- Derek M. Hansen – November 24, 2008 -
A few months back, I had the opportunity to do some hamstring rehab work on an athlete I had worked with in the past. He had been training another city for the past year and had torn his hamstring in a 30 meter sprint test. Four days later, he eventually made it back to my city and we had to undergo some pretty intensive hamstring rehabilitation. He had four weeks to be ready for his first competition (bobsled). This would have been more than enough time for us to work with him. Having worked with sprinters and speed athletes for some time, it was pretty familiar territory for me. I had no doubt that we would successfully rehab him in time for him to compete in top condition. It is important to note that the process we undertook is no different from the framework I outlined in a recent article on Rehab and Dating Success.
The first day he was back under my supervision, we started with evaluation and observation. Simply speaking with the athlete and asking him about the injury and how it feels (standing, walking, sitting, getting out of bed in the morning, etc.) can yield a lot of useful information. Given that we were five days out from the initial injury, inflammation was not a significant concern for us. It was more about determining the athlete’s level of mobility and comfort.
Working Around the Injury
After letting the athlete walk around and passively test the hamstring, we had him lie down on his stomach. I carefully probed around the hamstring to determine the extent of the injury. He had indicated that the main injury was located around the middle to upper portion of the left hamstring, specifically in the semintendinosus. I performed light massage on the hamstring using massage cream to ensure that the passes were superficial and not stretching the muscle and fascia too much. My main intent was to determine the status of muscle tone for the strained muscle (above and below the injury site), as well as the tone of surrounding muscles (biceps femoris, semimembranosus, gracilis, adductors, soleus, gastrocnemium). As you might expect, every muscle was hypertonic and bordering on spastic. I continued to work all of these muscles, including the gluteal muscles, to not only bring down muscle tone but also increase circulation around and toward the injury site to facilitate healing and increased suppleness.
It is important to note that I did not work into the injury site on this first session. There was a lot of work to be done elsewhere in the surrounding tissues. I did not feel that it was prudent to work into the site, given that the athlete was only five days out from the injury and endured a 12 hour drive the day before. Another consideration was that I did not have to get him ready in 10-14 days. I had a much longer time-line and exercising caution was the best possible option.
Implementing Acceleration Work and Drills
After loosening him up sufficiently, we had him perform some easy accelerations over 5 to 10 meters to see what he could do. I made it explicitly clear to him that he only needed to exert himself in a safe manner at 50-60% of his top acceleration rate at best. As you can see from the first video below, his running stride is significantly hampered by the injury and his foot placement on the left side is very guarded. This is normal under these circumstances. The intent of each run is to run as naturally at possible, at a conservative pace, without putting the hamstring in danger of re-injuring. I tell the athlete that he should feel a slight tug on the hamstring, as if it is being worked lightly, but not to the point that it becomes sore.
After performing a number of sets of 5 repetitions over 10 meters, the athlete indicated that he felt the hamstring getting noticeably tired. In this situation, you have a number of choices. You could have him take longer recoveries to ensure there was little to no fatigue in the muscle, or you could change the type of work. We decided to change the type of work. In the video below, you can see that we decided to do a running high knee drill (Running ‘A’). This drill allows him to perform dynamically without putting the hamstring in danger of re-injuring. The action is primarily vertical in nature, unlike actual sprinting which requires a greater horizontal extension component. He is permitted to work aggressively in a manner that bolsters good running mechanics, builds lower leg elasticity and rigidity,and gives him the feeling of performing a full workout, as this is an important psychological factor in rehabilitation.
Initially, working over 5 meters is sufficient to work the running motion, which should work out to 15 to 20 steps when performed correctly. Recoveries between repetitions, in this particular workout, may be between 1 to 2 minutes, over 4 to 5 reps total.
By the beginning of the second week post-injury, we had made significant improvements. Continuing along with the iterative process of performing running drills and accelerations, along with constant manual therapy, we were able to effect big improvements from day to day. Warm-up would include light jogging, dynamic flexibility and PNF work around the hips, and light, flushing massage throughout the lower extremities. Accelerations have gone from 10 meters in the first week, to 20-25 meters in the second week. In between sets, we are continuing to perform massage on the hamstrings, calves and glutes to ensure they are available for recruitment, and that any kinetic chain disruptions are minimized.
I have found that hamstring rehabilitation is primarily about restoring proper intra- and inter-muscle coordination. When a hamstring is injured, the involved and surrounding muscles tend to seize up and minimize range of motion in a protective response. The massage repetitions we are performing help to reduce spasticity and enhance circulation in the region, while the acceleration reps and drills help to re-activate and re-educate the hamstrings and connected muscles (glutes, calves, hip flexors) to recruit in proper amounts and the proper sequence. I am a firm believer that if you free up the muscles to do their proper job, the appropriate sequence of movement will return. While many individuals will say that the prescription requires strengthening protocols, I would go much further to say that an appropriate coordination pattern must be restored. Obviously strengthening is part of the process, but it is a very specific form of strengthening (specificity of velocity, load and order of recruitment). This is why sprinting must be the primary source of work in a hamstring rehabilitation program. It is not a problem that can be adequately resolved in the weight room or physio clinic.
The acceleration repetition in the video clip below shows the athlete not only running faster, but striding through more naturally, with much less apprehension than the previous week. If you look very closely, you can see that the left leg is still not extending as it normally would. Prior to ground contact, you can see the stride shortening on the left side, whereas the right foot extends and lands slightly in front of the center of mass. Similarly, on the extension phase of the stride, the left leg is shortening the cycle ever so slightly and not extending as fully as the right leg. The result is a slight anomaly in the stride cycle that you can pick up through a visual sampling of the entire 20 meter run.
Feedback from the athlete revealed that he felt only a slight, subtle stiffness in an isolated area of the hamstring, but not any pain or discomfort. By this time in the rehabilitation process we were beginning to work deeper into the tissue with massage techniques to break up and mobilize any scarring in the area. It is important to remember that we were not constrained by a short timeline and we had enough time to gradually effect a positive result. I was determined to make sure that when the athlete was ready to push at 100%, there would be no doubt in my mind or his mind that the hamstring would be ready to handle the load over many repetitions. This meant that the sprint workouts were drawn out gradually in terms of adding both distance and intensity for the runs. The same approach applied to manual therapy on the hamstring. We did not force the issue with deep tissue massage until I was sure that the muscle tone had appropriately been reduced through a gradual means. In some sense, we had to “peel the layers of the onion” until the whole of the muscle had been stripped of spasticity and discomfort.
One measure that always seems to work well with muscles that have not fully “released” or joints that still feel tight is to have the athlete apply a heat rub on the injury in the evening and then lightly wrap it with a tensor bandage. The athlete then sleeps with the light wrapping. This basically enhances blood flow to and through the injury site. I always use Tiger Balm ointment for this process, as I’ve had very good personal success with it. It does, however, smell pretty bad and I recommend showering it off in the morning. This process is akin to the wrapping of the legs of thoroughbred horses after intense workouts and when a trainer suspects there may be a slight strain or sprain. In the case of horses, they may refer to wrapping of the legs as stable bandages or sweat wraps.
So the first 8-10 days of rehabilitation went very smoothly with no mistakes on my part. I have learned over the years to be extremely explicit in my descriptions of intensity and velocity to the athlete when preparing him for runs. I would say that I significantly overstate the need to be cautious in each individual run. I have had too many occasions when the athlete told me that he was feeling good and then proceeded to push it a little too hard on the very next repetition, resulting in a minor re-strain of the muscle. Placing significant restrictions on the athlete is critical, regardless of how good or normal they feel. The coach is always the best judge of the rate of progression, whether it is through visual assessment, tactile sensation of the muscle itself or even something as simple as the amount of time that has passed. The progression must always be smooth and gradual.
In Part 2 of this discussion of hamstring rehabilitation, I will discuss how we progressed the athlete to full speed runs. We will also cover the other types of work that were being done in the weight room and with explosive work, taking into consideration the status of the hamstring and the stage of rehabilitation.