One of the most common injuries that occur to the sporting population is the dreaded hamstring injury. It has become such a popular injury that when out socially the retired sporting population will inform me as soon as they find out that I am a physiotherapist that in ‘their day, they didn’t have hamstring injuries.’ Which of course, unless they are Phylogenetically a different species, is most likely not true. In fact, all of us should have 3 hamstrings on both sides, not including the adductor magnus’s role as a hamstring. So what is happening to our sporting population? Why is it affecting our young and professional athletes?
Hamstring injury: a case study
It is my belief that one of the easiest ways to explain injury is through a case study format. It lacks the statistical power of randomised control study but there is enough evidence in the last 10 years to show the treatments discussed in this article are viable and have improved the management of hamstring injuries.
The case study involves a male 20 year old world class sprinter. His complaint was recurring right hamstring injury off and on for approximately 3 years. He was unable to participate in running activities and training recently due to pain, hamstring cramping, and continuous injury. Previous treatments had included deep soft tissue work, hamstring stretching and strengthening, and modalities (e.g. ultrasound, interferential therapy). Treatment aided him, but he soon presented again with the same signs and symptoms.
During the physiotherapy assessment, he presented with tight hip flexors, decreased gluteus maximus strength. His hamstring strength was 5/5, or as good as it gets. Other causes were ruled out through testing also. His revised treatment plan included discontinuation of hamstring training. Concentration was on hip flexor stretching and gluteus maximus strengthening. Obviously he improved and started running again, or else, why would I be writing this article. The question is why did this work?
Hip flexor stretching and gluteous maximus strengthening
During gait the hamstrings have a very strong eccentric component (eccentric contraction is the muscle contracting while lengthening, which is very strong contraction of the muscle, also called ‘negatives’ in a gym). The hamstring works with his ‘buddy’ the gluteus maximus to perform this action to decelerate the leg when travelling forward fast. If the gluteals are not performing their job, that places more stress on the hamstrings overloading them. No matter how strong the hamstrings are they are not built to do this job alone. They need a functioning and strong gluteus maximus.
The second component of the treatment was concentration of stretching of the hip flexors. In the body, on one side of a given joint (depending on the movement), the muscles are called the agonists. That muscle’s brother on the other side (to produce the exact opposite movement) is the antagonist. Using the elbow as an example, to produce elbow bending (flexion), the bicep contracts. The antagonist is the triceps, which straightens the elbow. If you want to bend your elbow you activate the biceps (agonist), and deactivate the triceps (antagonist). Otherwise if both activated the arm, they would fight each other and the arm wouldn’t move much. This is called reciprocal inhibition.
Now, if a person has tight active hip flexors, they will most likely be shutting off their counterpart (antagonist) hip extensors, otherwise known as the gluteus maximus. Therefore the hamstrings end up doing all the work again.
So the next time your hamstrings are getting tight, cramping, or if you have torn your hamstring while you are on the bed getting a rub or massage ask your clinician what about your butt? The evidence is there to make all clinicians reconsider the way they handle hamstring issues.