MasterclassThe management of hamstring injury—Part 1: Issues in diagnosis
Introduction
Hamstring injuries are common in all sports requiring rapid acceleration and maximum speed running. Injury surveillances have found hamstring injuries to be the most common injury in athletics (especially in sprinters) (McLennan and McLennan, 1990; Bennell and Crossley, 1996), soccer (Woods et al., 2004), Australian Rules football (Orchard and Seward, 2002), cricket (Orchard et al., 2002a; Stretch, 2003), touch football (Neumann et al., 1998) and hurling (Watson, 1996), whilst they are very common in rugby league (Gabbett, 2003) and rugby union (Targett, 1998). Using an injury definition as that preventing player participation in a match, as a percentage of total injuries occurring, prevalence has been measured between 11% (Stretch, 2003) and 15% (Orchard et al., 2002a) in cricket, 11% (Dadebo et al., 2004) and 12% (Woods et al., 2004) in soccer and 16% in Australian Rules football (Orchard and Seward, 2003). In terms of injury incidence, approximately 6 players out of each squad will injure a hamstring each season in professional soccer (Woods et al., 2004) and Australian Rules football (Orchard and Seward, 2003). With regards to severity, injury will cause a player to miss approximately 3 matches or weeks of play (Orchard and Seward, 2003; Woods et al., 2004). Given the high incidence of hamstring injuries, diagnosis of injury and identification of underlying risk factors is essential in directing treatment and management efforts. Additionally from a monetary perspective, high net worth professional athletes and clubs that employ them may potentially loose a significant amount of income in the time lost to these injuries. Identification and elimination or reduction of risk factors and the application of evidenced based management strategies would likely reduce the burden on the players and the system that supports them.
This article will use the current available evidence to document the aetiological factors and pathogenesis behind hamstring injuries. 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. Particular focus will be given to non-local spinal aetiologies of hamstring dysfunction and injury. 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 few high-quality studies were available for comment.
Section snippets
Anatomy and biomechanics
The hamstring muscle group comprises semitendinosus and semimembranosus medially and biceps femoris, short and long heads, laterally. All muscles attach proximally to the ischial tuberosity, except for the short head of biceps femoris, which originates at the linea aspera and lateral supracondylar line of the femur (Moore and Dalley, 1999). Semitendinosus attaches to the medial surface of the superior tibia, semimembranosus to the posterior part of the medial condyle of the tibia and the
Diagnosis, prognosis and severity
Diagnosis is based on the typical injury mechanism and clinical findings of local pain and loss of function, demonstrated by palpation, range of motion and muscle testing (Kujala et al., 1997). Sonography, computer tomography and magnetic resonance imaging (MRI) can provide information on the extent of injury (Brandser et al., 1995), with MRI being the most sensitive (Speer et al., 1993). Imaging is more likely to be performed on elite athletes, when there is severe pain and no obvious
Location of injury
Hamstring strain classically occurs proximal to the distal muscular–tendon junction where force is concentrated (Kirkendall and Garrett, 2002; Slavotinek et al., 2002). This has implications for the length of rehabilitation, as injuries to the tendon or muscular–tendon junction are worse than the muscle belly due to the limited blood supply (Garrett et al., 1984). Biceps femoris has consistently been found to be the most commonly injured of the hamstring muscle group (Garrett et al., 1989;
Aetiology of injury
Hamstring injuries occur distinctively via a strain method in an acute mechanism, which may represent a continuum of injuries from delayed onset muscle soreness (DOMS) and partial strain to complete muscle rupture (Kujala et al., 1997). Injury surveillance and reports have found injury to classically occur when accelerating or running at maximum speed (Sherry and Best 2004; Woods et al., 2004). Hamstrings have a relatively high proportion of fast twitch type II muscle fibres which are capable
Risk factors for injury
Several factors have been hypothesized to be a risk for hamstring injury. This includes hamstring muscle strength and balance, warm-up, fatigue, flexibility, body mechanics, sports specific activities, psychosocial factors and running technique. Injury may occur due to a single factor but is likely to be more the result of an interaction between several factors, which suggests a multimodal and multidisciplinary approach is necessary. Identification of risk factors leading to injury is required
Conclusions
Given the high incidence of hamstring injuries, rates of recurrence and costs involved, future research should investigate risk factors for injury and re-injury. Identification of aetiological factors and their subsequent diagnosis is required in long term prospective epidemiological studies performed at different grades of play across different sports. This could potentially lead to improved player injury management, research and ultimately injury prevention. 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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