that have been covered in previous reviews (Agre, 1985; Worrell, 1994; Kujala et al., 1997; Clanton and Coupe, 1998; Croisier, 2004; Hoskins and Pollard, 2005b). In presenting this article the Medline, Mantis, Sports discus, Pedro, Cochrane and Cinahl databases were reviewed (from inception to present) with the following key words: hamstring, injury, treatment, prevention. All papers were considered in the review as due to a lack of quantity of high-level evidence; particular emphasis could not be given to the methodology used.
Section snippets
Treatment
Little consensus exists as to how hamstring injuries should be effectively treated, although a multidisciplinary approach has been recommended (Croisier, 2004). Treatment should be aimed at both the local hamstring muscle injury and the non-local functional deficiency or aetiological factor responsible for the overload causing injury, if they exist (See Table 1) (Hoskins and Pollard, 2005a, Hoskins and Pollard, 2005b). Only one randomised controlled trial could be found that investigated
Non-hamstring sources of pain and dysfunction
The sacroiliac joint (SIJ) is the link between the lower extremities and spine (Brolinson et al., 2003). It has been suggested that during athletic activities the SIJ sustains higher loads than normal, predisposing dysfunction (Brolinson et al., 2003). Dysfunction is related to reduced or asymmetric range of motion at the hip (Cibulka et al., 1998), altered gait (Herzog and Conway, 1994), earlier activation of biceps femoris during forward flexion and altered lumbopelvic stabilization (
Rehabilitation
No consensus exists for the rehabilitation of hamstring strains. This may be due to the lack of knowledge of the aetiological and predisposing factors for injury. Correct treatment should take steps to address the aetiological factors underlying initial injury to prevent recurrence (Croisier, 2004). Several individual rehabilitation protocols have been published; however, only one small randomly controlled trial () has been performed looking at rehabilitation methods (Sherry and Best, 2004
Conclusions
Given the prevalence of hamstring injuries, rates of recurrence and costs involved, future research should investigate treatment efficacy, prevention and return to play outcomes in an evidence-based paradigm. Randomized controlled trials with long-term follow up are encouraged. In addition, less emphasis should be given to unimodal methods of treatment and a greater emphasis on multimodal aspects of care. On the basis of the indirect evidence and speculation, it would appear that several
Acknowledgements
No source of funding was used in the preparation of this manuscript. The authors have no conflict of interest that is directly relevant to the content of this manuscript.
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