Thigh Pain: Hamstrung by leg pain

Terrific to see Suns get up over the weekend.  Always nice to start the year with a win even a wet one.  12 goals at one end always indicate certain meteorological conditions.  Also great to see the Titans visiting Toowoomba, my old stomping ground, for the game against St George.  Unfortunately the result was a bit one sided but having those teams visiting our rural centres is fantastic- I’m sure some of my old patients were in the audience.

I was browsing the afl injury lists and was interested to see nine clubs had at least one player affected by a hamstring injury.  This sort of injury is often seen in kicking and sprinting sports making AFL players sitting ducks for this type of injury. In fact in AFL these injuries constitute 15% of all injuries with about six per club per season. The hamstrings are a group of muscles that run down the back of the leg, made up of semimembranosus, semitendinosis and biceps femoris. Starting at a point on the pelvis called the ischial tuberosity they extend down past the knee to the lower leg. Usually an athlete will know the moment they have injured themselves. There are two main ways of injuring the hamstring first is due to excessive stretching of the muscle groups and second if the muscle is under pressure while lengthening.

I’m sure more than a few readers may be able to identify with having been running and experiencing sudden onset of pain on their hamstrings. This is the most common mechanism for sustaining whats referred to as a Type 1 acute hamstring tears. It is thought to be due to the muscle being prone to injury during the end of the stride in sprinting, a time when the muscle is loaded in an attempt to slow the lower leg getting ready for the foot to touch down on the ground. These type 1 injuries will more than likely result in the person being unable to complete the exercise. A second type of hamstring injury results when the leg is excessively stretched, particularly in sports like gymnastics. Surprisingly, they are called Type 2 injuries. This results in pain higher in the back of the leg and does not necessarily limit the patients exercise.

You often hear in the news about an athlete being out for a certain number of weeks for rehabilitation of their hamstring injury. In fact there is very little evidence on the best ways to rehabilitate these injuries and 1 in 3 injuries will occur again.  The complicating factor in the question of when to return to play is that there is on real objective way for identifying recovery thus doctors have to rely on subjective measures of an athletes or patient’s recovery. The most common way to do this is to assess if the patient experiences return of pain in the hamstring when they start to exercise again. This is further complicated by the fact that on returning to sport athletes will often have decreased strength in the affected limb suggesting comprehensive rehabilitation may not have been achieved during the rest period and perhaps making them more vulnerable to further injury. Type 1 injures in elite sprinters have typically required 4 months on average before they are able to return to competition. Type 2 injuries however tend to have a slower recovery with return to play averaging around 8 months to a year.

With respect to treatment of either type 1 or type 2 injuries it is very important to get a treatment plan tailored to the specific player of patient. RICE is important to commence ASAP after an injury (for more information RICE please read here) and continue for 48 hours. Non steroidal anti inflammatories such as Ibuprofen have been utilised in the past although there is now some evidence that they may impede the muscles ability to recover properly so paracetamol is considered a more suitable simple analgesic. . Activity modification is however generally considered the main stay of acute treatment.  Rehabilitation of these injuries must address not only the strain itself but the underlying modifiable factors that may have contributed to the injury. Strengthening of the muscle group and addressing lumbopelvic control is important. The is often best done through a physiotherapy program. (Please keep an eye out for my series on Exercises targeting specific muscle groups coming soon)

If pain is prolonged its best to get a comprehensive assessment form your GP to develop a return to exercise program. Prolonged pain can sometimes be treated with an injection of corticosteroid however this is a medical procedure associate with certain complications at times including inflammation and risk of further tears. If this was something you were considering your GP or sports physician could discuss the pros and cons of this as they applied specifically to you. Surgical intervention for hamstring strains are limited.

When addressing return to play the patient must be pain free on examination of the site of injury, should be able to flex and extend the hip and knee fully with no pain on running drills.

Prevention is always better than cure and currently increasing in popularity is the use of eccentric hamstring curls. This has seen the increasing popularity of Nordic Hamstring Exercise although evidence can be conflicting. This exercise requires the patient to be kneeling with their lower legs held immobile at the ankle. Leaning forward the torso is then dropped to the floor. Balance training has also been seen to help some athletes avoid injury. However identification of the at risk player and modifying their activity appears to be the best way to avoid injury, which needs on and off season monitoring by a medical team.

  • Hamstring GPearls on the GC
    • Always RICE your ham
    • Scandinavian countries are all over hamstring stretching
    •  Pork/ham/bacon puns are quite difficult to combine with medical conditions
%d bloggers like this: