Is There a Potential Relationship Between Prior Hamstring Strain Injury and Increased Risk for Future Anterior Cruciate Ligament Injury?

doi:10.1016/j.apmr.2013.07.028

Archives of Physical Medicine and Rehabilitation

Volume 95, Issue 2, February 2014, Pages 401-405

https://doi.org/10.1016/j.apmr.2013.07.028 Get rights and content

Abstract

Hamstring strain injuries (HSIs) are the most prevalent injury in a number of sports, and while anterior cruciate ligament (ACL) injuries are less common, they are far more severe and have long-term implications, such as an increased risk of developing osteoarthritis later in life. Given the high incidence and severity of these injuries, they are key targets of injury preventive programs in elite sport. Evidence has shown that a previous severe knee injury (including ACL injury) increases the risk of HSI; however, whether the functional deficits that occur after HSI result in an increased risk of ACL injury has yet to be considered. In this clinical commentary, we present evidence that suggests that the link between previous HSI and increased risk of ACL injury requires further investigation by drawing parallels between deficits in hamstring function after HSI and in women athletes, who are more prone to ACL injury than men athletes. Comparisons between the neuromuscular function of the male and female hamstring has shown that women display lower hamstring-to-quadriceps strength ratios during isokinetic knee flexion and extension, increased activation of the quadriceps compared with the hamstrings during a stop-jump landing task, a greater time required to reach maximal isokinetic hamstring torque, and lower integrated myoelectrical hamstring activity during a sidestep cutting maneuver. Somewhat similarly, in athletes with a history of HSI, the previously injured limb, compared with the uninjured limb, displays lower eccentric knee flexor strength, a lower hamstrings-to-quadriceps strength ratio, lower voluntary myoelectrical activity during maximal knee flexor eccentric contraction, a lower knee flexor eccentric rate of torque development, and lower voluntary myoelectrical activity during the initial portion of eccentric contraction. Given that the medial and lateral hamstrings have different actions at the knee joint in the coronal plane, which hamstring head is previously injured might also be expected to influence the likelihood of future ACL. Whether the deficits in function after HSI, as seen in laboratory-based studies, translate to deficits in hamstring function during typical injurious tasks for ACL injury has yet to be determined but should be a consideration for future work.

Section snippets

Mechanisms of ACL injury

ACL injury typically occurs at foot plant with concurrent low knee flexion angle, knee joint rotation, and valgus collapse.¹⁷ This kinematic profile is thought to elongate the ACL and also result in increased shear forces of the femur over the tibia, resulting in greater anterior tibial translation.¹⁷ In noncontact ACL injuries in field sports, this kinematic profile is most commonly seen when changing direction while running—specifically, when executing a sidestep cutting maneuver.17, 18, 19

Neuromuscular characteristics of the female hamstring

Numerous studies have identified divergence in neuromuscular hamstring function of the woman and man athlete, particularly after puberty.²² Relevant to the proposed hypothesis, from a neuromuscular perspective, these studies have examined the coactivation of the hamstrings and quadriceps, the hamstrings-to-quadriceps strength ratio, the preactivation of the hamstrings before potentially injurious tasks, and the difference in lateral-to-medial hamstring activation patterns. Compared with men

Maladaptation after HSI

Previous HSI has consistently been identified as the primary risk factor for future HSI,27, 28 and while this has been classified as a nonmodifiable risk factor, several functional deficits have been identified in athletes with a history of HSI.¹⁶ These neuromuscular maladaptations include but are not limited to the following: lower eccentric knee flexor strength (10%–24%)9, 10; lower voluntary myoelectrical activity during maximal knee flexor eccentric contraction (18%–20%)11, 15; lower knee

Is there potential for an increased risk of noncontact ACL injury because of hamstring maladaptation after HSI?

Optimal hamstring function may be crucial to the protection of the ACL. When compared with uninjured hamstrings or men athletes, both previously strained and female hamstrings have been shown to have lower hamstring-to-quadriceps strength ratios during isokinetic or handheld dynamometry,9, 23 lower knee flexor rate of force development during either eccentric isokinetic contractions¹² or isometric contractions,²⁵ and lower electromyographic hamstring activity during isokinetic eccentric knee

Does the specific hamstring muscle injured affect the risk of ACL injury?

One further consideration is that while HSI can lead to general alterations in sagittal knee joint function, the medial and lateral hamstrings have different roles in coronal knee joint control. As such, the specific hamstring muscle injured may have a direct influence on the potential increase in ACL injury risk. The BF is the hamstring muscle most commonly afflicted by strain injury.³¹ The BF is responsible for knee valgus,³² and excessive knee valgus, reached through compression of the

Future direction

Previous severe knee injury is known to increase the likelihood of future HSI.⁷ We have suggested the possibility that prior HSI may increase the risk of future ACL injury. Evidence indicating that a limb that has sustained a previous HSI is more susceptible to ACL injury would strengthen the proposed hypothesis. Furthermore, whether the specific hamstring muscle that was previously injured influences the risk of sustaining an ACL injury is worthy of consideration. While a number of

Conclusions

The prevention of HSIs and ACL injuries is of great concern in elite sporting environments; however, consideration of the effect of HSI on potential ACL injury has not been investigated. We propose that the maladaptation associated with a prior HSI could result not only in an increased risk of HSI recurrence, but also in an elevated risk of ACL injury. Future work should consider the examination of athletes with a history of hamstring injury to determine whether functional deficits related to

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Posterior thigh muscles activity during the active H-test: An electromyographic and kinematic analysis
2024, Journal of Bodywork and Movement Therapies
The Askling's H-test is considered a useful return to play criterion after a hamstring muscle injury (HMI). However, it assesses only the active and passive flexibility of posterior thigh muscles. This may lead the practitioner to underestimate a compensation or abnormal movement pattern. The aim of this study was to analyze these kinematic aspects and their reliability, and evaluate the hamstring (HM) and gluteus maximus (GM) muscles' activities. Twelve healthy male volunteers were tested during two session of three trials for passive and active tests. Dynamic flexibility (97.2 ± 6.0°) was significantly greater than the passive one (70.5 ± 14.7°) (p < 0.001), and good intra-individual reproductibility for most kinematic characteristics was observed. Biceps Femoris long head, semitendinosus and GM mean activities (20.1 ± 11.2%; 14.3 ± 7.3% and 25.2 ± 22.1%, respectively) were found to be low to moderate, indicating that only a moderate level of activity occurred during the active H-test, in comparison to other movements such as sprinting itself. In addition, the activity of the posterior thigh muscles during the active H-test appeared to be variable among the volunteers. These findings suggest that the H-test should be interpreted on an individual basis rather than relying on general characteristics, and be considered as an intermediate tool before more strenuous activities such as returning to sprint. With this comprehensive approach, clinicians can gain a more accurate understanding of their patients' progress and make more informed decisions about their readiness to return to play.
Changes in passive hamstring stiffness after primary anterior cruciate ligament reconstruction: A prospective study with comparison of healthy controls
2024, Clinical Biomechanics
The mechanical properties of knee flexors muscles contribute to reducing anterior cruciate ligament loading. This case-control study evaluated the passive knee flexors stiffness after primary anterior cruciate ligament reconstruction with comparison of healthy controls.
After anterior cruciate ligament reconstruction, 88 participants (24.5 [8.6] years, 56,8% males) had two isokinetic tests at 4 and 8 postoperative months with measurement of the passive resistive torque of knee flexors and extensors/flexors strength. In the control group, 44 participants (24.5 [4.3] years, 56,8% males) had one visit with the same procedures. Passive knee flexors stiffness was calculated as the slope of the passive torque-angle curve on the last 10° of knee extension (Nm/°). We investigated the impact of timing and type of surgery (autograft and combined meniscus repair) and persistent knee extension deficits on knee flexors stiffness.
At 4 and 8 postoperative months, passive knee flexors stiffness was lower on the operated limb than on the non-operated limb (P < 0.001) but both limbs had significant lower values than controls (P < 0.001). Stiffness was positively correlated with knee flexors strength (P < 0.010), and knee flexors stiffness at 4 months was lower in individuals who underwent surgery <6 months from injury (P = 0.040). Knee extension deficit or the type of surgery did not have a significant influence on knee flexors stiffness.
Similarly to neuromuscular factors that are traditionally altered after anterior cruciate ligament reconstruction, evaluating passive knee flexors stiffness changes over time could provide supplementary insights into postoperative muscle recovery.
The immediate effect of IASTM vs. Vibration vs. Light Hand Massage on knee angle repositioning accuracy and hamstrings flexibility: A pilot study
2020, Journal of Bodywork and Movement Therapies
Citation Excerpt :
Hamstrings flexibility and neuromuscular activation patterns may be important predictors not only for hamstrings muscle strains (de la Motte et al., 2019) but also for knee joint injury (Opar and Serpell, 2014). Previous hamstring strain injuries have also been proposed as potential risk factors for anterior cruciate ligament (ACL) injury (Opar and Serpell, 2014), especially when the significant contribution of the hamstrings in generating posterior shear forces that are protective for the ACL during cutting maneuvres is considered (Maniar et al., 2018). Indeed, strength, timing of activation as well as flexibility enhancement of the hamstrings are amongst the main components of ACL injury prevention programs (Padua et al., 2018).
The effectiveness of novel soft-tissue interventions relative to traditional ones requires further exploration. The purpose of this pilot study was to evaluate the immediate effect of Instrument Assisted Soft Tissue Mobilization (IASTM) compared to Vibration Massage or Light Hand Massage on hamstrings’ flexibility and knee proprioception.
16 healthy non-injured male participants (mean age 23.7 years, height 1.80 cms and body mass 77.7 kg) were randomly assigned to the following interventions: (a) 5min IASTM, (b) 5min Vibration Massage and (c) 8min Light Hand-Massage, sequentially delivered to all participants with an in-between 1-week time interval. A single application of each intervention was given over the hamstrings of their dominant leg (repeated measures under 3 different experimental conditions). An active knee angle reproduction proprioception test and the back-saver sit and reach flexibility test were performed before and immediately after each intervention. Reliability of outcomes was also assessed.
Reliability for flexibility (ICC_3,1 = 0.97–0.99/SEM = 0.83–1.52 cm) and proprioception (ICC_3,1 = 0.83–0.88/SEM = 1.63–2.02°) was very good. For flexibility, statistically significant immediate improvement (p < 0.001) was noted in all 3 groups (1.61–3.23 cm), with no between-group differences. For proprioception, improvement in the IASTM (2.12°), Vibration Massage (0.32°) and Light Hand-Massage (1.17°) conditions was not statistically significant; no between-group differences were also evident.
Our findings indicate that muscle flexibility was positively influenced immediately after a single intervention of IASTM, Vibration Massage or Light Hand Massage. Proprioception changes were not statistically significant either within or between groups. Further evaluation of those interventions in a larger population with hamstrings pathology is required.
Hamstring injury prevention: A role for genetic information?
2018, Medical Hypotheses
Citation Excerpt :
As an illustration, in an eleven-season study of 24 European soccer clubs, lower injury prevalence was associated with a greater number of points gained per match, and a higher final league ranking [9]. Perhaps most insidiously, prior HSI serves to increase the risk of further HSI [10], other injuries [11], and future performance potential [12]. Consequently, avoiding, or at least reducing, HSI is a crucial consideration for many sports performance staff.
Hamstring Strain Injuries (HSI) are common within many sports, imposing a significant burden in terms of both financial cost, recovery time, and loss of performance. Recently, research has focused on better understanding the factors that increase an individual’s risk of suffering a HSI, with both lower strength (particularly eccentric strength) and shorter hamstring muscle fascicles found to play a significant role. Such findings have led to an increased popularization of eccentric hamstring exercises, such as the Nordic Hamstring Exercise, the correct utilization of which has been shown to reduce HSI rates. However, despite the robust evidence of their efficacy, adherence to eccentric loading exercises is often poor, with concerns about soreness often cited. Here, we advance the hypothesis that the utilization of genetic information will, in the future, allow for the optimization of HSI prevention programmes, both in terms of training adaptations, and both muscle damage and soreness in the acute phase of post-training recovery. We also discuss whether this information could be utilised in sport in order to predict HSI injury. Such an hypothesis, if correct, could have important implications for the implementation of injury prevention programmes, particularly with regards to adherence, which evidence suggests is currently a major barrier to the utilization of eccentric hamstring exercises.
Quadriceps Tendon Autograft in Anterior Cruciate Ligament Reconstruction: A Systematic Review
2018, Arthroscopy - Journal of Arthroscopic and Related Surgery
Citation Excerpt :
A randomized controlled trial by Buescu et al.30 found that QT and HT result in similar levels of immediate postoperative pain. QT also has the added advantage over the preservation of the hamstrings, given that decreased hamstring strength has been linked to ACL injuries and Farber et al.47 found hamstring weakness to be the greatest concern among surgeons treating elite soccer players.48,49 Knee stability was similar between QT and HT, with QT having greater KT-1000 arthrometer results.
To systematically review the current evidence to ascertain whether quadriceps tendon autograft (QT) is a viable option in anterior cruciate ligament reconstruction.
A literature review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Cohort studies comparing QT with bone–patellar tendon–bone autograft (BPTB) or hamstring tendon autograft (HT) were included. Clinical outcomes were compared, with all statistical analyses performed using IBM SPSS Statistics for Windows, version 22.0, with P < .05 being considered statistically significant.
We identified 15 clinical trials with 1,910 patients. In all included studies, QT resulted in lower rates of anterior knee pain than BPTB. There was no difference in the rate of graft rupture between QT and BPTB or HT in any of the studies reporting this. One study found that QT resulted in greater knee stability than BPTB, and another study found increased stability compared with HT. One study found that QT resulted in improved functional outcomes compared with BPTB, and another found improved outcomes compared with HT, but one study found worse outcomes compared with BPTB.
Current literature suggests QT is a viable option in anterior cruciate ligament reconstruction, with published literature showing comparable knee stability, functional outcomes, donor-site morbidity, and rerupture rates compared with BPTB and HT.
Level III, systematic review of Level I, II, and III studies.
The Evaluation of Asymmetry in Isokinetic and Electromyographic Activity (sEMG) of the Knee Flexor and Extensor Muscles in Football Players after ACL Rupture Reconstruction and in the Athletes following Mild Lower-Limb Injuries
2023, Journal of Clinical Medicine

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Special communicationIs There a Potential Relationship Between Prior Hamstring Strain Injury and Increased Risk for Future Anterior Cruciate Ligament Injury?

Abstract

Section snippets

Mechanisms of ACL injury

Neuromuscular characteristics of the female hamstring

Maladaptation after HSI

Is there potential for an increased risk of noncontact ACL injury because of hamstring maladaptation after HSI?

Does the specific hamstring muscle injured affect the risk of ACL injury?

Future direction

Conclusions

Aust J Physiother

J Biomech

J Sci Med Sport

Clin Biomech (Bristol, Avon)

Injury report 2010: Australian football league

Sport Health

Does anterior cruciate ligament reconstruction restore normal knee kinematics? A prospective MRI analysis over two years

J Bone Joint Surg Br

Magnetic resonance imaging parameters for assessing risk of recurrent hamstring injuries in elite athletes

Am J Sports Med

Clinical risk factors for hamstring muscle strain injury: a prospective study with correlation of injury by magnetic resonance imaging

Br J Sports Med

Predicting hamstring strain injury in elite athletes

Med Sci Sports Exerc

Hamstring muscle strain recurrence and strength performance disorders

Am J Sports Med

Running biomechanics and lower limb strength associated with prior hamstring injury

Med Sci Sports Exerc

Knee flexor strength and bicep femoris electromyographical activity is lower in previously strained hamstrings

J Electromyogr Kinesiol

Rate of torque and electromyographic development during anticipated eccentric contraction is lower in previously strained hamstrings

Am J Sports Med

MR observations of long-term musculotendon remodeling following a hamstring strain injury

Skeletal Radiol

Selective strength loss and decreased muscle activity in hamstring injury

J Orthop Sports Phys Ther

Special communication
Is There a Potential Relationship Between Prior Hamstring Strain Injury and Increased Risk for Future Anterior Cruciate Ligament Injury?