Nikos Malliaropoulos Director of the Athletics National Sports Medicine Centre Thessaloniki Greece. Consultant SEM Physician Barts and The London Clinical Senior Lecturer QMUL CSEM. - The rehabilitation of Hamstring injuries - Can we be more injury specific? (6th MuscleTech Network Workshop) 14th October, Barcelona

1. “Research on Hamstring Injuries:From scientific evidence to clinical practice”
•6th MuscleTech Network Workshop
•13th and 14th October 2014

3. HMIs are defined as having a non-contact-induced, stretch-induced or contraction-induced mechanism, with or without ‘macroscopic evidence’35 of structural muscle changes or functional issues. Moreover, HMIs are characterised by acute incidence , well-defined localized posterior thigh pain during training or competition.4 ,35–39

4. “The rehabilitation of Hamstring injuries - Can we be more injury specific ?”
•Nikos .G.Malliaropoulos
•National Athletics SEM Centre, Thessaloniki, Greece.
•European Sports Care ,London,UK.
•Sports Clinic Barts and The London

5. Facts to Consider
•Mechanism of the Injury Plays a Role
•During Stance or Swing Phase
•Hip & Pelvis
•Site of the Injury
•Intensity –Right Selection
•Sports Specific
•Return to play tools

6. The Role of Stretching in Rehabilitation of Hamstring Injuries: 80 Athletes Follow-Up
MALLIAROPOULOS, NIKOS; PAPALEXANDRIS, STELIOS; PAPALADA, AGAPE; PAPACOSTAS, EMANUEL
The Role of Stretching in Rehabilitation of Hamstring Injuries: 80 Athletes Follow-Up.
Med. Sci. Sports Exerc., Vol. 36, No. 5, pp. 756–759, 2004.
For years, stretching has been an integral part of fitness, practice, and rehabilitation programs to decrease muscle stiffness and relieve pain associated with it. The increased joint range of motion (ROM), indicating the degree of muscle flexibility, has a benefit of stretching proven for healthy tissues.
Purpose: The objective of our study was the assessment of the effects of stretching in the rehabilitation of hamstring injuries.
Methods: We followed up 80 Greek athletes, of average age 20.5 yr, with “second-degree” strain of the hamstring muscles. The athletes were divided into two groups, A and B. For both groups, we estimated the time required for the rehabilitation of the decreased knee ROM and the total time before the athletes could return to a full training program.
Results: Group B, which carried out a more intensive stretching program, was found to have a statistically significant shorter time of regaining normal ROM (5.57 ± 0.71 d) and rehabilitation period (13.27 ± 0.71 d) in comparison with group A (7.32 ± 0.525 d and 15.05 ± 0.81 d, respectively).
Conclusion: Our results suggest that stretching is of great importance in treating muscle strain injuries in that it improves the effectiveness of the rest rehabilitation program.
Medicine & Science in Sports & Exercise: May 2004 - Volume 36 - Issue 5 - pp 756-759
Mechanism of the Injury Plays a Role
During Stance or Swing Phase
Hip & Pelvis
Site of the Injury
Intensity –Right Selection
Sports Specific
Return to play tools

7. Clinical Grade
AROM deficit
FRT
1ST
<10ο degrees
6.9 (2.0)
2ND
10ο – 19ο degrees
11.7 (2.4)
3D
20ο - 29ο degrees
25.4 (6.2)
4TH
>30ο degrees
55.0 (13.5)
Mechanism of the Injury Plays a Role During Stance or Swing Phase Hip & Pelvis Site of the Injury Intensity –Right Selection Sports Specific Return to play tools

8. Active Knee Range of Motion Assessment in Elite Track and Field Athletes Normative Values N.Malliaropoulos, et all
Athletes’ physiological characteristics are fundamental both in terms of performance and injuries prevention. One of those characteristics is flexibility. Using an easy and cheap method, goniometry, estimating active knee Range of Motion could possibly establish normative reference values of Elite athletes’ posterior thigh muscle flexibility. Conclusion:Elite track and field athletes are mean posterior thigh muscle flexiblity is likely to be between 72.3o and 73.9o when tested with the AKE test.
Clinical Prognostic value
Mechanism of the Injury Plays a Role
During Stance or Swing Phase
Hip & Pelvis
Site of the Injury
Intensity –Right Selection
Sports Specific
Return to play tools

9. Br J Sports Med. 2012 Sep;46(12):846-51
Easy to implement
Cost-effective
Closed-chain
Open Kinetic
Core Element
Muscles operating at long lengths
Multi-joint
Bilateral exercises to avoid asymmetries
High/moderate eccentric force activities
Mechanism of the Injury Plays a Role
During Stance or Swing Phase
Hip & Pelvis
Site of the Injury
Intensity –Right Selection
Sports Specific
Return to play tools

10. Single leg deadlifts. Example of
closed kinetic chain ( fixed distal segment) single leg
 HIP dominant exercise.Hip “hinge” and lumbopelvic neutral alignment and
 Neuromuscular control is required
Nordics Example of a
 closed kinetic chain
 KNEE dominant exercise
Core Element Concentric knee flexion during pulling and eccentric knee flexion in order to counteract cable imposed forces is done. Stability of the hip at the weight bearing leg and neuromuscular controlof the core in order to counteract thetorsional forces created at the trunk are required. .

11. Hip or knee dominant:
When sprinting, the function of the hamstrings in the late swing phase is that of hip extension concentrically,
acting to quickly swing the thigh backwards, while also acting as knee flexors to eccentrically decelerate
the forward swing of the lower leg. Therefore, the hamstrings show a dual role for which they have to be prepared.
Sprinter eccentric Leg curl. Example of
open kinetic chain
 KNEE dominant exercise.
Neuromuscular control is required Concentric knee flexion during pulling and eccentric knee flexion in order to counteract cable imposed forces is done. Stability of the hip at the weight bearing leg and neuromuscular control of the core in order to counteract the torsional forces created at the trunk are required. .

12. Figure 3. Hamstring catapult. Example of
open kinetic chain, single leg
HIP dominant exercise. Concentric hip extension is done during descending phase and eccentric hip extension in order to counteract hip flexion is done during recovering phase. Core muscle activation msut be emphasized during the exercise.

13. Slide Leg curl. Example of
combined hip and knee
open kinetic chain ( mobile distal segment) double leg exercise.
Neuromuscular control is required Combined hip extension and knee flexion exercise. Eccentric knee flexion is done during descending phase and concentric knee flexion concomitantly with hip extension during the ascending phase

14. Barbell Leg curl. Example of
closed kinetic chain ( fixed distal segment)
combined hip and knee
 double leg Concentric knee flexion during ascending and eccentric knee flexion during descending is created with the only movement of the hip. Barbell grip add posterior trunk muscle involvement

15. Figure 2: Kinematic symmetry data for pelvis and hip movement during the average stride (101 points, foot strike centred) in the sagittal plane.
Green = mean and standard error for previously injured group.
Black = mean and standard error for uninjured group.
Areas of significant difference are shaded
The Biomechanics of Running in Athletes with Previous Hamstring Injury Colm Daly , Ulrik McCarthy Persson , Richard Twycross-Lewis , Roger Woledge , Dylan Morrissey.
1.Centre for Sports and Exercise Medicine, William Harvey Research Institute, Bart's and the London School of Medicine and Dentistry, Queen Mary University of London.
2. Public Health, Physiotherapy & Population Science, Health Sciences Centre, University College Dublin, Belfield, Dublin 4, Ireland.
Mechanism of the Injury Plays a Role
During Stance or Swing Phase
Hip & Pelvis
Site of the Injury
Intensity –Right Selection
Sports Specific
Return to play tools

16. It has been suggested that neuromuscular control of the lumbopelvic region is needed to enable optimal function of the hamstrings during normal sporting activities. Orchard J, Best TM, Verrall GM. Return to play following muscle strains. Clin J Sport Med. 2005;15:436-441. Significant reduction in injury recurrence when individuals with an acute hamstring injury were treated using a progressive agility and trunk stabilization (PATS) program compared to a progressive stretching and strengthening (STST) program. The PATS program consisted primarily of neuromuscular control exercises Compared to the STST group, there was a statistically significant reduction in injury recurrence in the PATS group at 2 weeks (STST, 55%; PATS, 0%) and 1 year (STST, 70%; PATS, 8%) after return to sport. Best TM, Verrall GM. Return to play following muscle strains. Clin J Sport Med. 2005;15:436-441.
Neuromuscular control of the lumbopelvic region

17. Targeting different parts of the hamstring with different exercises
.
Non-uniform changes in MRI measurements of the thigh muscles following two hamstring strengthening exercises Jurdan Mendiguchia1, Mirian Aranzazu Garrues2, John Barry Cronin3,4, Bret Contreras3, Asier Los Arcos5, Nikos Malliaropoulos6, Nicola Maffulli7, Fernando Idoate8. ELC exercise was better suited for loading all regions of the ST muscle while the L exercise was more effective for loading the proximal regions of biceps femoris and adductor magnus.
Mechanism of the Injury Plays a Role
During Stance or Swing Phase
Hip & Pelvis
Site of the Injury
Intensity –Right Selection
Sports Specific
Return to play tools

18. Jay K, Frisch D, Hansen K, et al. Kettlebell training for musculoskeletal and cardiovascular health: a randomized controlled trial. Scand J Work Environ Health 2011,37:196-203.
Two-hand Kettlebell Swings (KS).
Targeting muscle
Mechanism of the Injury Plays a Role During Stance or Swing Phase Hip & Pelvis Site of the Injury Intensity –Right Selection Sports Specific Return to play tools

19. Supine one-leg curls (SuLC). The subject is lying supine on the floor with arms to side, knees bent, and heels on two pieces of rug which can easily slide over the floor. The hips are kept extended and lifted off the floor and one leg is straightened. The other leg is kept off the floor. When the knee of the working leg is straight the leg is curled back
Targeted muscle

20. Exercise intensity (%MVC)
MTU length change
Kinetic chain
EXERCISE
Ham Ori
BFlh
ST
None
decrease
increase
OKC
CKC
Lunge
14.1
13.87
21.06
Deadlift
23.86
24.84
30.44
Kettle swing
30.19
27.48
38.93
Bridge
50.15
41.20
49.14
TRX
65.40
84.24
75.29
Hamstring bridge
62.58
64.29
66.31
Curl
57.75
56.34
63.70
Nordic
65.22
57.33
65.02
Juve
94.02
111.99
98.41
Slide leg
144.72
145.47
142.20
Muscle and intensity based hamstring exercise classification in elite female track and field athletes. Implications for exercise selection during rehabilitation. Tsaklis P, Malliaropoulos N, Mendiguchia J, Papadopoulou S , Korakakis V, Dev Pyne , Malliaras P .
Mechanism of the Injury Plays a Role
During Stance or Swing Phase
Hip & Pelvis
Site of the Injury
Intensity –Right Selection
Sports Specific
Return to play tools

21. Return to play
•Return to play by injury Mechanics High-speed type /Stretching-type
•Return to play By Imaging (32%)
MRI
•Return to play by Clinical (29%)
Time to walk pain free,AKE ,Asymptomatic
•Testing
•Functional Performance Tests
Mechanism of the Injury Plays a Role During Stance or Swing Phase Hip & Pelvis Site of the Injury Intensity –Right Selection Sports Specific Return to play tools

22. Mechanism of the Injury Plays a Role During Stance or Swing Phase Hip & Pelvis Site of the Injury Intensity –Right Selection Sports Specific Return to play tools

24. The FASH is a self-reported questionnaire developed for patients with acute HMI.
The FASH is not a ‘diagnostic tool’ nor does it play a role in decision-making about treatment options. Clinical assessment and diagnosis are essential before administration of the FASH to patients with HMI.
The FASH had a large ES revealing that it is responsive to changes in clinical course and can potentially be used to monitor changes in symptoms over time and for specific interventions.

25. Practice and Research Gaps
•Proper Diagnosis
•Proper Treatment
•Close and Open Kinetic
•Hip and Knee Dominant
•Eccentric and Concentric
•Core Stability
•Targeting the right Muscle
•Choosing the right Intensity
•Sports Specific
•Access them and Return to Play
Mechanism of the Injury Plays a Role
During Stance or Swing Phase
Hip & Pelvis
Site of the Injury
Intensity –Right Selection
Sports Specific
Return to play tools