{"id":5059,"date":"2013-06-27T08:35:10","date_gmt":"2013-06-27T07:35:10","guid":{"rendered":"https:\/\/blogs.bmj.com\/bjsm\/?p=5059"},"modified":"2013-06-27T08:44:37","modified_gmt":"2013-06-27T07:44:37","slug":"managing-hamstring-tears","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bjsm\/2013\/06\/27\/managing-hamstring-tears\/","title":{"rendered":"Managing hamstring tears – a physiotherapist’s personal story as a patient"},"content":{"rendered":"

Originally posted on<\/span> Running Physio<\/a>\u00a0a handy information resource (for both runners and physios) created by<\/span>\u00a0@tomgoom<\/a><\/em><\/span><\/p>\n

Hamstring tears are incredibly common, so common in fact that occasionally us physios get them! Richard Norris knows hamstring injuries inside out, partly because he\u2019s a clinical specialist in lower limb injuries and partly because he recently pulled his hammy! He\u2019s kindly agreed to share his experience with us and link it with some excellent recent research.\u00a0<\/strong><\/p>\n

Richard is the co-founder of a private clinic\u00a0The Physiotherapy Centre\u00a0<\/a>in Liverpool. He is also an\u00a0orthopaedic physiotherapy specialist in lower limbs at Warrington and Halton Hospitals NHS Foundation Trust.\u00a0<\/strong><\/strong><\/p>\n

You can follow him on Twitter via\u00a0@Richnorris00<\/a>\u00a0or his clinic account\u00a0@PhysioCentre1<\/a>.<\/strong><\/strong><\/p>\n

\"2764629805_cc185c4053_z\"Picture the scene..17th May, 2013. Long day at work completed, legs feeling heavy but my guilty conscience won\u2019t let me skip the usual\u00a0Friday evening\u00a0interval workout at the gym. A warm up is usually standard practice before any exercise but with energy levels waning it seemed a good idea at the time to just get the intervals over and done with. BAD MOVE. At full running speed I felt the lateral aspect of my hamstring muscle belly tear and, on reflection, did well to dismount the treadmill while still being vertical.<\/p>\n

After a few minutes of self-condemnation I realised that this acute hamstring tear presented an opportunity to put some new rehabilitation principles into practice and Tom has been kind enough to let me share my experience in his ever-popular blog.<\/p>\n

Hamstring muscle injuries are regularly referred to as \u2018heterogenous\u2019, meaning they come in a variety of types, sizes and locations. Consequently, two people can tear exactly the same muscle but recover at different speeds. Fortunately, a consensus statement was developed last year to provide a clear muscle injury classification system and this open access article is freely\u00a0available online<\/a>\u00a0(the picture below is sourced from this paper).<\/p>\n

In brief, muscle problems are split into two main categories<\/strong>: functional muscle disorders and structural muscle injuries, with the following definitions.<\/p>\n

    \n
  1. Functional muscle disorder: Acute indirect muscle disorder \u2018without macroscopic\u2019 evidence (in MRI or ultrasound) of muscular tear.<\/li>\n
  2. Structural muscle injury: Any acute indirect muscle injury \u2018with macroscopic\u2019 evidence (in MRI or ultrasound) of muscle tear.<\/li>\n<\/ol>\n

    Unfortunately it was impossible to grade my tear exactly as, by definition, this is determined by the findings on MRI or ultrasound scanning and I don\u2019t have a spare one of those lying around. I definitely felt a tear with well-defined, localised pain but there was no obvious palpable defect in the muscle, or haematoma. Stretching definitely reproduced the pain but I hadn\u2019t lost function and therefore I can only assume it was either a minor or moderate tear. Tears lesser or greater than a fascicle (equivalent to a strawberry lace) represent minor and moderate tears respectively. Ekstrand et al (2013)<\/a> have since utilised this classification system and found that structural injuries take longer to recover than functional disorders, with larger tears taking longer than smaller tears, as basic logic would imply.<\/p>\n

    \"muscle\"<\/a><\/p>\n

    With the POLICE<\/a> on the scene I then sought out some high quality research looking at potential rehabilitation programmes and found a RCT from March, 2013 by Carl Askling <\/a>and colleagues.\u00a0 Carl has published numerous papers on hamstring injuries and there is also a fantastic BJSM podcast with Karim Khan\u00a0<\/a>for those that don\u2019t like reading. What I liked about their work is that, although MRI is useful, there are other clinical indicators that help to determine prognosis. The rehabilitation exercises are the same regardless of the grade of tear and require no equipment, so there\u2019s no excuse for not doing them.<\/p>\n

    In summary<\/strong>:<\/p>\n

      \n
    1. Approximately 70% of hamstring injuries occur during high-speed running, the other 30% during stretching manoeuvres. Running injuries (me) recover quicker than stretching injuries.\u00a0GOOD NEWS.<\/li>\n
    2. The maximal point of tenderness indicates where the tear is: the closer this point is to the ischial tuberosity the longer it takes to recover. Mine was a fair way down the thigh. GOOD NEWS.<\/li>\n<\/ol>\n

      The conclusion drawn from the RCT was that patients recovered significantly quickly using rehabilitation exercises that involved lengthening the muscle (L-protocol) rather than conventional exercises that concentrated less on lengthening. The 3 lengthening exercises (\u2018the Extender\u2019, \u2018the Diver\u2019 and \u2018the Glider\u2019) are started 2 days after the onset of injury and are demonstrated in videos on the BJSM website (linked below)\u00a0but be warned, they can take a while to load.<\/p>\n