VOLUME 8

TARGETED TOPIC 18
2019

INTERVIEW

CLAUDE
MAKELELE
"The Makalele Role"
Makelele was the heart of
Galacticos Real Madrid
Publishing

TARGETED TOPIC
Hamstring Injuries – Aspetar Experience
EDITORIAL

THE EDITORIAL TEAM

LOCATION
Aspetar – Orthopaedic and Sports
Medicine Hospital.
Sport City Street, Near Khalifa Stadium
P.O. Box 29222, Doha, Qatar
Tel +974 4413 2000
[email protected]
www.aspetar.com

Aspetar Sports Medicine Journal is a free

publication produced and distributed
by Aspetar – Orthopaedic and Sports
EXECUTIVE COMMITTEE Medicine Hospital, member of the Aspire
Zone Foundation.
Mohammed K. Al Suwaidi Abdulaziz Jaham Al-Kuwari Hakim Chalabi
CEO of Aspire Zone Foundation MD MD, MBSM CONTACTS
EDITORIAL & ADVERTISING
EDITOR-IN-CHIEF ENQUIRIES
[email protected]
Nebojsa Popovic
MD, PhD
SUBSCRIPTION ENQUIRIES
[email protected]
DEPUTY
EDITOR-IN-CHIEF
WEBSITE
Khalid Al-Khelaifi www.aspetar.com/journal
MD

MANAGING EDITOR PRODUCTION

& DESIGNER DIRECTOR

Ivan Stankovic Reem Al-Muftah

©2012 Aspetar – Orthopaedic and Sports

Medicine Hospital, Qatar. Aspetar Sports
ASSOCIATE EDITORS
Medicine Journal is published every 2 months
Philippe Landreau Abdulla Saeed Al-Mohannadi Rodney Whiteley Mathew Wilson Karim Khan or unless otherwise stated by Aspetar –
MD MPH PT, PhD PhD MD, PhD Orthopaedic and Sports Medicine Hospital.
Aspetar – Orthopaedic and Sports Medicine
Hospital is not liable for the accuracy or
EDITORIAL BOARD
completeness of the information in this
Gerard Saillant Mohamed Ghaith Al-Kuwari Jan Ekstrand Peter Dzendrowskyj publication. The information in this publication
MD, PhD MD, ABCM, FFPH MD, PhD MD cannot replace professional advice and is not
intended to present the only or necessarily
Roald Bahr Riadh Miladi Yorck Olaf Schumacher Celeste Geertsema
best methods or procedures for the medical
MD, PhD PT MD, PhD MD
situations discussed. The opinions expressed in
Cristiano Eirale Marc Martens Katharina Grimm Paul Dijkstra all articles published in Aspetar Sports Medicine
MD, PhD MD, PhD MD MD Journal are those of the authors. Similarly, the
publication of advertisements does not represent
Johannes Tol Mohammed al Alteeq Ali Guermazi Nathan Riding
any form of endorsement of the product or
MD, PhD MD MD, PhD PhD
service being promoted by the advertiser by
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PhD MD, PhD MD MD, PhD

Clare Ardern Bruce Hamilton Charles Cassidy Nicol Van Dyk Published By
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Milena Tomovic
MD

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HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 3

International Conference
on Medicine and Science in Athletics
3rd - 5th May 2019
Aspire Academy Football High Performance Center

REGISTRATION NOW OPEN

Join us at this conference which offers you the unique opportunity to combine an athletics focused professional development using
a world-class faculty of clinicians and scientists with seeing elite athletes in action during the 2019 IAAF Doha Diamond League.
They include Jan Ekstrand, Roald Bahr, Clare Ardern, Andrea Mosler, Juan-Manuel Alonso, Rod Whiteley, Kieran O’Sullivan, Marco
Cardinale and many more!
The faculty will address the latest evidence on topics relevant to athletics’ science and medical teams, including training and
performing in the heat, preventing injuries and illnesses, managing in-season tendon pain, hamstring, and bone stress injuries.
Target Audience: Physicians, Nurses, Pharmacists, Allied Health Professionals (Physiotherapists, Nutritionists, Podiatrists),
others (including but not restricted to Researchers, Coaches, and Managers)
Registration is now open; do not miss this opportunity to visit Doha before the September 2019 IAAF World Championships in
Athletics - seats are limited!

We look forward to welcoming you to Aspire and Doha.

CONTENTS

86 WHAT IS THE DIAGNOSIS?

44 Hamstring Injury

CLAUDE
A clinical diagnosis
By Johannes L Tol et al

MAKELELE IS IT SERIOUS?
50 The Prognostic Role of
“Players should be Magnetic Resonance Imaging
receptive to medical and Injury Classification
advice since most Systems
players see the doctor By Anne D van der Made et al
only when injured
and then it’s already HOW DO WE DEAL WITH IT?
sometimes too late.
54 Medical Treatment Modalities
However, the true
champions are the in Hamstring Injuries
Beware to do no harm
ones that take the By Gustaaf Reurink et al
medical advice before
an injury occurs.”
60 Surgical Management of
Proximal Hamstring Rupture
By Navraj Atwal et al
MERGING RESEARCH WITH CLINICAL PRACTICE
12 LESSONS LEARNED FROM TWO DECADES OF WHEN WILL I BE READY TO
INJURY SURVEILLANCE IN ELITE FOOTBALL PLAY?
66 Rehabilitation and Return To
By Jan Ekstrand
Sport After Hamstring Injury
18 HAVE WE CHANGED OUR APPROACH Be wary of anyone who
tells you they have a simple
TO HAMSTRING INJURIES? and effective solution for
hamstring injury
A risk factor review By Rod Whiteley et al
By Roald Bahr and Nicol van Dyk

26 HAMSTRINGS ARE DANGEROUS FOR WILL IT INFLUENCE MY

PERFORMANCE?
SPORT AND SPORT IS DANGEROUS 74 Defining Performance After
FOR HAMSTRINGS Hamstring Strain Injury
By Cristiano Eirale and Jan Ekstrand By Darren Paul et al

CONCLUSION
WHAT IS A HAMSTRING INJURY? 78 The Complexity of Bees,
Bicycles, and Injuries
34 WHAT IS A HAMSTRING INJURY? An overview of the prevention
paradigm shift and advice for
An overview of anatomy, muscle healing and clinical practice
optimal loading By Nicol van Dyk et al
By Robin Vermeulen

LETTERS FROM
HOW DOES IT HAPPEN? 94 PARIS: Hamstring injury
prevention in elite football –
40 THE ARCHITECTURE OF A HAMSTRING a contemplative walk through
the City of Lights
STRAIN INJURY By Cristiano Eirale
By Fearghal P. Behan et al

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 5

6
EDITORIAL

HAMSTRING INJURIES – MERGING

RESEARCH WITH REAL LIFE

In past years, Aspetar has supported clinically orientated research. This has led to greater
practitioner involvement in both projects design and interpreting whether outcomes are
clinically meaningful. Now we have also improved the communication of our findings
to our stakeholders (players, sporting authorities, community leaders and governing
bodies). This growing awareness is no more apparent than in the wealth of work around
hamstring injuries, particularly in football.

Aspetar currently hosts the largest clinical data set worldwide on acute hamstrings
injuries and has established a strong research infrastructure.

Over the years we have learned that the value for MRI in predicting return to play is
limited and inferior to standardised clinical assessment, that platelet rich plasma is not
the supposed magic bullet to speed up recovery and that Aspetar’s criteria rehabilitation
based program enables safe return to play.

To move in the field forward and to answer new emerging questions in the field
we need higher numbers and worldwide collaboration between the different research
centres.

This targeting issue on Hamstring Injuries in football is our latest update on years
of common efforts of the team in Aspetar, Aspire Academy and the National Sports
Medicine Programme (NSMP) on this topic.

I would like to thank our guest editor Nicol Van Dyk for his outstanding work to make
this issue possible and to all the authors for their valuable contribution making their
sport a safer environment for our athletes.

Nebojsa Popovic MD PhD

Editor-in-Chief

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 7

 Aspetar
Hamstring
Protocol

Aspetar Hamstring Protocol Available Now

Aspetar brings you the official, free Aspetar Hamstring Protocol.
The Aspetar Hamstring Protocol is an evidence-based rehabilitation
protocol, with criteria based progression that was developed to
include clinical experience, latest research findings, and patient
involvement in a shared decision making model; allowing the clinician
to adapt the protocol for the player as needed. Scan the code to see the Scan the code to view
35 free guide videos on the free accompanying
Consisting of 6 stages, 3 physiotherapy and 3 sport specific, some the Aspetar YouTube PDF booklet
overlap of exercises between the stages is allowed in recognition of channel now
the fluidity of the rehabilitation process and reflecting an integrated
protocol with set criteria for progression. Each stage features the early
but safe resumption of repeated high speed running and direction
change movements.

Orthopaedic & Sports Medicine Hospital

www.aspetar.com

twitter.com/Aspetar
facebook.com/Aspetar
instagram.com/Aspetar
8
GUEST EDITORIAL

HAMSTRING INJURIES –
CREATING BETTER OUTCOMES
TOGETHER

Across all sports, athletes engage in a trade-off between risk and reward; the risk of injury
versus the reward that comes with performance. And for all athletes, from recreational to
elite, the “main thing” is to participate, and to do it as well as possible. Hamstring injuries
remain the most common injury in football. A hamstring injury happens to a person,
who is part of a team, within a specific environment and culture. We are becoming more
aware of the contextual factors that influence injury, as well as the underlying complexity
when dealing with these injuries. This understanding is crucial to move sports medicine
forward, and for us to better serve our athletes. And it is only possible with the support
from a much larger team. For us, this team is represented by our colleagues within the
Aspire Zone Foundation, and includes: collaborations with the Aspire Academy, every
practitioner working in the National Sports Medicine Programme, integration between
the different departments at Aspetar, and most of all, the players that willingly participate
in much of our research efforts. We are grateful to each member of our incredible team.
We will continue working together, and we encourage you to do the same.

At Aspetar, we have been able to contribute to the care of athletes with hamstring
injuries; efforts that are supported through engagement from local and international
collaborators. This experience has improved our medical management of hamstring
injuries and, importantly, taught us how to support our athletes and their teams more
holistically.

In this special edition of the Aspetar sports medicine journal, we have brought
together much of the work performed here in Doha over the past ten years. The different
sections are constructed around key questions we might ask about hamstring injuries -
questions our athletes often ask us. Why does it happen? What exactly is it? How do we
deal with it? What makes it better? Will it influence my performance? Can we prevent it?
The results from recent publications are presented from this clinical perspective. In some
cases, we have also drawn from our previous hamstring edition in 2013. Additionally, we
present the results of considerable efforts that have been made to identify risk factors
and investigate the effect of prevention programmes to reduce hamstring injuries. It is
not our intention to provide finality around these issues, but rather to stimulate how we
answer these questions now, and how we might improve our ability to answer them in
the future.

With Qatar hosting the 2022 FIFA World Cup®, and as newly crowned champions of
Asia, it is no accident that hamstring injury research has been a focus area at Aspetar. We
hope this special edition provides you with some insight into the management of the
most common injury we see in the most popular sport in the world.

Nicol van Dyk PhD

Physiotherapist & Clinical Researcher
Aspetar – Orthopaedic and Sports Medicine Hospital, Qatar

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 9

HAMSTRING – ASPETAR EXPERIENCE

MERGING RESEARCH
WITH CLINICAL
PRACTICE

10
 © Francois Nel/Getty Images

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 11

MERGING RESEARCH WITH CLINICAL PRACTICE

LESSONS LEARNED
FROM TWO
DECADES OF INJURY
SURVEILLANCE IN
ELITE FOOTBALL
– Written by Jan Ekstrand, Qatar

In 2001, UEFA (Union of European Football being recruited from 20 different countries. been introduced into other regions and
Associations) commenced a research project The study has been conducted by the leagues around the world, such as the Asian
that aimed to reduce the number and Football Research Group (FRG) at Linköping Football Confederation (AFC)3.
severity of injuries and, therefore, increase University in Sweden, under the leadership
safety in football. This initiative was the of Prof. Jan Ekstrand, the former vice- Which teams are invited to participate and
culmination of several years of preparatory chairman of the UEFA Medical Committee how is injury defined?
work by the UEFA Medical Committee as and now Chief Medical Officer at Aspetar UEFA invited the 32 clubs that qualify for
well as internal discussions within UEFA on Orthopaedic and Sports Medicine Hospital the UEFA Champions League to participate
optimal study design and standardizing the in Doha, Qatar. in the study. To allow increased continuity
definitions of injury. The design of the study is aligned with and prevent teams from potentially leaving
the FIFA (Fédération Internationale de the study, clubs that have participated
WHY AND HOW IS THE UEFA INJURY Football Associations)-UEFA consensus earlier but have not made the 32-team list in
SURVEILLANCE CARRIED OUT? statement on injury definitions and the current year are permitted to continue
The so-called UEFA Elite Club Injury data collection procedures1 and the ge- their involvement. Within each team, all
Study (ECIS) has subsequently been run neral methodology is reported in detail first team squad members are invited to
every season for the last 18 years with elsewhere2. Injury surveillance work using participate. In the study, an injury is defined
more than 50 top European football clubs the same study design has subsequently as any physical complaint sustained by

12
 summers and cooler winters (teams from
England, Scotland, Germany, Holland,
Belgium, northern France and northern
Italy) had a higher incidence of injury when
compared to teams from southern Europe
which tend to have a Mediterranean climate
(teams from Spain, Portugal and middle or
southern Italy). The injuries that followed
this general trend include both traumatic
and overuse injuries. However, the incidence
of anterior cruciate ligament (ACL) injury,
and in particular non-contact ACL injury,
followed a reverse trend with teams with a
Mediterranean climate experiencing more
ACL injuries. The authors suggested that the
reason for the higher risk of ACL injuries in
Mediterranean countries could be higher
shoe-surface traction resulting from a
warmer climate.

Lesson 3: Thighs are the most injured

Between 85-90% of all injuries are to the
lower extremity, with the most common
sites among elite male players being the
thigh (25%), knee (18%), hip/groin (14%) and
ankle (14%). A majority of these injuries are
due to trauma (70%), with the remainder
being due to overuse (30%).

Lesson 4: Muscle injuries are the most

a player that occurred during a football clubs also receive an instrument to evaluate common at the elite level
training or match which resulted in the the effect of any prevention measures Muscle injuries are a substantial problem
player being unable to participate in future implemented during the season. for both players and their clubs. They
football training or match play (i.e. a time constitute almost one third of all time-
loss injury)1,2. The player is then considered LESSONS LEARNED TO GUIDE THE FUTURE loss injuries in men’s professional football,
to be injured until the club medical staff Lesson 1: Injuries influence players’ and 92% of all injuries affect the four
have allowed him full participation in availability major muscle groups of the lower limb6,7.
training or match play. Since the study’s inception, more than Hamstring injuries are most frequently
17,000 injuries have been reported. The data reported, which probably relates to the
Feedback of results and information to clubs shows that a male professional football speed of the game at the elite level. A team
is vital for participation team with 25 players in its squad can expect consisting of 25 players in the squad can
During each season all participating clubs approximately 50 time-loss injuries each expect an average of 15 muscle injuries per
receive reports at three different time points: season, which results in an average of two season, with approximately 6-7 of them
after preseason, at mid-season, and post- injuries per player4. The impact of injuries affecting this muscle group8. The average
season. These reports summarize the results on team performance is huge, as almost 12- time to return to sport for all muscle injuries
for their club together with the average data 14% of the squad would be unavailable due is around 16 days, but there can be large
from all participating clubs. To maintain to injuries at any time during the season. variations in this figure. Factors such as the
confidentiality this is done without muscle(s) involved, type, and size of injury
revealing the names of other participating Lesson 2: The injury risks vary between are all potential sources of variance.
teams. These reports enable club medical countries in Europe
and coaching staff to proactively introduce Waldén et al studied the influence of Lesson 5: At elite level, imaging may be
injury prevention measures. It also allows climate types on injury epidemiology in advantageous
clubs to closely examine variations in both men’s professional football in Europe5. They Magnetic Resonance Imaging (MRI) can
injury incidence and their characteristics reported that teams located in northern be used to verify the diagnosis and prognosis
within- and between seasons. In addition, Europe, which typically have milder of a hamstring injury. Radiological grading

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 13

MERGING RESEARCH WITH CLINICAL PRACTICE

(categorizing the severity of muscle injury diagnosis of an ACL injury is quickly European football. These new pitches offer
by analyzing MRI images taken 1-2 days post- established (on average within 8 days), football-specific features that are similar to
injury) demonstrated a relationship with allowing very experienced surgeons to those found with well-maintained natural
the time to return to sport8. Most hamstring perform the reconstruction at an optimal turf pitches. Consequently, in 2004 FIFA
injuries (70%) seen in professional football time. An intensive, individually-tailored decided that matches may be played on
are of radiological grade 0 or 1, indicating no post-surgical rehabilitation programme artificial surfaces. To this end, the laws of
signs of fiber disruption, however, these are then follows, supervised by highly the game (FIFA 2009) state “Where artificial
still responsible for the majority of absentee experienced physiotherapists10. Under these surfaces are used in either competition
days. circumstances, it is possible to achieve matches between representative teams of
greater than 90% rate of return to the pre- member associations affiliated to FIFA or
Lesson 6: More muscle injuries happen injury level of performance. international club competition matches, the
during matches, and in older players However, even under the most ideal surface must meet the requirements of the
The risk of muscle injury is six times environment of care, the rehabilitation FIFA Quality Concept for Artificial Turf or
higher in matches compared to training. process is still considerably long after ACL the International Artificial Turf Standard,
The fact that muscle injuries are more injury. The mean time to return to full unless special dispensation is given by FIFA”.
frequently seen towards the end of each team activity after ACL surgery still ranges The FIFA Quality Concept is an evaluation
half of play suggests that fatigue is a between 6 to 7 months, and the mean programme consisting of laboratory and
factor6. Furthermore, the risk of injury of the absence before match play is almost 8 field tests which aim to set high quality
hamstring and calf muscles increases with months (82% of players return to match play standards and criteria for artificial surfaces.
age. within 8 months). FIFA and UEFA have introduced the
The fact that it is possible for almost all terminology of “football turf” for artificial
Lesson 7: Almost all male elite footballers elite level players to return to football post turf pitches meeting these standards and
with ACL injuries return to full play, but it ACL reconstruction does not necessarily criteria.
takes 6-7 months mean that return-to-play is always ideal Playing football on older generations
The ECIS also includes sub-studies of from a medical point of view. Many elite level of artificial surfaces has been associated
specific injuries. With respect to ACL injury, footballers suffer from localized swelling with various disadvantages; for example,
Waldén et al9 reported that under ideal and overuse symptoms shortly after their performance characteristics are believed
circumstances, more than 90% of players return to football. These signs might to change as do the typical injury patterns
can return to football at an equivalent level indicate that their return is premature11. of the sport12. Despite the wide use of turf
of play compared to pre-injury. Injuries pitches by non-elite football players, and
to the ACL only make up around 1-2% of Lesson 8: No increased risk of playing on their obvious advantages such as increased
all time loss injuries; however, they are a “football turf” compared to playing on pitch utility and potential to provide year-
associated with the longest time to return natural grass round pitch quality (regardless of the
to sport. A male elite team with a squad The latest generation of artificial turf weather), their acceptance is still limited by
of 25 players can expect an average of one surfaces are increasingly being used within elite teams.
ACL injury every second season. Female
footballers have a 2-3 times higher ACL
injury risk when compared to their male
counterparts. Females also tend to sustain
their ACL injuries at a younger age than
males. Approximately 19 out of 20 elite
Many elite level footballers
football players who sustain an ACL injury
end up having an ACL reconstruction. This
suffer from localized swelling
is consistent with the common opinion that
elite level players with an ACL rupture must
and overuse symptoms
have surgery to be able to come back on a top
level of football. Although some anecdotal
shortly after their return to
and isolated case reports suggest otherwise,
at the elite level it is rare for players to return
football. These signs might
to football without the reconstruction of the
ACL.
indicate that their return is
The elite-level footballer with an ACL
injury is presented with a near perfect
premature11.
environment for care. Players are supported
by a highly qualified medical team, the

14
 Injury characteristics when playing on involved in the study22. Hamstring muscle surprising at the time, but it demonstrates
artificial turf, in comparison to playing on injuries, the most common injury type, even that the health situation in any professional
natural grass, have been studied in both increased from year to year23. One reason football club could be considered similar to
male and female elite level players13-15, for this finding may be that the intensity that found in most workplace environments.
amateurs16,17, youths18 as well as during of play at the elite level has increased over For instance, sick leave is dependent on
tournament play19. All these studies have time. If this is true, it further strengthens the the workload imposed on employees, the
shown no major differences in the overall importance of rethinking our prevention leadership style of management, internal
injury risk between the two surface types. efforts to account for the increase demands communication in the work place as well as
However, differences may exist in the of the sport, and achieve buy-in from our the overall well-being of employees.
pattern of injury sustained on these two elite players to improve compliance with
types of surfaces. There has been some such programmes. Lesson 11: The load on players is frequently
indication of a lower risk of muscle strain measured in elite level teams and it is
when playing on the new generation of Lesson 10: We need to think differently to associated with the injuries, however the
artificial turf pitches, although coupled with prevent injuries in elite level football predictive power is poor
suggestions of a higher risk of ankle sprain. To further develop our knowledge McCall et al25 examined the association
and processes relating to the ECIS study, and predictive power of internal workload
Lesson 9: Traditional preventive methods do UEFA hosts an annual conference with an and non-contact injuries during a single
not seem to be enough to decrease muscle invitation extended to all head medical season in a sub-group of five ECIS teams.
injuries and severe injuries officers from participating clubs. These The authors found that the internal acute:
An advantage of the long term ECIS study clinicians work 24/7 with the best European chronic workloads (using the session rating
is that it reveals trends. In a prospective football teams containing many of world’s of perceived exertion (RPE) scale) of 1:3 and 1:4
follow-up of the first eleven years of the best players. When this group was asked in weeks are associated with a higher number
study (2001-2012), some injury types (such 2013, ‘What are the most important factors of non-contact injuries in elite football
as ankle sprains and medial collateral in preventing injuries in elite level football?’, players. However, these workload markers,
ligament injuries of the knee) showed a the most common answers were: load on the when considered in isolation, showed poor
tendency to decrease20,21. However, the players, internal communication, leadership predictive ability in identifying individual
total injury risk remained the same despite style of the coaches and the well-being of players who actually went on to develop a
extensive preventative work by the clubs players24. These answers were considered non-contact injury.

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 15

MERGING RESEARCH WITH CLINICAL PRACTICE

Lesson 12: Communication between the head Clubs with good quality
internal communication
coach/manager and the medical team is
vital for maintaining players on the field

showed fewer injuries and

With respect to the quality of internal
communication, we sought the opinion of

greater player availability

medical staff from elite football teams to
determine whether internal communication

when compared to clubs with

was in fact correlated with injuries and/
or player availability at training and

poor communication.
matches26. Clubs with good quality internal
communication showed fewer injuries and
greater player availability when compared
to clubs with poor communication. The
most notable finding of the study was
that internal communication between
the head coach and the medical team was
of great importance. We found that low
or poor communication quality between Lesson 14: The key to get attention from youth level. However, our work conducted to
the head coach and the medical team was coaches: Show the correlation between date suggests that this may be insufficient
significantly associated with the injury rate. injuries and performance for the demands of elite level football.
Teams with low or poor communication The key for medical teams to gain Opinions derived from team doctors
quality had a 6–7% lower player availability attention from coaches is to transform working in elite football clubs, pointed
at training and matches, and a 50% higher medical information into tactical football to the fact that we should be thinking
injury burden, when compared to teams strategies. The bottom line for any elite outside of the box. We should not only be
with a moderate-high communication level team is performance, with coaches/ considering player-related variables but
quality26. managers chasing trophies. However, club/team factors such as load, internal
a team can only be successful and win communication, and leadership style. The
Lesson 13: The coaches are the most important championships if players are available at results from our previous work has shown
people for the injury situation in elite level training and matches. the association of such factors with injury.
football teams In a sub-study of the ECIS, Hägglund The key to keeping elite level players on
Following on from the evidence produced et al28 showed that in male professional the pitch and avoiding injury is to widen
in 2013, we investigated the leadership styles football, injuries had a significant influence the horizon and consider other factors
of head coaches in elite men’s football to on performance in the domestic leagues as that are potentially associated with injury.
evaluate the association between leadership well as in the European cup competitions. Communication and co-operation within
style, injury rate, and player availability27. These findings stress the importance of clubs may be as important as player-related
The resulting data revealed that a injury prevention to increase a team’s factors.
correlation existed between the head chances of success.
coach’s leadership style and the incidence The association between injury and
of severe injury and player availability; performance is probably one of the most
transformational leadership associated with important messages to convey to the References available at
fewer injuries than transactional leadership. technical/coaching staff and to other www.aspetar.com/journal
To explain this finding further, teams that stakeholders in professional sports clubs.
had coaches with a democratic leadership This message is needed to further improve
style had a lower incidence of severe injuries medical services to players and to bolster
within their teams. The incidence of severe injury prevention efforts.
injuries was 29–40% lower in teams where Jan Ekstrand M.D., Ph.D.
coaches communicated a clear and positive Lesson 15: The main message from 18 years Football Research Group
vision of the future, supported their staff of injury surveillance in the UEFA study: Department of Medical and Health
members, and gave staff encouragement Communicate and co-operate! Sciences, Linköping University,
and recognition27. The findings from the ECIS could be Linköping, Sweden
Further, attendance at training was considered as eye opening. The traditional
Aspetar Orthopaedic and Sports Medicine
higher in teams where coaches provided preventative methods aimed at player-
Hospital
encouragement to their staff members, related factors such as strength and
Doha, Qatar
encouraged innovative thinking, as well as flexibility have been evaluated in well-
fostering trust and cooperation among its designed studies and have been proven to
team members27. be very effective at both the amateur and Contact: [email protected]

16
 A UNIQUE DESTINATION
for Speedy Recovery

Rehabilitation at Aspetar is designed to provide intensive, interdisciplinary support from around

50 highly skilled and expert physiotherapists from across 20 countries, all are well trained in
the use of state-of-the-art technology and techniques that return patients to their pre-injury
lifestyle as quickly and safely as possible.

Rehabilitation is an integral part of Aspetar’s multidisciplinary approach to athlete management,

and with one of the most advanced services in the region the hospital focuses on creating
personalised injury treatment programmes for all patients.

Book your appointment now by calling 44132000 or by visiting our website

www.aspetar.com.

Orthopaedic & Sports Medicine Hospital

www.aspetar.com
twitter.com/Aspetar
facebook.com/Aspetar
instagram.com/Aspetar
MERGING RESEARCH WITH CLINICAL PRACTICE

HAVE WE CHANGED
OUR APPROACH
TO HAMSTRING
INJURIES?
A RISK FACTOR REVIEW
– Written by Roald Bahr and Nicol van Dyk, Qatar

INTRODUCTION until 20149. These results are worrying, RISK FACTORS AND PREVENTION
Hamstring injuries represent a considering that investigations identifying A number of intervention studies have
substantial injury burden in football1, and risk factors associated with these injuries shown to be effective at reducing hamstring
is the most common non-contact muscle have been plentiful10-12. Unfortunately, these injuries; the greatest effect found in studies
injury overall2. It has been demonstrated studies continue to provide contrasting focused on eccentric strengthening6,7,13.
that player availability impacts negatively conclusions, often directly contradicting Although not specifically aimed at
on team success3-5, and therefore the each other’s findings. This is evident in hamstring injuries, similar success was
management of hamstring injuries systematic reviews that do not provide observed where the intervention was aimed
continue to receive much attention in the substantial evidence for any specific, at neuromuscular function and improving
literature6-8, as well as the mainstream modifiable risk factor10-12. flexibility3,14,15. There are perceptions and
media. However, injury prevention efforts In this report, we highlight some of the beliefs around these prevention strategies,
have not reduced the number of injuries recent risk factor findings in the larger from the players regarding soreness or the
at the elite level. Incidence patterns context of injury prevention. We consider coaching staff regarding usefulness, that
in the UEFA Champions League have what clinical implications these findings pose serious barriers to implementation16,17.
demonstrated a steady increase of 2.3% in might hold and make recommendations for These issues are important to address if
the hamstring injury rate per year, at least clinical practice. we are to have success in implementing

18
 Hamstring injury
25
No hamstring injury
25
Proportion of subjects (%)

Proportion of subjects (%)

20
20

15
15

10
10

5 5

0 0
1 2 3 4 5 1 2 3 4
BW-adjusted quadriceps concentric torque at 60 deg/s (N∙m) BW-adjusted hamstring eccentric torque at 60 deg/s (N∙m)

70 40

60
Proportion of subjects (%)

Proportion of subjects (%) 30

50

40
20
30

20
10
10

0 0
0 20 40 60 80 100 120 140 160 0 5 10 15 20 25 30
Passive knee extension range of motion (º) Ankle dorsiflexion range of motion (cm)

Figure 1: Distribution of injured (closed symbols) and uninjured players (open symbols) for significant variables a) strength and b) flexibility.

prevention programmes in the real world. these two risk factors, one modifiable and two potential theories to explain the
However, there seems to be a “disconnect” the other non-modifiable, may be important. relationship between previous injury
between the identification of risk factors Recent studies from large investigations and subsequent injury28. Firstly, a causal
associated with hamstring injury, and the on risk factors from the Arabic peninsula relationship exists between previous injury
results of injury prevention studies. did not find ethnicity to be associated with and future risk of injury, most likely due to
an increased risk of hamstring injury18,22,23. inadequate rehabilitation. This might lead
NON-MODIFIABLE RISK FACTORS The role of ethnicity and how it may impact to incomplete healing, weakness of the
Age, ethnicity, and playing position injury risk is still poorly understood24. previously injured tissue, and other possible
Age is consistently identified as a risk Predictably, goalkeepers are much functional movement or even psychological
factor for hamstring injury. It is not clear why less likely to sustain a hamstring injury factors that persist after return to sport28.
older players are at greater risk of injury12,18,19. when compared to outfielders. High speed Alternatively, a “no causal marker” theory is
Some theories have been suggested, such running is considered the predominant proposed, where previous injury is simply a
as loss of muscle mass leading to decreased hamstring injury mechanism involved marker for other factors that would cause
strength, and changes in muscle structure. in football, and outfielders are naturally an individual to be at greater risk of injury.
Arnason et al did not find a mediating effect required to do much more running This would suggest that confounding bias is
of previous injury on age, confirming an compared to goalkeepers25,26. present when a history of previous injury is
independent relationship between age and examined as a potential risk factor.
risk of hamstring injury20. However, in a Previous injury is not associated with risk of Recent investigations from Qatar provide
separate investigation, the risk associated injury... wait, what? some interesting results. Previous injury
with increased age was mitigated by A history of previous injury has been was found to be a risk factor in the first study
improvements in eccentric strength21, identified as a risk factor for hamstring over a four-year period. However, during the
suggesting that the interaction between injury11,12,20,27. Hamilton et al explores subsequent two seasons, previous injury

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 19

MERGING RESEARCH WITH CLINICAL PRACTICE

was not found to be associated with an In a comprehensive isokinetic strength attention in the literature, in particular the
increased risk of hamstring injury. assessment in the largest cohort of football hamstrings to quadriceps (H:Q) ratio12,38-40.
To interpret these contrasting results, let us players to date, a significant association was Interestingly, there is inconsistency in
consider the context of this investigation. Two found between lower concentric quadriceps identifying the H:Q ratio as a risk factor for
large randomised control trials (RCT) were and eccentric hamstring strength, hamstring injury, as observed in the meta-
being conducted at the Aspetar Orthopaedic normalised to bodyweight, at slow speed18. analysis by Freckleton and Pizzari12. Several
and Sports Medicine Hospital during this Confirming the results from previous meta- candidate H:Q ratios, both conventional
period. Both studies incorporated a structured analysis12, another large prospective cohort and dynamic entities of mixed isokinetic
criteria-based rehabilitation programme and study indicated that greater quadriceps strength, had no association with
included a large number of football players. strength was associated with an increased subsequent injury.
While the second RCT is currently being risk of hamstring injury22. There has been some debate over how
concluded, the first RCT reported a 12-month The findings in both our studies indicate these ratios are interpreted statistically41.
re-injury rate of 6%29,30, which is low compared that there is a relationship, albeit weak, A ratio assumes that the slope of the
to reports from other football populations31. between strength and risk of hamstring relationship between the logarithmically-
If we consider previous injury a “no causal injury. transformed numerator and denominator is
marker” for other predisposing factors, one. If this assumption is violated, then the
present in certain individuals, our finding Ratios – an imperfect solution ratio will scale inaccurately at the lower and
suggest that the introduction of a systematic, In addition to peak strength measures, higher ends of the range measured, leading
criteria based rehabilitation programme may different strength ratios have received much to errors in interpretation. Also, when
have reduced the risk associated with previous
injury by addressing some of these factors.
Alternatively, if we assume that a causal
relationship exists between previous injury
and subsequent hamstring injury, the player
may have received adequate rehabilitation,
including optimal loading and criteria-
based progression to address predisposing
risk factors32,33. Either way, this study did not
aim to measure the effect of a rehabilitation
programme for hamstring injuries on the
risk of subsequent injury. However, in this
cohort, with the study centre being the focal
point of care for the entire football league, it
seems a plausible explanation. Such an effect
has also been observed in volleyball, where
the association between previous injury
and ankle sprains was no longer identified
after the implementation of a structured
rehabilitation programme34.

MODIFIABLE RISK FACTORS

Strength – an oldie but a goodie?
Isokinetic dynamometer strength
testing is still considered a reliable measure
of determining the strength profile of
individual players35. At the elite level, coaches
and medical staff rely heavily on isokinetic
testing, often making recommendations
for training or rehabilitation based on
the results of these tests17,36,37. Previous
prospective studies have investigated a
host of measures derived from these tests,
including peak torque, both as an absolute
value and normalised to bodyweight,
leading to contradicting results12.

20
 Clinically, it is likely that the strength
of players will change in response
to team training and individual
strengthening regimens. Risk factors
are time-based, and we observe
substantial temporal variability.

normally distributed variables are divided Nordic hamstring strength test may be a demonstrated a significant association
by each other, it is unlikely that the resulting useful tool to the clinician. In fact, it has with increased risk of hamstring injury19.
ratio is normally distributed itself41. arguably been shown as the most effective Interestingly, both these tests represent
intervention tool to reduce the incidence range of motion changes in the posterior
Nordic hamstring exercise – does it deserve of hamstring injuries in football6,7,20. In the kinetic chain.
the attention it’s getting? clinical context, it might still be useful to
Nordic hamstring exercise, performed perform the Nordic hamstring strength The relationship between intrinsic
as a screening test, was previously test to determine a baseline before neuromuscular function and risk of
dichotomised into a pass/fail result based implementing a specific eccentric strength hamstring injury
on range of motion, it was not identified as a training programme. However, in a large It is difficult to encapsulate all the
risk factor for injury42. With the subsequent middle east cohort, eccentric hamstring components necessary for optimal
development of a novel testing device, the strength measured during the Nordic neuromuscular function in one single test,
eccentric force produced during the test hamstring exercise was not identified as or even a combination of variables. Recent
was made measureable43. The novel test risk factor for hamstring injury. investigations into the lumbo-pelvic-hip
device has been used in preseason Nordic complex suggest that the neuromuscular
hamstring exercise strength assessments Flexibility of the posterior thigh and ankle coordination in the posterior kinetic chain
in football and Australian football, with Two studies have reported a significant influences the risk of hamstring injury
these studies reporting players with lower association between hamstring flexibility in male football players61. This suggests a
eccentric strength during the Nordic and injury, measured with the supine protective effect if the global musculature
hamstring exercise being more likely straight leg raise test15,46. In contrast, studies is addressed in terms of neuromuscular
to suffer a hamstring injury21,44. In these that measured flexibility using the active function51,52. In the first investigation of
studies, other potential effect modifiers, and passive knee extension test did report intrinsic neuromuscular function pre-
such as previous injury, age and biceps an association20,42,47. The sit-and-reach test injury, neither rate of torque development
femoris fascicle length, were included in a has also been used to determine hamstring nor the onset of muscle activity for any of
multifactorial model, but did not markedly flexibility, with no association between the concentric or eccentric quadriceps and
improve the association between limb hamstring flexibility and risk of hamstring hamstring isokinetic modes of testing were
strength imbalances with risk of hamstring injury48. Measures other than the tests associated with risk of hamstring injury.
injury45. However, considering that these that measure posterior thigh flexibility Considering previous findings, differences
studies identified increased risk of injury have also been suggested as potential risk in rate of torque development and muscle
with eccentric strength measured during factors49,50. The dorsiflexion lunge test, activity32 are most likely the consequence
the Nordic hamstring exercise, it highlights measuring ankle range of motion, has been of the injury, and both these variables may
the importance of validating these risk investigated previously49. A recent meta- be altered post-injury. Previous findings
factors in different cohorts45. analysis reported conflicting evidence suggest that insufficient capacity to generate
The use of the Nordic hamstring exercise for the ankle dorsiflexion lunge test12. force (altered rate of torque development)
in intervention programmes has been However, both passive knee extension and and delayed muscle activity during the early
successful, and we do not contest that the ankle dorsiflexion range of motion have phase of the movement may represent a

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 21

MERGING RESEARCH WITH CLINICAL PRACTICE

Care structure
Popularity of sport Country
Socio-economic position
Figure 2: A socioecological view

Environmental/policy level
Association of sports injuries that includes
Governance context at multiple levels, i.e.
Policy individual, sociocultural and
Budget Sports environmental. Bolling et al

Socio-cultural level
Sports Medicine (2018):1-8.

Individual level
Level Athlete
Culture
Social structures
Injury
Beliefs
Perceptions
Attitude

reduction in ‘early neural drive’, indicating small sample sizes, with inconsistencies in Is screening a waste of time?
altered neuromuscular function53,54. These the variables reported to have a significant Co-investigations were performed
differences post-injury might be expected association with injury. at the Aspetar Orthopaedic and Sports
to influence the stimulus needed to induce A potential modifiable hamstring injury Medicine Hospital aimed to determine
muscle hypertrophy and sarcomerogenesis, risk is workload (training and match load whether screening is useful to identify risk
predominantly during eccentric contraction, undertaken by the players). In the past factors for hamstring injury, hip and groin
needed for adequate rehabilitation53. It ten years, the number of publications injury, as well as the predictive value of
is important to acknowledge that these investigating the relationship between functional movement screening (FMS)62,63.
measures only represent one aspect of training and injury has increased four-fold; Overall, none of these studies provided any
intrinsic neuromuscular function. yet, our ability to appropriately quantify screening test with high predictive value
Fyfe et al has suggested a conceptual this relationship is still poorly understood. and cannot identify players at high risk of
framework where neuromuscular injury successfully. The large variability we
inhibition persists after hamstring injury, CLINICAL IMPLICATIONS identified between seasons in tests results,
therefore sabotaging the rehabilitation Injury prediction vs risk factor identification together with similar distribution of injured
process, leading to several maladaptations, The purpose of any screening strategy is and uninjured players emphasise the lack
poor outcomes, and elevated risk of re- the early detection of pathology or disease of clinical utility in the current tests used to
injury55. General consensus regarding return (usually in a symptom free population) to screen for risk of injury.
to play criteria after hamstring injury do not allow appropriate and early intervention However, significant group findings of
include an assessment of neuromuscular which hopefully leads to prevention of certain variables associated with increased
function7,56. In fact, due to the difficulty in the pathology, and reduces the morbidity risk of injury were identified. These
defining and assessing neuromuscular and mortality45. In sports medicine, we findings might assist in how we design our
function, it was specifically excluded have adopted this strategy from general prevention programmes, specifically which
from one of the consensus statements57. It medicine, aimed at addressing risk factors to include in a multifactorial injury
raises two questions - are we addressing factors to prevent injury. But it seems prevention model. Verhagen et al uses the
neuromuscular function appropriately in the interpretation of risk identification example of previous injury to demonstrate
our rehabilitation? And secondly, should has been “lost in translation” in sports how we may find meaning in identifying
the player that has suffered a hamstring medicine. One purpose of the periodic at risk players, where the risk interpretation
injury continue to receive training focused health evaluation (screening) may indeed is different for players with a history of
on resolving neuromuscular inhibition even be to identify risk factors present in previous injury68.
after return to play? individuals that may allow early targeted
intervention and prevent injury. However, A complex and temporal problem
Workload – the new kid on the block? as demonstrated in Figure 1, even if the Prospective cohort studies are aimed at
Emerging evidence supports the clinical group average differs, the distribution of identifying certain risk factors associated
hypothesis that the amount of training injured and uninjured players completely with injury, thus “explaining” the injury by
and competition undertaken is related to overlap. We might then question the identifying its cause. Rothman describes
the incidence of injuries and illnesses in value of screening, and ask if we can a cause as an inciting event - either in
competitive athletes58-60. However, to date, still make meaningful conclusions from isolation or in conjunction with other events
investigations into the relationship between the information we collect during the - that initiates or allows a sequence of events
workload and injury have been limited to screening process. which results in an effect (i.e. hamstring

22
injury)64. A cause which inevitably produces subsequent season. Unfortunately, we do WHAT THESE FINDINGS ADD TO OUR
an effect is described as sufficient. Our not monitor how the factors we measure CLINICAL PRACTICE
findings suggest that both strength and change over time, and therefore our To assist the clinician with translating
flexibility are perhaps components in a analyses are based on the assumption that this information into clinical practice, we
larger sufficient cause of hamstring injury. our screening results are “frozen-in-time”; have summarised the findings. The five key
Therefore, by addressing one component representative of that factor at the time of points are:
needed to produce a sufficient cause for injury. The investigation into the stability 1. Strength and Flexibility are weak risk
hamstring injury it is, at least theoretically, of these tests support our clinical intuition, factors for hamstring injuries and
possible that the intervention could prevent that there is substantial variability in continue to form a small but important
the injury from occurring. these measurements over time. It provides part of the causal pathway. Although the
However, these programmes aimed at motivation to move away from isolated evidence for stretching is lacking, multi-
one of the identified risk factors are often time-point testing towards continuous faceted prevention programmes might
not adapted in practice16. Recently, the monitoring of these risk factors, allowing consider including these components
context (and complexity) that underly the the clinician to identify changes in these risk to be successful in the prevention of
implementation of prevention programmes factors, and how these changes might be hamstring injuries.
has been emphasised (Figure 2)65. It is associated with risk of injury. The template 2. Intrinsic neuromuscular function may
important that we include these components for this type of monitoring has been be altered post-injury. Clinicians should
when we plan our prevention strategies. provided in overuse injuries focused around focus on returning the player to full
Without it, successful adoption of the injury burden rather than time loss due to function during the rehabilitation of
intervention remains unlikely. injury66, yet the hypothesis of monitoring hamstring injuries, which may include
Clinically, it is likely that the strength risk factors as an alternative to once-off specific targeted intervention even after
of players will change in response to team screening has not been investigated. As return to play.
training and individual strengthening injury risk is influenced by workload67, 3. Our common strength and flexibility
regimens. Risk factors are time-based, and we might expect that strength and other tests have poor predictive value, and do
we observe substantial temporal variability. factors would be affected. However, we have not possess the characteristics needed
In most prospective risk factor studies, the yet to establish a better understanding of to successfully identify individual
risk factor identification was determined the interactions between these factors, and players at greater risk of hamstring
during a pre-season screening examination, how these factors may respond to different injury. This is evident in the large
and the players were followed for the fluctuation in applied load over time. amount of variability between seasons,

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 23

MERGING RESEARCH WITH CLINICAL PRACTICE

It provides motivation to move away

from isolated time-point testing
towards continuous monitoring
of these risk factors, allowing the
clinician to identify changes in these
risk factors, and how these changes
might be associated with risk of injury.

and poor sensitivity and specificity inciting event we could recreate in a safe Roald Bahr, M.D., Ph.D.
demonstrated for these measurements. way to test risk patterns and behaviour. Professor
The wide overlap in distribution of pre- This would include factors such as fatigue,
Oslo Sports Trauma Research Center
season strength between injured and dual cognitive tasks, and sport specific Department of Sports Medicine, Norwegian
uninjured players demonstrates the movements. Unfortunately, many sports School of Sport Sciences
difficulty in identifying a subgroup of medicine research groups continue to
Oslo, Norway
at-risk players that might benefit from work in silos and ultimately answer similar
targeted intervention. It is therefore research questions, published as isolated
recommended that prevention small studies. The clinical indications Nicol van Dyk, Ph.D.
programs be implemented for all from these results often differ, and with Physiotherapist & Clinical Researcher
players. the discrepancies among studies. A Aspetar – Orthopaedic and Sports
4. Workload monitoring provide another collaborative effort is needed to establish Medicine Hospital
potential way in which we may reduce several well-organised successive research
Doha, Qatar
the risk of injury. The aggregation of studies. This calls for a shared collaboration
chronic workload, as well as careful between institutions and research groups
planning of acute workload increases, to perform collective data analyses and Contact: [email protected]
may reduce the risk of hamstring injury. combine the results of individual projects.
However, high-level evidence to support
this is lacking.
5. Understanding the context in which
injuries occur and appreciating the
complex nature of these injuries are
important considerations to better
manage players with hamstring
injuries.

ADVICE FOR FUTURE RESEARCH

We continue to utilise performance tests
when we assess risk of injury. Perhaps we References available at
need to consider what elements of the www.aspetar.com/journal

24
 IOC Manual of
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MERGING RESEARCH WITH CLINICAL PRACTICE

HAMSTRINGS ARE
DANGEROUS FOR
SPORT AND SPORT
IS DANGEROUS
FOR HAMSTRINGS
– Written by Cristiano Eirale and Jan Ekstrand, Qatar

Analysis of epidemiological studies Hamstring injuries can occur in a variety

assessing sports constantly rank hamstring of sports and movements. A high number
injuries as one of the most prevalent occur in sports where the hamstrings
factors resulting in missed playing time by are stretched eccentrically at high speed Hamstring
lesions can
athletes1-3. One could therefore conclude such as athletics5, and in running contact
that hamstrings are dangerous for sport. sports such as Australian Rules football
Identifying the real incidence of hamstring
injury in each sport is difficult due to the
(AFL)6, American football7 and soccer1,3,8.
Hamstring injuries can also occur in
make up 6 to
varying definitions used by different recreational sports such as water-skiing 25% of injuries,
researchers. However, it seems universally and bull riding, where the knee is forcefully
accepted that hamstring lesions make up fully extended during injury9,10. Within depending on the
sport.
a substantial percentage of acute, sports- individual sports different positional roles
related musculoskeletal injuries with a dictate different physical demands, and it’s
prevalence of 6 to 25%, depending on the seen that hamstring strains are far more
sport4. common in positions in which sprinting is

26
 © FRANCK FIFE/AFP/Getty Images
Image: Lionel Messi touching his right distal hamstrings during the 2013 Champions League quarter of final against Paris Saint Germain.

more often required7,8,11, such as strikers in to more than 80 lost football days and declining from over 40% to an average of
football. 14 missed matches8. Despite a massive 13.5% in the last 3 years. Speculatively, this
amount of recent research and consequent may be the result of more cautious return to
HAMSTRINGS IN SOCCER: THE MAIN prevention programmes, hamstring injury play strategies.
INJURY incidence is not decreasing. These injuries Interestingly, AFL is a good example of
Generally, muscle injuries are common in undoubtedly have an impact on the how the rules of the game can affect the
soccer8. Surveillance of injuries in the UEFA performance of the team and consequently, risk of injury. In 2006 the rules of AFL were
Champions League showed that muscle on a club’s economy. These considerations changed in order to improve the spectacle
injuries make up more than 30% of all aside, when the injured hamstring belongs of the event such that the breaks in play,
player injuries and cause about 1/4 of total to Lionel Messi and the lesion occurs in a and therefore rest time for players, were
time lost due to injury12. Over 90% of muscle crucial period of the Champions League, reduced13. Moreover, rule-makers have
injuries seen in this study involved four the influences become widespread and tried to reduce the amount of ‘dead time’,
major muscle groups of the lower extremity: significant. in order to achieve an effective 80 minutes
hamstrings, adductors, quadriceps and of time ‘in play’. The rule changes also
gastrocnemius8. Injury to the hamstring HAMSTRINGS IN AUSTRALIAN FOOTBALL: effected an increase in the number of player
muscle group is reported to be the most AN EXAMPLE OF HOW THE RULES OF THE interchanges from an average of around 30
common injury subtype representing 12% of GAME AFFECTS INJURIES to more than 100 per team, per game. An
all injuries and more than 1/3 of all strains8. As with the other football codes, analysis of the effect of these rule changes
These normally occur with an acute onset hamstring injuries are responsible for the on injury rate showed them to be protective
(70%) and in a non-contact situation (96%)8. highest number of matches missed (20 per against hamstring injuries. It seemed that
The incidence of hamstring injury during season per club on average), and sprinting the athletes benefited from the increased
matches and training sessions are 0.43 and is seen to be the main mechanism of injury. number of interchange ‘rests’ – players
3.70/1000 hours of exposure, respectively. On average, each AFL club may expect who had seven or more interchanges in
Accordingly, a professional male soccer six hamstring strains per season11. The the previous 3 weeks had approximately
team with 25 players may expect about five recurrence rate (26% on average) has shown 25% less hamstring injuries. On the other
hamstring injuries each season, equivalent a steady drop over the last 21 years (P <0.01), hand, increased interchanges by one team

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 27

MERGING RESEARCH WITH CLINICAL PRACTICE

gave the opposing team a higher number game injuries. They are the second most season. However, since this high incidence is
of hamstring injuries: when a team made common pre-season injury, with an injury not found in the pre-season period for other
60 or more interchanges during a game, rate of 1.79 per 1,000 athlete-exposures sports, training and match strategies should
the opposition had approximately 40% for practices and 4.07 per 1,000 athlete- be reviewed in NFL. Moreover, sport-specific
increased incidence of hamstring injury. We exposures for games22. Furthermore, more conditioning, particularly with regard to
can interpret this data to mean that when than half (53.1%) of all hamstring injuries strengthening and maximum-velocity
players get more breaks during the game, occurred in the 7-week pre-season, before sprinting, is suggested7.
as opposed spending the game chasing the teams had even played their first
‘fresher’ players, they are less likely to get a regular-season game. This data is striking IT’S ALMOST ALWAYS THE BICEPS FEMORIS
hamstring injury. The sum of these opposing when compared with the 16-week regular MUSCLE
forces are that hamstring injury rates have season, in which only 45% of injuries In soccer, as in similar sports24, most (84%)
not fallen, rather their distribution has occurred, and the post-season, in which only hamstring strains affect the biceps femoris1;
changed relative to these interchanges. 1.1% of injuries occurred7. exactly the same results were found in AFL25.
This may point to the role of fatigue in Almost 4/5 (78.9%) practice injuries Interestingly, the percentage of hamstring
hamstring injury, already hypothesised in occurred in the pre-season, with more lesions located at the semimembranosus
soccer, where the rate of hamstring strains than 70% of those occurring in July, the (SM) and semitendinosus were almost
are seen to increase toward the end of each first month of football participation. The identical (11% and 5% in soccer, 10% and
half12. first month of National Football League 6% in AFL, respectively). In accordance with
(NFL) pre-season games, August, is also the the findings in AFL26, Ekstrand et al1 found
HAMSTRINGS AND TRACK AND FIELD: month with the highest incidence of game no relation between the specific muscles
WATCH OVER THE SPRINTERS injuries7. These high pre-season injury involved and lay-off time. There is no
Thigh strain was the most common incidences are devastating not only because preferred leg for a hamstring lesion in soccer:
diagnosis (16%) in sports injury of their immediate impact but also because Ekstrand et al8 found that exactly 50% of the
surveillance studies at the 2007, 2009 and primary hamstring lesions are associated injuries will occur in the kicking leg.
2011 IAAF (International Association of with decreased performance upon return to
Athletics Federations) World Athletics competition and have a high risk of re-injury STRETCHING IS DIFFERENT
Championships14-16. In a recent prospective during the competitive season23. Elliott et Dancers suffer different hamstring in-
study the most frequent diagnosis in al7 explain these results mainly with the juries: their injuries mostly happen during
sprinters was hamstring strain17. In relative deconditioning that occurs in the off- stretching exercises, taking their limb out
athletics, the most common mechanism
of hamstring injury is sprinting18 and the
most common injury site is the long head of
the biceps femoris5. Biomechanical studies
have shown that a powerful eccentric
contraction in the late swing phase is the
likely time when the hamstrings are most
prone to injury19 although others argue that
hamstrings are at higher risk of injury in the
early phase of sprinting20.

HAMSTRINGS IN AMERICAN FOOTBALL:

MIND THE PRE-SEASON
Muscle injuries are a cause of con-
siderable disability in American football
both at senior and high school level21. The
injury rate per 1000 hours of exposure is
0.47 for trainings and 2.7 for matches, with
relative match-training risk of 5.74.
While the impact of hamstring strains
in American Football7 is similar to other
sports such as soccer and AFL, their temporal
distribution is worthy of review, particularly
from a prevention point of view.
The pre-season is seen to be a high risk
period. Muscle strains account for 46% of Image: Paris Saint-Germain training session during their Qatar Tour 2019 in Aspire Zone.
practice injuries and 22% of pre-season Doha, Qatar.

28
 A professional male soccer team may
expect about five hamstring injuries
each season, equivalent to more than
80 lost football days and 14 missed
matches.

to an extreme joint position. These injuries A majority of studies show that re- in AFL and soccer1,25,26,32,33 have shown the
most often involve the proximal free injuries cause longer absence from sport possibility of using MRI to predict lay-off
tendon of the SM muscle and require much than acute injury8,12,31 with just one recent time after hamstring injury. Clinically,
more time to come back to the pre-injury paper showing no difference in lay-off proximity of the injury to the ischial
level24,27,28 than the running type injury seen time between re-injury and first injury1. tuberosity, as estimated both by palpation
in football. This specific mechanism of injury The authors of this recent paper have and MRI, is associated with longer time
with a combination of end range hip flexion speculated that this may indicate that top- to return to pre-injury level24. The size of
and full knee extension can lead to a specific level clubs in Europe have greater medical a strain, as seen on MRI, has the strongest
injury to the proximal part of the posterior support, providing more individualised association with recurrence25,26. While MRI
thigh in other sports as well29, although in rehabilitation for injured players. These seems to have similar potential to evaluate
these sports the stretching to end range workers added that the frequently used the prognosis as clinical examination32,
knee extension combined with full flexion is radiological examinations for diagnostics further subgrouping into injury type,
seen to happen at higher velocity. Clinically and return-to-play decisions could possibly intramuscular location and dimension of
it is imperative to inform the athlete that help to reduce the re-injury rate. pathology might be of additional value
this type of injury, despite its relatively mild in prognosis33. Despite this data, it is our
initial symptoms, generally implies a longer DO WE NEED IMAGING? opinion that ultrasound is at least as valid
return to play time. The majority of hamstring injuries as MRI for the evaluation of hamstring
occurring in players from European high- strains34.
HIGH RATE OF RECURRENCE level professional football clubs were
Together with its high incidence and examined by MRI, US or a combination of PAIN DOESN’T ALWAYS MEAN STRAIN
important time lost from competition, these examinations. Imaging is frequently Not all causes of posterior thigh pain are
hamstring injuries have a high recurrence used to enhance the quality of the diagnosis the result of a hamstring muscle strain35.
rate. As previously stated, in AFL it has in order to better prognosticate healing Ekstrand et al1 have shown that 13% of MRIs
been estimated that 1/3 of all hamstring time and lay-off from football. At the elite performed for a suspected hamstring strain
strains are a recurrence of a previous lesion level, the frequent use of imaging may also are negative.
although quite recently it appears that this be justified by the scrutiny of the media A negative MRI finding in the context
trend is improving, possibly because of a and public of the health of these athletes. of clinically suspected hamstring strain is
more conservative management approach11. MRI has been the preferred modality associated with shorter recovery time1,25,26.
High rates of recurrence have also been in recent years and has offered a highly The actual cause of posterior thigh injury
reported for American football (16.5%)7, detailed imaging analysis of the extent of where MRI shows no pathology is unclear.
rugby union (21%)30 and soccer (16%)8. injury1,25,26. It seems logical that radiological It is possible that these injuries are subtle
In soccer, a study of elite professional severity is correlated to clinical severity, muscle injuries and below the sensitivity
football1 showed that all the re-injuries thus indicating that an MRI examination of MRI detection26. Another explanation
(n=30) were in the biceps femoris muscle done 24 to 48 hours after a hamstring injury is that these athletes in pain may have an
and none to the semitendinous and could provide information about what alternative diagnosis such as back-related
semimembranosus. absence is to be expected. Several studies problem, neural tension or muscle spasm25.

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 29

MERGING RESEARCH WITH CLINICAL PRACTICE

Image: Proximal hamstring

avulsion surgical repair.

SURGERY IS RARE in total days lost due to hamstring injury in reliable injury surveillance methods37. No
Surgical repair is normally reserved Qatar. doubt more dead ends await us, but we can
for ruptures (mainly proximal avulsion hope that this information is feeding back
injuries) but these are rarely seen in football: NOT JUST “A LITTLE HAMMY TEAR” into management and resulting in reducing
the UEFA Champions League hamstrings The deeper we have delved into the burden of this complex and difficult
sub-study has shown an incidence of 3%1. hamstring injury over the last few decades, injury.
Complete avulsions are more common with the more we have learnt as clinicians.
sports such as water-skiing, dancing, weight However, we are clearly still some distance
lifting, and ice-skating. In this case, the away from being able to say that we have This paper originally appeared in Aspetar
mechanism of injury is commonly through solved this problem. Time has been spent Sports Medicine Journal Volume 2, TT 2.
an eccentric contraction with the hip flexed researching novel treatment approaches but
and the knee extended10,36. hamstring management hasn’t (objectively)
gotten much better. Maybe therefore this
HAMSTRINGS IN QATAR is an injury we need to prevent rather
The incidence of hamstrings strain in than treat. The first step in a systematic
professional football in the Qatar Stars approach needed to build an evidence base References available at
League (QSL)3 is almost identical to the for prevention of sports injury is valid and www.aspetar.com/journal
UEFA Champions League (UCL)12 (0.927 vs
0.924/1000 hours). However, the percentage
of hamstrings strains in the total number
of injuries is a little higher (18% compared
with 12% in Europe). More than half of the
observed muscle strains are located in the

Hamstring strains may

hamstrings.
This difference is due to the fact that the
total injury incidence in Qatar is lower than
in Europe, both in training (3.2 vs 4/1000
hours) and in matches (18.9 vs 25.0/1000 be an injury we need to
prevent rather than treat.
hours) (Figure 2).
Similarities between QSL and UCL
have also been found for hamstring strain
severity (18±18 vs 19±17 days), while the
recurrence rate in Qatar is slightly lower
(12 vs 16%), also implying a lower impact

30
 QSL UCL
12%
18%

82% 88%

Hamstrings Hamstrings

Other injuries Other injuries

Figure 1: Percentage of hamstring injuries in Qatar Stars League (QSL) and UEFA
Champions League (UCL).

2a
40
Incidence / 1000h

30

20

10

0
01/02 02/03 03/04 04/05 05/06 06/07 07/08 08/09 09/10 10/11 11/12 Cristiano Eirale M.D., Ph.D.
Sports Medicine Physician
PSG Football Club
2b Paris, France
30.0 Aspetar – Qatar Orthopaedic and Sports
25.0 Medicine Hospital

20.0 Doha, Qatar

15.0
JJan Ekstrand M.D., Ph.D.
10.0
Football Research Group
5.0
Department of Medical and Health
0 Sciences, Linköping University,
2008-2009 2009-2010 2010-2011 2011-2012 Total Linköping, Sweden
Aspetar Orthopaedic and Sports Medicine
Hospital
Training Matches
Doha, Qatar

Figure 2: (a) Match and training injury incidence in UEFA Champions League (2001 to 2012).
(b) Match and training injury incidence in Qatar Stars League (2008 to 2012). Contact: [email protected]

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 31

HAMSTRING – ASPETAR EXPERIENCE

WHAT IS A
HAMSTRING
INJURY?

32
HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 33
WHAT IS A HAMSTRING INJURY?

WHAT IS A
HAMSTRING
INJURY?
AN OVERVIEW OF ANATOMY, MUSCLE
HEALING AND OPTIMAL LOADING
– Written by Robin Vermeulen, Qatar

INTRODUCTION Even more problematic, they have a high 1. semitendinosus (ST) and semimem-
One only needs to look back to the tendency (up to 16%) to re-occur1,2. branosus (SM) form the medial group,
2018 FIFA World CupTM in Russia to see Hamstring injuries receive considerable 2. biceps femoris long head (BFlh) and
that hamstring injuries are still a major attention in both clinical practice biceps femoris short head (BFsh) form
problem in football. In the opening match and research studies. Risk factors are the lateral group.
of the biggest sports event in the world, investigated, rehabilitation trials are The hamstrings are a major knee flexor
Russian midfielder Alan Dzagoev sustained conducted, and prevention efforts are and hip extensor. Furthermore, they
a hamstring injury in the 22nd minute. He studied to better manage this common act as the antagonist to the quadriceps
was set to miss the rest of the World Cup but football injury. However, to support these muscle and also prevent excessive anterior
luckily he recovered, and was able to play a efforts in managing this very common but translation of the tibia. Separately, the
major role in the quarterfinals. complex injury, we must first revisit the medial group assists with internal rotation
This is just one example of the many basics. and the lateral group with external rotation
hamstring injuries that affect football of the tibia (and they act as antagonists in
players and athletes every year. In fact, THE ANATOMY OF THE HAMSTRINGS this regard)3.
hamstring injuries remain the most The hamstring muscle group Although the hamstrings function as
frequent muscle injury in elite football, (Figure 1) consists of four muscles divided a group, the individual muscles all vary
accounting for 34% of all muscle injuries1. into two groups: significantly in morphology, architecture,

34
 1 2

tendon
Free
Intramuscular
tendon
Figure 1: Anatomy of the
hamstring muscles. 1
Semitendinosus muscle. 2
Raphe. 3+4 Length and width
of raphe. 5 Semitendinosus
tendon. 6 Biceps Femoris Long
Head. 7 Biceps Femoris Short
Head. 8 Distal tendon of Biceps
Femoris. 9 Ischial tuberosity. 10
Conjoint tendon. Reproduced
from van der Made et al Knee
Surg Sports Traumatol Arthrosc.
2015 Jul;23(7):2115–22 with
permission of copyright owner.
Figure 2: Schematic overview
of free tendon, intramuscular
tendon and the relationship of
proximal (combined free and
intramuscular tendon) versus
distal tendon. Reproduced from
van der Made et al Br J Sports
Med. 2018 Jan;52(2):83–8 with
permission of copyright owner.

and injury mechanisms. Many have to its raphe (discussed in following section). league (AFL) and rugby; but high quality
hypothesised correlations between ham- These motor branches split proximally for evidence is still lacking7,8.
string anatomy and injury patterns, but to the BFlh and ST and more distally for the
date no strong clinical evidence exists for SM, BFsh and the distal part of the ST (past Biceps Femoris long head
any of these hypotheses4. However, we do the raphe)3. The BFlh has received much research
have a growing understanding of the type Currently, hamstring injuries involving interest as it is the most commonly injured
of injury and their overall rehabilitation the intramuscular tendon (sometimes muscle of the hamstring group (more than
period. referred to as the central tendon) are 80%)1. It is most frequently injured during
The proximal myotendinous junction is receiving much attention in the literature6–9. sport involving high speed running such as
the most injured location in acute hamstring The intramuscular tendon is defined by van football, AFL, rugby and athletics; injuries
injuries and these injuries generally have der Made et al as ‘’the part of the tendon to occur predominantly in the proximal
a shorter return to play time than injuries which the muscle fibres attach’’ (Figure 2)6. In musculotendinous junction (MTJ)10,11. The
affecting the free tendon (Figure 2). Likewise, a study compromised of primarily football BFlh shares its proximal origin with the ST
complete avulsions occur predominantly players, a full thickness injury accompanied muscle at the posteromedial aspect of the
in the proximal tendons but fortunately, by a wavy appearance of the tendon ischial tuberosity12. At the posterior margin
avulsions are rare. This rarity, however, can increased return to play by ten days6. of this origin, the sacrotuberous ligament
make it a blind spot for clinicians5. However, there was no difference in re-injury commonly inserts into (and is continuous
The hamstrings are innervated by the rates as compared to non-intramuscular with) the conjoint tendon and ischial
sciatic nerve and its subdivisions, the tibial tendinous injuries6. At the same time, it tuberosity. The sacrotuberous ligament
branch (BFlh,SM,ST) and the fibular branch is important to recognise that due to the might play an important role in complete
(BFsh) (Figure 3). All muscles are innervated different biomechanical demands, these (re-) tendinous avulsions; if it stays intact the
by one motor branch, except for the ST injury rates might be higher in other sports muscle tends to retract less than when it is
which is innervated by two branches due such as (elite) athletics, Australian football disrupted (Figure 4)13.

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 35

WHAT IS A HAMSTRING INJURY?

a
The conjoint tendon is shaped like an
oval at the origin and as it travels into the
muscle belly of the BFlh it becomes more
sheet-like in appearance. The (common)
distal tendon overlaps with the proximal
tendon and has a bifurcated insertion into
the posterolateral edge of the head of the
fibula (direct arm) and the lateral edge of
the head of the fibula (anterior arm)14. The
distal biceps tendinous insertions have an
important function as dynamic stabilisers
of the posterolateral knee complex and run
close to the common peroneal nerve, which
can cause an entrapment neuropathy15.

Semimembranosus
In professional football, the SM muscle
is the second or third most injured muscle
b of the hamstring group, depending on the
study (interchanging with the ST)11,16. Injuries
occur predominantly in the proximal MTJ. In
other sports such as ballet the proximal free
tendon is the most injured location and this
injury is recognised as being of the slow-
speed stretching type17. The SM originates
anterolaterally from the common BF-ST
origin at the ischial tuberosity, where it has
a crescent-shaped footprint. Its proximal
tendon is the longest of all the muscles in
the hamstring group and starts out as an
asymmetrical, aponeurotic sheath before
any fascicles attach to it at around 10 cm
from the ischial tuberosity18. The distal
insertion of the SM is varied and complex,
but at least three major insertion points
have been recognised in the literature19:
1. The oblique popliteal expansion, that
runs across the popliteal fossa from its
c proximal superomedial aspect to its
distal inferolateral aspect and inserts
into the posterior capsule,

Figure 3: Hamstring innervation (lateral view)

a-c. 1 Ischial tuberosity. 2 sciatic nerve. 3
motor branch to BFlh. 4 recurrent branch
to the proximal attachment of conjoint
tendon. 5 motor branch to the ST. 6 motor
branch to the SM. 7 motor branch to the
BFsh. Reproduced from Stepien et al Knee
Surg Sports Traumatol Arthrosc (2018) with
permission of copyright owner.

36
 STL STL STL

explained due to the fact that they share a

distal MTJ.
The BFsh muscle is the only muscle in
the hamstring group that does not have
a proximal tendon but its fibers originate
directly from the linea aspera, the lateral
TUB TUB TUB intermuscular septum and the lateral
supracondylar line.

MUSCLE HEALING – A SIMPLIFIED

OVERVIEW
As clinicians dealing with hamstring
muscle injuries, it is pivotal to understand
BF/ST BF/ST BF/ST the basics of muscle healing to optimise
our rehabilitation of these injuries.
Simultaneously, this knowledge is useful
to manage stakeholder expectations
Figure 4: Schematic drawing of relationship of Sacrotuberous Ligament (STL) to the ischial and most importantly, the athlete’s risks
tuberosity (TUB) and the conjoint tendon (BF/ST). BF/ST retraction might be less with an of (early) return to sport. Most muscle
intact STL. Reproduced from Bierry G, Simeone FJ, Borg-Stein JP, Clavert P, Palmer WE. injuries happen at the MTJ. This area is
Sacrotuberous ligament: relationship to normal, torn, and retracted hamstring tendons on MR frequently thought of as the weakest link
images. Radiology. 2013;271(1):162–171 with permission of copyright owner.
in the chain, because the MTJ is where the
projections of the myofibers interface with
the connective tissue23. These projections
maximise surface area and thus provide
2. the anterior expansion, that runs to ‘strut’ that divides the ST into two regions. better mechanical force transmission be-
the anteriomedial part of the knee and It is thought that this raphe, together with tween the muscle and the extracellular
inserts in the medial meniscus and the the ST having the smallest physiological matrix23. Whenever an injury occurs at
medial collateral ligament, and cross-sectional area of the all the hamstring the MTJ several distinguishable phases of
3. the direct expansion, that inserts into muscles, might be protective against healing happen23–25. For example, during
the medial tibial condyle and the fascia injury18. The distal tendon of the ST is the a hamstring injury, the myofibers are
of the popliteus muscle. These distal longest free tendon of the hamstrings. For disrupted, and their associated basal lamina
insertions contribute to the stability this reason, it is commonly harvested for use and blood vessels rupture and retract. This
of the posteromedial knee complex. in ACL and other ligament reconstruction leaves a gap in the junction which is filled in
Similar to the BFlh, the proximal and surgeries20. It inserts into the anteromedial with hematoma rich in monocytes. These
distal tendon overlap3,12. side of the tibia. Just proximal to this monocytes remove necrotic tissue through
insertion it fuses together with the Gracilis, phagocytosis. Subsequently, myoblasts (for-
Semitendinosus and this combined tendon, together with med from satellite cells) appear around
As described previously, the ST is the the insertion from the Sartorius muscle, the damaged fibers and fibroblasts appear
second or third most injured muscle in the form the Pes Anserinus. Along the way, the in the gap. To replace damaged muscle
hamstring group, depending on which ST tendon can give off aponeurotic bands fibers, myoblasts merge together to form
literature you consult. It shares most of its to various structures such as the medial myotubes in the old basement membrane
tendinous origin with the BFlh but a small gastrocnemius, popliteal fascia and various which functions as a scaffold for the dura-
amount of muscle fibers arise directly from parts of the tibia21. tion of myofiber regeneration whilst ne-
the ischial tuberosity. This common tendon crotic tissue is removed by macrophages25.
is mostly occupied by the muscle fibers of Biceps Femoris Short Head With subsequent maturation of these
the ST. More distally, the fibers of the BFlh The BFsh is an often underappreciated myotubes into new myofibers they form
arise (around 10 cm from the ischium). part of the hamstring group due to the their own basement membrane and the old
Unlike the BFlh and SM, the proximal and low injury rates in this muscle, which may one is shed25. Fibroblasts deposit scar tissue
distal tendon of the ST do not overlap. be related to its uni-articular nature. In in the gap and as this scar tissue matures,
Going from proximal to distal in the ST, you isolation it accounts for 7% of the injuries it forms new MTJs with the stumps of the
encounter a reverse V-shaped tendinous to the distal MTJ of the lateral hamstring damaged fibers24. This maturation is driven
inscription called the raphe. Currently it is complex22. Unsurprisingly, an injury to the by mechanical loading. This is exactly the
still unclear what the function of this raphe BFsh occurs more frequently in conjunction process where the clinician can provide the
is, though it might function as a sort of with an injury to the BFlh22. This might be most benefit through mechanotherapy.

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 37

WHAT IS A HAMSTRING INJURY?

OPTIMAL LOADING – HOW TO OPTIMISE myotubes, resulting in less disorganised players. The MTJ is the most injured location
MECHANOTHERAPY scar tissue and normotrophic uninjured and requires a balanced but active approach
In elite sports it is of paramount myotubes26. in treatment. Considering the anatomy,
importance to get an athlete ready to return Traditionally, management of acute physiology and mechanotherapy presented
to sport as soon as possible after an acute hamstring injuries (or other acute muscle here, we might suggest a basic clinical
hamstring injury. It is a blend of art and injuries) included a set amount of days of guideline:
science to balance the exposure to sufficient treatment with (P)RICE, usually combined Respect the healing tissue, but start
load in a safe and efficient manner, and with passive/active stretching before active loading early!
minimising the risk of worsening the injury, loading is commenced. However, there is no  
thus delaying the return to sport process. It strong evidence supporting this approach
requires a lot of decision making concerning when managing acute hamstring injuries
the micro-environment (e.g. tissue healing), in the early period. Bleakley et al already
the macro-environment (e.g. re-injury suggested a revision of this model called
risk management, retaining fitness, POLICE, adding in Optimal Loading (OL)
external pressures) and their interaction. as a replacement for Rest (R)27. The aim is
In this section we will focus on the micro- to encourage clinicians to think about the
References available at
environment, i.e. tissue healing, as it is optimal progression of rehabilitation and
www.aspetar.com/journal
modifiable through mechanotherapy. apply an appropriate loading strategy during
The underlying mechanism for mecha- the first crucial days of rehabilitation27. Most
notherapy is mechanotransduction, which likely, relative rest is not ideal as confirmed
is defined by Khan and Scott26 as ‘the pro- by recent studies suggesting that an early Robin Vermeulen M.D.
cesses whereby cells convert physiological start with rehabilitation expedites return to Ph.D. candidate
mechanical stimuli into biochemical sport.28. Research Department
responses’. Muscle is already a highly
Aspetar Orthopaedic and Sports Medicine
adaptive tissue and this is reflected in CONCLUSION
Hospital
the process of mechanotransduction as The hamstrings are a heterogeneous
Doha, Qatar
well: loading the newly formed scar tissue and complex group of muscles that require
facilitates maturation through better an in depth knowledge of the anatomy to
alignment and faster regeneration of accurately diagnose and treat our football Contact: [email protected]

38
HOW DOES IT HAPPEN?

THE ARCHITECTURE
OF A HAMSTRING
STRAIN INJURY
– Written by Fearghal P. Behan, Qatar, Ryan G. Timmins and David A. Opar, Australia and Qatar

INTRODUCTION connective tissue) and the angle of these at 4.4 times greater risk of a subsequent
In previous issues of the Aspetar Sports fascicles relative to the tendon (pennation HSI than stronger players9. If high levels
Medicine Journal, risk factors for hamstring angle), within a given muscle (Figure 1). of eccentric knee flexor strength and long
strain injury (HSI) have been thoroughly The majority of the research on muscle BFlh fascicles were present, the likelihood of
reviewed1,2. These articles identified age, architecture concentrated on performance a future HSI in older athletes or those with
previous injury, strength and perhaps parameters of these architectural variables a HSI history was reduced9. The presence
flexibility as the main risk factors for HSI (e.g. relationship of fascicle length and of short fascicles and lower eccentric
after rigorously reviewing the literature1,2. In running speed) in a variety of muscles6,7,8. strength is now affectionately known as
recent years large prospective cohort studies However, an Australian research group the ‘quadrant of doom’ (Figure 2). These
have confirmed a significant, albeit weak, completed a series of studies that results suggest, albeit indirectly, increasing
association between strength and flexibility demonstrated shorter fascicle lengths of biceps femoris fascicle length in concert
as risk factors for HSI, alongside age, body the biceps femoris long head (BFlh), the with improvements in eccentric hamstring
mass and playing position3,4,5. However, most commonly injured hamstring muscle strength may be an effective strategy for
more recent research efforts have focused in high speed running, were associated reducing HSI injury risk.
on muscle architecture and its relationship with an increased risk of HSI8,9. Initially, a The mechanism by which shorter
with risk of hamstring injury9,13. retrospective design showed fascicle length fascicles are more prone to injury remains
of previously injured BFlh was significantly ambiguous. Theoretically, shorter fascicles,
MUSCLE ARCHITECTURE AND ‘THE less than the contralateral BFlh8. This same with presumably fewer sarcomeres in
QUADRANT OF DOOM’ research group, using a prospective study series, will be more susceptible to damage as
Muscle architecture assessment is per- design in 152 Australian soccer players, a consequence of sarcomere ‘popping’ while
formed using two-dimensional ultrasound demonstrated that athletes with shorter lengthening10. It could then be hypothesised
to determine the muscle thickness (distance BFlh (<10.56 cm) were 4.1 times more likely that fascicle lengthening may be mediated
between superficial and deep/ intermediate to sustain a HSI than those with longer by the addition of in-series sarcomeres that
aponeuroses), fascicle length (a fascicle is fascicle lengths9. Also, athletes with lower would reduce excessive lengthening of each
a collection of muscle fibres wrapped in eccentric hamstring strength (<337 N) were sarcomere during eccentric exercise10-13.

40
Fortunately, clear clinical strategies are
available to alter fascicle length in hamstring
muscles utilising eccentric strengthening.

IT WORKS IN THEORY BUT NOT IN

PRACTICE?
Repeatedly, eccentric strength training
intervention studies have demonstrated
an increase in fascicle length of the
BFlh14-17, with concentric interventions
demonstrating a decrease in fascicle
length15,18. These varied interventions
include: isokinetic dynamometry15, leg-
curls14,18, 45° hip extensions16 and the Nordic
Hamstring Exercise (NHE) (Figure 3)16,17.
The NHE in particular has received much
interest in the HSI literature16,17,19,20, with
clear evidence from robustly designed Figure 1: An ultrasound image of the biceps femoris long head.
randomised controlled trials of a reduction
in HSI19,20. Furthermore, a recent systematic Injured
review has further demonstrated the
Uninjured
efficacy of the addition of the NHE into HSI
prevention programmes, displaying a 51%
reduction in HSI risk with the inclusion of
this exercise21. 14
Due to the significant success of the NHE
in reducing HSI, it has been described as a
Fascicle length (cm)

hamstring injury ‘vaccine’ and may well be

seen by some as the panacea for hamstring 13
injury prevention. If this is the case, surely
then HSI rates must be reducing dramatically
since all of this level 1 evidence has
emerged? In elite European football (soccer), 10
hamstring injuries rates have not changed
(or even slightly increased) between 2001
and 201422. High speed running demands
may have increased in elite football during 0
this period which could partly explain
0 200 400 600
the increased injury rates. An apparent
contradiction exists between the effective Nordic strength (N)
method for reducing hamstring injuries
Figure 2: Distribution of biceps femoris fascicle length (y-axis) and eccentric Nordic
(with evidence from rigorous randomised hamstring exercise (NHE) strength (x-axis) for the injured (blue) and uninjured (grey) players.
controlled trials) and reports of increasing The bottom left quadrant represents the greatest proportion of injured players known as the
hamstring injury rates. In response, a “quadrant of doom.” The distribution of injured and uninjured players are demonstrated for
follow-up study of elite football teams was each variable at the top (eccentric NHE strength) and right (fascicle length) of the graph.
undertaken to investigate their adherence With permission from Nirav Maniar.
to the evidence-based exercise programmes
involving the NHE23. Staggeringly, more Most of the NHE programmes used intervention based study compared a high
than 83% of the clubs were seen as non- a progressively increasing high volume volume to a low volume NHE programme17.
compliant with the exercise programme prescription: within 5 weeks of commencing The low volume group commenced with
outlined in the randomised control trial the exercise, athletes are asked to complete two weeks of relatively high volume, where
by Petersen et al20,23. Of course, a ‘vaccine’ up to 3 sessions a week, each session for two days that week they completed four
will never be effective if it is not actually comprising of 3 sets of up to 12 repetitions per sets of six repetitions of the NHE, similar
taken. Perhaps the exercise dosage has set20. The lack of adherence in elite football to the high volume group. Thereafter, the
been excessive in previous studies and not might be in response to the volume of the low volume group only completed one
feasible for sporting implementation. training programme, therefore, a recent session a week of 2 sets of 4 repetitions,

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 41

HOW DOES IT HAPPEN?

while the high volume group increased

in volume up to 5 sets of 10 repetitions
(Table 1). Surprisingly, both groups had
similar increases in eccentric knee flexor
strength and BFlh fascicle length, with no
statistical differences between the two
groups for either variable in response to
training17. Although this study did not report
prospective injury rates, it is very promising
regarding the effectiveness of a dramatically
lower volume of NHE on indirect markers of
HSI risk.
It would be logical that an athlete
already engaging in on-field training,
strength training, and competitive matches
Figure 3: The Nordic Hamstring Exercise.
would be much more likely to adhere
to 8 repetitions a week of NHE, rather
than over 90 repetitions per week, as per
previous protocols20. Investigations on the
effectiveness of even lower doses of NHE
on these variables has already commenced
and soon a minimal effective dose may
be established. Hopefully, these lower
volume interventions can subsequently
be implemented in prospective trials to
investigate their effect on HSI levels directly.

NOT THE ONLY ONE

Although much of the research discussed
involves NHE, this exercise certainly is
not the only show in town for improving
strength and architectural parameters. This
was well demonstrated in a recent trial com-
paring the NHE to the 45° hip extension16.
The two exercises resulted in similar
outcomes for both BFlh fascicle length and
eccentric knee flexor strength16. Alongside
previous alternative exercise protocols that
increased both eccentric strength and BFlh
fascicle length14,15,18, these findings illustrate
the options and variety available in exercise
prescription. It is apparent that eccentric
hamstring interventions can be altered,
adapted, progressed, and varied depending
on the reasoning of skilled practitioners,
always with consideration for athlete
preference and adherence.

CAN WE (RELIABLY) MEASURE

ARCHITECTURE OUTCOMES?
If you’re convinced that assessing
muscle architecture may be a worthwhile
and valuable method to add to your injury
prevention and rehabilitation toolkit, you
may ask how reliable are the available Figure 4: DTI MRI images of the biceps femoris long head.

42
 Table 1

High Volume Intervention Low Volume Intervention

Week Frequency Sets Reps Total Reps Frequency Sets Reps Total Reps

1 2 4 6 48 2 4 6 48

2 2 4 6 48 2 4 6 48

3 2 4 8 64 1 2 4 8

4 2 4 10 80 1 2 4 8

5 2 5 10 100 1 2 4 8

6 2 5 10 100 1 2 4 8

Total 440 128

Table 1: Low and High dose Nordic hamstring exercise strengthening interventions (adapted from Presland et al17).

methods of assessment? Analysing these clinical practice for BFlh28. Unfortunately, References available at
variables (muscle thickness, fascicle length, this simplified version does not compare www.aspetar.com/journal
pennation angle) utilising ultrasound favourably with ultrasound and does not
in BFlh has yielded very positive results. appear accurate enough to recommend
Excellent reliability has been reported at rest for clinical practice28. Therefore, at present
and under varying intensities of isometric for the assessment of muscle architecture,
contraction8. The comparison between mea- ultrasound remains a reliable and valid
suring BFlh with ultrasound and directly method and certainly the most convenient.
through cadavers has also demonstrated With the available expertise, specialist
robust outcomes24. Although there are DTI processing is an intriguing area with
clear limitations with measuring a three research currently being undertaken, and it
dimensional structure in two dimensions, may find its way into clinical practice in the
certainly it seems to be a reliable, valid near future. Fearghal P. Behan Ph.D.
and cost effective method for assessing
Research scientist
or monitoring muscle architecture6,8,24, CONCLUSION
particularly with the development of Many questions remain regarding the Aspetar Orthopaedic and Sports Medicine
Hospital
improved methodology25. Technology has role of muscle architecture in hamstring
inevitably introduced advanced methods injuries. Future prospective studies Doha, Qatar
for assessing muscle architecture, including assessing architectural variables would
diffusion tensor magnetic resonance be informative for this area. However, Ryan G. Timmins Ph.D.
imaging. These methods have produced presently muscle architecture appears to
Lecturer in Exercise Science
fascinating images and demonstrated be a valuable target to assess and include
exceptional results for muscles such as the in injury prevention programmes within
gastrocnemius and soleus26,27. However, sports medicine. The importance of muscle David A. Opar Ph.D.
this imaging technique is expensive and architecture in rehabilitation is also Senior Lecturer in Exercise Science
requires specialised, time consuming currently being investigated. In the coming
post-processing. We recently investigated years, we might be able to inform clinicians
School of Exercise Science, Australian
whether a simplified diffusion tensor on the effectiveness of various interventions Catholic University
imaging (DTI) analysis method (Figure on muscle architecture and hamstring
Melbourne, Australia
4), that could be feasibly implemented strain injury prevention, rehabilitation and
clinically, was reliable or sensitive enough successful return to play. Ultrasounds at the
to be recommended in musculoskeletal ready…. Contact: [email protected]

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 43

WHAT IS THE DIAGNOSIS?

HAMSTRING
INJURY
A CLINICAL DIAGNOSIS
– Written by Johannes L Tol, Qatar and Arnlaug Wangensteen, Norway and Qatar

INTRODUCTION or avulsion of the tendinous insertions by itself provide an accurate diagnosis in

An accurate diagnosis is essential to (with or without a bony fragment) usually many cases. Even in the acute situation on
ensure that the injured athlete receives have a worse prognosis and in some cases, the field, the athlete will tell you in that he
appropriate treatment and rehabilitation, surgery may be warranted9,10. Therefore, an has sustained a hamstring injury and, in the
and correct information related to the important goal of these initial investigations majority of the cases, is unable to continue.
prognosis1. In most cases the diagnosis is is to identify those infrequent yet severe The patient history provides an important
straightforward and already put forward by cases where surgical treatment might be overall picture of the injury situation and
the athlete himself. However, these ‘simple’ indicated9. a preliminary impression of the injury
cases might not be as simple as initially severity. In order to get a good assessment
expected. CLINICAL EXAMINATIONS of the injury situation, the clinician gathers
The diagnosis and prognosis for time to The initial clinical examination starts information about:
return to sport (RTS) after acute hamstring with a comprehensive medical history 1. the injury mechanism (i.e. high-speed
injuries are mainly based on a comprehen- taking followed by specific physical asses- running or more slow stretching related
sive clinical examination2–7. In cases where sments and tests2,3,5, preferably performed type of injury)5,17,
the clinical appearance and severity is within the first days after injury5,11–15. An 2. whether there was a sudden onset with
unclear, determining the optimal treatment early initial clinical diagnosis is essential to sharp/severe pain in the posterior thigh,
can be difficult. Additional radiological initiate optimal loading and rehabilitation 3. if the athlete was forced to stop
imaging is often used to confirm the after the injury3,4,16. immediately, and
diagnosis and to provide information about 4. an audible ‘pop’.
the severity and the location of the injury. PATIENT HISTORY This can aid the clinician in confirming
This information can provide guidance Patient history is considered the foun- the diagnosis, and might give some
for further treatment8. Complete ruptures dation of the diagnosis. In fact, it might indication about severity6,7. Commonly,

44
subjective pain at the time of injury is commonly seen in patients sustaining a most likely occurs during this terminal
measured with a visual analogue scale proximal hamstring tendon avulsion injury. swing phase of high-speed running.
(VAS) or a numeric rating scale and higher Recently, an alternative injury mechanism During this terminal swing phase, the
scores have been associated with longer was suggested in a smaller case series peak hamstring musculotendinous stretch
time to full RTS18. (n=3), involving a substantial hip abduction seems to occur, and is significantly greater
component (flexion-abduction injury for biceps femoris (probably because of a
INJURY MECHANISM mechanism)26. The biceps femoris long head shorter knee extension moment arm)30.
Injury type and injury situation / mechanism is reported to be the most frequently injured However, controversies exist and the early
The evidence regarding the actual injury muscle21,27–29. stance phase has also been suggested as
mechanism related to acute hamstring Biomechanical studies show that the highest risk period during the gait cycle,
injuries is limited, and the subject of much hamstrings are most active from the mid- since the hamstring muscles are also
debate. The majority of hamstring injuries swing until the terminal phase of the stride working against potentially large opposing
are reported to occur during high-speed cycle during running and sprinting30–34. forces42.
running when the athlete is accelerating or It actively lengthens during the terminal
running at (or close to) maximal speed13,17,19–22 swing phase with a combination of hip RED FLAGS DURING HISTORY TAKING - DO
typical in sports like football20,21, rugby23, and flexion and knee extension, absorbing NOT MISS COMPLETE AVULSIONS
athletics13,24. Another hamstring injury type energy from the decelerating limb in To rule out more severe injuries, consider
is referred to as the slow-speed stretching preparation for foot contact6. a combination of signs and symptoms
type of injury17, occurring during slow Muscle strain injuries during high- that include excessive pain located at the
movements with excessive stretch and speed running are thought to occur during tendons insertions (proximally at the ischial
large joint excursions including hyper- eccentric muscle contractions when the tuberosity or distally); and typical acute
flexion of the hip combined with knee muscles are lengthened while producing injury situations with a mechanism of
extension, typically seen in dancers14,25. forces35,36. Other biomechanical studies37–41, extreme hip flexion with the knee extended
Other injury situations, such as kicking, including two independent case reports (e.g. sagittal split or falling forwards with
high kicking, glide tackling, twisting and with video footage of hamstring injuries the upper body while the leg is fixated to
cuttings are also reported17,19. Hip hyper- occurring during high-speed running38,39,41, the ground). Combined with an audible
flexion combined with knee extension is have hypothesised that hamstring injuries ‘pop’, this should raise concern for a possible

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 45

WHAT IS THE DIAGNOSIS?

Box 1: Clinical features suggestive of proximal

hamstring tendon avulsion injury44
isometric pain provocation, and muscle
Clinical features suggestive of proximal hamstring tendon avulsion injury
strength testing2,5,6,11. Pain provocation tests
• Trauma mechanism involves combined hip flexion with knee fully extended
and deficits compared to the contralateral
• Tearing or popping sensation
uninjured leg are usually registered5. A
• Severe pain, sitting is painful
VAS or a numeric rating scale is used to
• Severe loss of function, walking is difficult
• Extensive posterior thigh bruising appears within days quantify the athlete’s subjective pain5,45
• Pain on palpation of ischial tuberosity during flexibility and strength testing. To
• Palpable loss of bone-tendon continuity during resisted knee flexion measure side-to-side differences in ROM
and muscle strength, objective assessment
Pitfalls tests use goniometers or inclinometers and
• Bruising can be subtle, located only at the proximal part of the back of the knee hand-held dynamometers5,11,15,46. Hamstring
• Loss of function (knee flexion) may not be complete, as it can be masked by flexibility of the injured leg is usually
intact gastrocnemius muscle function reduced compared to the uninjured leg after
• Range of motion (straight leg raise and active knee extension test) may be full acute hamstring injury5,6,11,47, and commonly
or even more than the contralateral leg examined in conjunction with other
assessments to establish a diagnosis.
Key differences with acute partial-thickness hamstring injury The active and passive straight leg
• Trauma mechanism typically involves high-speed sprinting raise tests and active and passive knee
• Mild loss of function extension tests are most commonly
• Bruising is limited if present referred to in the literature following
• Pain on palpation of muscle belly only hamstring injuries5,11,15,48–50. In studies among
• Range of motion is reduced healthy participants, these flexibility tests
demonstrate moderate to good reliability49.
total rupture of the proximal tendon(s), not completely exclude complete avulsions But since these tests are usually limited by
and further radiological investigations are and without the need to flag every patient, pain and discomfort in an acutely injured
indicated10. Less common in football, the clinicians should be aware of the risk that athlete, reliability results from healthy
type of sport may lead to a suspicion of a these injuries might be missed (see Box 1)44. participants may not be directly applicable
complete rupture; for example, water skiers to injured athletes. To date, only one study
are at a high risk of avulsion injuries8,43. PHYSICAL ASSESSMENT has reported on the reliability of flexibility
Red flags on history taking include The physical assessment starts with testing in athletes with acute hamstring
pain on sitting, severe loss of function and observation of gait pattern and function, injuries50, showing good intertester
force on isometric contraction, as well as followed by inspection of the injured area, reliability for the active and passive knee
difficulty when walking. Extensive bruising palpation of the hamstring complex, active extension tests. Pain with isometric
after some days are indicative of a complete and passive flexibility and range of motion contraction and hamstring muscle strength
avulsion. However, absence of these signs do (ROM) testing of the hip and knee joint, deficits compared to the uninjured leg is

Simple clinical tests allow the

practitioner to perform a reliable
assessment to confirm the presence of
hamstring injury. A lack of flexibility,
strength, and pain on palpation are
the main objective features, but more
importantly, listen to the athlete.
46
commonly present initially after an acute
hamstring injury5,6,51. Just recently, a meta-
analysis reported that lower isometric
strength was found in the first week post-
injury, but did not persist beyond seven
days51. However, there are few studies that
have reported strength deficits immediately
after the injury, as the focus in the literature
mainly has been directed towards isokinetic
and eccentric strength deficits at or
after RTS51. Additional neurological and
diagnostic tests may also be performed to
rule out other possible sources of posterior
thigh pain6,52,53.
In adolescents reporting an acute onset
injury, the possibility of an apophyseal
avulsion fracture must be excluded54,55. The
cartilaginous growth plates at the apophyses
of adolescents are more vulnerable than
other parts of the musculotendinous unit,
and are the first to fail, resulting in avulsion
fractures. The pain is typically more severe
during activity and decreases with rest,
and clinical examination reveals local
tenderness, reduced ROM and swelling56.
Radiography (X-ray) of the pelvis in at least
two planes should be performed in athletes
with typical clinical findings and a relevant
history of trauma54.

POST RETURN TO SPORT: CLINICAL

FOLLOW-UP
In daily clinical practice, an athlete is CONCLUSION Johannes L Tol M.D., Ph.D.
generally regarded as being fit to RTS if there Simple clinical tests allow the practitioner Sports Medicine Physician
is an absence of pain on palpation, absence of to perform a reliable assessment to confirm
Aspetar, Orthopedic and Sports Medicine
pain during strength and flexibility testing the presence of hamstring injury. A lack of
and asymptomatic completion of sports- flexibility, strength, and pain on palpation Hospital,
specific testing. Despite this approach, re- are the main objective features, but more Doha, Qatar
injury rates remain high during the first two importantly, listen to the athlete. Very often
months after RTS57. elite athletes know their bodies well or Amsterdam University Medical Centers,
Clinical examination during the first have experienced similar injuries before. A Academic Medical Center, Amsterdam
week after RTS has been shown to be of detailed account of the injury mechanism Amsterdam Movement Sciences, Academic
significant value for identifying athletes at and situation may provide valuable Center for Evidence Based Medicine,
risk for re-injury. Significant independent information in the assessment process. Amsterdam IOC Center, ACHSS
predictors are the presence of localised Understanding the goals and expectations Amsterdam, The Netherlands
discomfort on posterior thigh palpation, of the athlete will ensure that both athlete,
more degrees of active knee extension support team and medical team are all Arnlaug Wangensteen Ph.D.
deficit, and isometric knee flexion force aligned to provide the best possible outcome
Physiotherapist
deficit at 15°58. With easy-to-assess clinical for the individual.
evaluation—performed by clinicians or Oslo Sports Trauma Research Center,
physiotherapists—those athletes with an Department of Sports Medicine, Norwegian
School of Sport Sciences
increased re-injury risk can be identified.
These findings emphasise that it is of major Oslo, Norway
importance to monitor the athlete in the References available at
first week after RTS58. www.aspetar.com/journal Contact: [email protected]

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 47

HAMSTRING – ASPETAR EXPERIENCE

HOW SERIOUS
IS THE INJURY?

48
HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 49
IS IT SERIOUS?

THE PROGNOSTIC
ROLE OF MAGNETIC
RESONANCE
IMAGING AND INJURY
CLASSIFICATION
SYSTEMS
– Written by Anne D van der Made and Gino M Kerkhoffs, The Netherlands

INTRODUCTION workup. Imaging can provide detailed LEANING ON MAGNETIC RESONANCE

The moment an athlete sustains a information on the exact location and IMAGING FOR A RETURN TO SPORT
hamstring injury, the first question that extent of the injury. Specifically, imaging has PROGNOSIS: IS IT THE ALL-SEEING ORACLE?
is immediately asked is: ‘Is it serious?’. a role in detecting or ruling out more severe Confirming the diagnosis and ruling out
The injured athlete, coaching staff, (e.g. full-thickness free tendon1) injury, as severe or associated pathology is merely the
management, media and fans look to the this will have consequences with regard starting point, as the question ‘Is it serious?’
medical staff for answers. As a result, there to treatment strategies. For this purpose, has only been partly answered. With
is often high pressure to obtain an imaging- magnetic resonance imaging (MRI) is regards to what comes next, MRI has gained
confirmed diagnosis and prognosis as soon considered the imaging modality of choice2. somewhat of a reputation. Widespread
as possible. Additionally, motives for obtaining an MRI reliance on MRI for a return to sport (RTS)
might not be exclusively medical. There is prognosis has resulted in the (tongue-in-
MAGNETIC RESONANCE IMAGING AS A often no rest within a team until an MRI has cheek) comparison with a crystal ball that
DIAGNOSTIC TOOL been done and imaging confirmation of an will answer the million-dollar question:
An acute hamstring injury is often a injury may give medical staff more leverage ‘When will I be able to play again?’3. In line
fairly straightforward clinical diagnosis. to keep an athlete side-lined when there is with this supposed predictive value, there
History-taking and physical examination external pressure to return the athlete to are various systems that utilize imaging
are the cornerstones of the diagnostic play prematurely. findings to make a distinction between

50
 a b
Mean = 23 days Mean = 23 days
SD = 10 days SD = 5 days

-1.96 SD: +1.96 SD: -1.96 SD: +1.96 SD:

3 days 43 days 13 days 33 days

Figure 1: a) In a normally distributed dataset, 95% of data will fall within 1.96 standard deviations of the mean. With a mean return to sport
(RTS) of 23 days and a standard deviation of 10 days, 95% of athletes will RTS between 3 and 43 days after injury. b): By reducing the
standard deviation, we can make a more precise RTS prediction.

different ‘grades’ or ‘types’ of hamstring there is enormous pressure to predict when individual athletes. Several imaging findings
injury4. Yet, while there is general consensus an athlete will be ready to RTS. While this and imaging-based grading systems are
that MRI is useful in supporting the clinical may seem reasonable considering the proposed for this purpose. Regrettably, this
diagnosis, there is an ongoing debate on stakes involved in elite sports, it has proven brings us to the second obstacle: the lack of
the role of imaging and imaging-based to be a major challenge. strong evidence to support the use of MRI
classification systems, in particular when findings for this purpose18. MRI findings
predicting the RTS duration. EVIDENCE AND OBSTACLES used currently provide no added predictive
As mentioned before, MRI can be used Difficulties with providing a RTS value over history taking and physical
to rule out severe pathology such as free prediction following acute hamstring injury examination.
tendon avulsion or rupture. These severe can be attributed to several issues. Firstly, A recent systematic review18 highlighted
injuries can be considered a different clinical there is a large range in RTS duration after that no strong evidence exists to support the
entity given the need for potential surgical an acute hamstring injury. Even if we only prognostic value of any MRI finding, largely
intervention and a clear prolongation of consider acute partial-thickness injuries, we as a result of high risk of bias in the included
RTS duration5–9. While conclusive data on can expect a large spread in time to RTS, as studies. However, there was moderate
RTS duration of these injuries are scarce5, reflected by reported standard deviations. evidence for two MRI findings:
RTS activity (either in a post-operative or For instance, the mean reported time to RTS 1. absence of hyperintensity on fluid-
primarily non-operative setting) is generally in large studies following acute hamstring sensitive sequences (i.e. MRI-negative
allowed after 4-6 months10–13. Needless to injury is around 23 days with a standard injury) was associated with a shorter
say, MRI-confirmation of tendon avulsion/ deviation of approximately 10 days5,15,17. RTS duration, and
rupture has a major impact on the prognosis. Assuming the data is normally distributed, 2. presence of free tendon injury was
Fortunately, these injuries are relatively RTS duration of 95% of study participants associated with a longer RTS duration.
rare. The vast majority of hamstring injuries lies within ±1.96 standard deviations of Undoubtedly, trying to predict RTS using
are partial-thickness hamstring injuries (i.e. the mean. Therefore, there is a 95% chance a single MRI finding is far too simplistic.
no complete disruption between proximal that the RTS duration for an individual lies Combining clinical and imaging-related
and distal attachments)5,14. The time to between 3 and 43 days (Figure 1a). This variables at baseline somewhat improves
RTS for these injuries is a matter of weeks outcome can hardly be regarded as a ‘precise our predictive ability, but arguably not
rather than months5,15–17. However, this does prediction’ and is more a ‘rough estimate’. satisfactorily15,18,19. Several studies have used
not make the job of the medical staff any Of course, this is a group estimate that regression models to evaluate to what
easier. In elite sports, several matches may we could further narrow down for the extent a combination of clinical and imaging
be scheduled per week. Prolonged absence, individual athlete by using tools that can variables could be employed to predict time
even by a couple of days, could be the divide this group into smaller subgroups to RTS. In these studies, only 30% to 50%
difference between being able to participate with distinct prognoses. Then, we would be of the variance of RTS duration could be
in a potentially important upcoming match abler to discriminate between RTS for dif- explained by clinical findings at baseline
or not. Therefore, it is understandable that ferent groups, and ideally also for different alone, with only a marginal increase (<3%)

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 51

IS IT SERIOUS?

when MRI findings at baseline were added sive combination of baseline variables will some time, due to the increasing availability
in the model. This indicated that our RTS further improve baseline RTS predictions. of imaging modalities such as MRI, several
predication at baseline using the variables imaging-based classification systems have
included in the regression model is not CLASSIFICATION SYSTEMS emerged in recent decades.
likely to be very accurate. Classification systems have been widely The most widely used imaging-based
The above-mentioned obstacles have used in various fields of modern medicine. muscle injury grading system is the
several implications. Firstly, one could Standardisation of injury description sup- (modified) Peetrons classification5,21 (Box 1).
argue that RTS prediction at the time of ports effective communication between Its popularity is likely due to its simplicity.
injury is not likely to be precise (to the day). medical professionals and enables proper It roughly takes the extent of damage on
Secondly, current evidence has shown that (between-group) comparisons in the research imaging into account, making it easy to use
our best bet for an accurate prediction is setting. Ideally, an injury classification
using clinical findings rather than imaging, also functions as a grading system and
ideally combined with clinical findings discriminates between injury (sub)types that Box 1: Modified Peetrons
during a follow-up assessment. In addition, have different prognoses or require different classification5,21
the low percentage of explained variance treatment strategies.
in the regression models indicates that There are different approaches to Grade 0: Negative MRI without any
RTS duration is very likely to be influenced classifying muscle injuries. These can visible pathology.
by several other (e.g. pathophysiological, include clinical findings such as mechanism Grade 1: Oedema but no architectural
psychological, and social) factors that of injury, onset, site of injury, affected muscle distortion.
were not included in these models. Future groups, as well as imaging characteristics Grade 2: Architectural disruption
efforts to identify prognostic factors such as lesion size and involvement of indicating partial tear.
should additionally focus on determining certain structures or tissues4,20. While clinical Grade 3: Total muscle or tendon rupture.
whether a different or more comprehen- classification systems have been around for

a b
25 25

20 20
Time to RTP (days)

Time to RTP (days)

15 15

10 10

5 5

0 0
No Yes No Yes
Factor X present Factor Y present
Figure 2: Two separate datasets in which injured athletes are subdivided into 2 groups based on presence or absence of a certain finding. In
both datasets there is a significant difference in time to RTS between groups (left: mean difference of 7 days, p<0.001. Right: mean difference
of 5 days, p<0.001). In the left graph, less between-group overlap and smaller within-group spread in time to RTS implies that dividing injured
athletes into groups using factor X is more useful for a more precise RTS prediction for the individual athlete than using factor Y.

52
in practice. However, because it does not those that will RTS early and late (Figure CONCLUSION
leave room for consideration of any other 2). Of course, the opposite is also true: An acute hamstring injury is a clinical
potentially relevant MRI findings, various any variable or classification that divides diagnosis that can be supported by MRI
additional classification systems have been athletes into subgroups with large within- to confirm or rule out severe or associated
recently proposed, including the Barcelona group spread and notable between-group pathology. At present, RTP prediction at
system (MLG-R)22, the British Athletics overlap has limited value for predicting baseline using clinical or imaging findings
Muscle Injury Classification (BAMIC)23, the time to RTS in the individual athlete. will not be accurate. A clinical assessment
Chan system24, the Cohen system25, and When taking a closer look at the at baseline combined with a follow-up
the Münich consensus statement26. These aforementioned classification systems, it assessment should be the gold standard for
comprehensive classification systems do cannot be ignored that there is substantial an individual RTP prediction. MRI findings
not only include the extent of the lesion, overlap in time to RTS between the and imaging-based classification systems
either in a qualitative or quantitative different injury grades31,32. Therefore, despite have limited value for predicting RTP in the
manner, but also consider a combination significant differences at a group level, these individual athlete.
of additional findings. These include onset classification systems arguably have limited
of injury, aetiology, injury mechanism, value for predicting RTS for the individual
location and involved anatomical structures. athlete with an acute hamstring injury.
While these separate classification systems
all have their strengths and weaknesses, IMPLICATIONS FOR CLINICAL PRACTICE
the most important issue appears to be AND FUTURE DIRECTIONS
a lack of consensus regarding muscle At the time of injury, the injured athlete
injury definitions. For a detailed critical and coaching staff look to the medical team
analysis, we refer to recent reviews on these for a quick, accurate and precise prognosis.
classification systems4,20,27. With current clinical and imaging findings, References available at
our ability to meet this demand is limited. www.aspetar.com/journal
PROGNOSTIC VALIDITY OF MRI-BASED While this is an unsatisfactory situation,
CLASSIFICATION SYSTEMS there may be short and long term solutions.
Classification systems aim at In the short term, combining the clinical
categorically dividing the muscle injury assessment at baseline with a follow-
continuum into separate injury (sub)types. up assessment one week post-injury
Although significant associations have been substantially improves the accuracy of
demonstrated between injury types/grades the RTS prediction. In a recent study, the
and RTS at a group level for several of these combination of an initial and a follow-up
systems25,28–30, success in predicting RTS for examination explained 97% of variance
Anne D. van der Made M.D.
the individual athlete is hardly guaranteed. in RTS19. This also implies that, at baseline,
We mentioned the large spread adequate communication with the injured PhD candidate
(standard deviation) in RTS and the athlete and coaching staff is vital for setting
ensuing difficulty of a precise RTS realistic expectations. Gino M Kerkhoffs M.D., Ph.D.
prediction for the individual athlete. In In the long term, further research is Orthopaedic surgeon, Professor and Head
our example, we estimated that there necessary to identify potentially relevant of Department
would be a 95% chance that an athlete prognostic variables. This requires large
with an acute hamstring injury would RTS multi-centre collaborations (i.e. large
between 3 and 43 days after injury. Ideally, prospective registries). In these future Department of Orthopaedic Surgery,
Amsterdam UMC, University of
we can make our estimation more precise efforts, it is of paramount importance that
Amsterdam, Amsterdam Movement
by using a grading system that subdivides the treating clinician and the clinicians Sciences, Amsterdam, the Netherlands
injured athletes into smaller subgroups, involved in the RTS decision remain blinded
Academic Center for Evidence-based
each with their own prognosis. To achieve to imaging findings to minimize risk of bias.
Sports medicine (ACES), Amsterdam UMC,
this, we would have to create subgroups While it is not assumed that knowledge Amsterdam, the Netherlands
that have a small within-group spread in of imaging results influences progression
Amsterdam Collaboration for Health and
RTS duration so that the RTS prediction through the rehabilitation programme and
Safety in Sports (ACHSS), AMC/VUmc IOC
for the individual athlete within a the RTS decision, it cannot be ruled out.
Research Center
subgroup will be more precise (Figure 1). Ultimately, a comprehensive prediction
Amsterdam, the Netherlands
In addition, these subgroups should have model including as many relevant
no or minimal between-group overlap prognostic variables as possible should be
to successfully discriminate between developed. Contact: [email protected]

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 53

HOW DO WE DEAL WITH IT?

MEDICAL TREATMENT
MODALITIES IN
HAMSTRING INJURIES
BEWARE TO DO NO HARM
– Written by Gustaaf Reurink and Anne D van der Made, The Netherlands

INTRODUCTION of suggested interventions. In this article, Anti-inflammatory medication, such

To get the athlete with a hamstring the rationale and evidence for the most as non-steroidal anti-inflammatory drugs
injury back to play as soon as possible and commonly practiced and/or promising (NSAIDs) and corticosteroids, are aimed at
minimize re-injury risk, there is a continuous medical treatment modalities for muscle reducing the inflammatory response after
search for medical treatments to improve injuries will be discussed. muscle injury. Historically, inflammation
and accelerate muscle healing. Skeletal was believed to be detrimental for
muscle tissue initiates a rapid healing ANTI-INFLAMMATORY THERAPY muscle injury healing, emphasized by
response following injury, which can be After injury, the gap created by the the traditional widespread use of anti-
divided in three (overlapping) phases1,2: rupture of muscle fibers is initially filled inflammatory medication post-injury,
1. degeneration & inflammation, with hematoma. Activated platelets and especially NSAIDs. However, more recently
2. regeneration and endothelial cells release factors that multiple studies have shown that the various
3. remodeling (Figure 1). activate and recruit inflammatory cells. phases of inflammation play a critical
Medical interventions are aimed at Inflammatory cells migrate into the role in orchestrating muscle regeneration
modifying one or more of these phases injured tissue to ‘clean’ the injured zone following injury. There is accumulating
by minimizing degeneration, optimizing and contribute to the degeneration and evidence that pharmacologically inhibiting
or inhibiting inflammation, maximizing inflammatory process. The inflammatory the inflammatory response is actual
regeneration and/or inhibiting fibrosis. phase typically lasts for 72 hours. After detrimental for acute muscle healing2.
Although modifying these aspects of muscle this phase, the inflammatory cells switch
healing may seem reasonable to facilitate to an anti-inflammatory profile to play NSAIDs
healing after injury, the scientific evidence an active role in promoting muscle Multiple studies in animal models found
remains limited for the almost endless list regeneration2. that the oral use of NSAIDs in muscle injury

54
 Skeletal myofibre

III b. Complete or Muscle damage I. Muscle degeneration

partial muscle healing and inflammation

Muscle rupture, myofibres Satellite cells

Fibroblast deposition and necrosis and inflammation myoblasts Secretion of growth factors
extracellular matrix (ECM) (IGF-1, HGF...), satellite cells
deposition, scar activation and proliferation that
tissue formation promote muscle regeneration

Fibroblasts
III a. Muscle fibrosis II. Muscle regeneration
+
ECM
Myoblast fuse to each other to
form myotubes that participate to
the repair of existing myofibres
Presence of TGF-β1 at the site of
injury, implication in the
development of muscle fibrosis
Figure 1: Sequential cycle of muscle healing phases. Adapted with permission from ‘Acute muscle injury’of Kerhoffs and Servien, page 19.

resulted in impaired myofiber regeneration and a low-level case series suggesting a MUSCLE REGENERATING THERAPY
and was associated with increased fibrosis2. role for corticosteroids injections in athletic The regeneration phase consists of
Although NSAIDs are usually administered muscle injury. Considering the known two processes: regeneration of muscle
orally, intramuscular injection of NSAIDs detrimental effects on muscle healing and fibers and the formation of connective
have been shown to be locally myotoxic, the lack of high-level clinical studies we (scar) tissue. Myogenic reserve cells
resulting in muscle degeneration, edema, do not support the use of corticosteroids in called satellite cells become activated,
hemorrhage, and increased plasma creatine muscle injury. migrate to the site of injury and fuse with
kinase levels3. myoblasts to form myotubes, which fuse
Only one clinical randomised control Traumeel® with existing damaged muscle fibers. Scar
trial (RCT) has assessed the efficacy of Traumeel® is a homeopathic combi- tissue formation occurs simultaneously and
NSAIDs administered orally in athletes nation of diluted plant and mineral extracts forms a matrix to bridge the gap between
with muscle injuries. This RCT showed that and is administered either orally, topically, the stumps of the ruptured muscle fibers.
NSAIDs did not have an effect on pain and or by injection. It is believed to have an Regenerating myofibers start to form new
muscle strength compared to a placebo anti-inflammatory effect5. The injection musculotendinous junctions and penetrate
intervention4. Considering the lack of clinical therapy is used alone or in combination the connective scar tissue. Ultimately, in
efficacy and the possible detrimental effect with Actovegin® (discussed later in this the remodeling phase, there is maturation
found in animal models, it is hard to justify article) in muscle injuries6, but any evidence of the regenerating myofibers that further
the use of NSAIDs in the management of regarding the effect of intramuscular replace the connective scar tissue by mature
hamstring muscle injury. injection of Traumeel® in muscle injuries is contractile tissue. A thin layer of scar tissue
absent. remains that separate the ends of the
Corticosteroids Given the increasing evidence that ruptured fibers.
Similar to NSAIDs, the purpose of pharmacological inhibition of the
corticosteroids is to reduce the inflammatory inflammatory response is detrimental for Platelet rich plasma (PRP)
response. Animal model studies have shown muscle healing after acute injury, and the Among all medical treatment modalities
that corticosteroids after muscle injury lack of evidence regarding clinical efficacy, for muscle injuries, platelet-rich plasma
delay the inflammatory response. However, it is hard to justify the use of any ‘anti- (PRP) is probably the most popular at present.
its use leads to increased necrotic tissue, inflammatory’ medical treatment modality Since the World Anti-Doping Agency
less regeneration, and atrophy after several in the management of acute hamstring permitted the intramuscular injection of PRP
weeks. Nevertheless, there are case reports injury. in 2011, this it has been increasingly used to

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 55

HOW DO WE DEAL WITH IT?

treat acute muscle injuries in athletes7. PRP injuries on the time to return to play and Actovegin®
is obtained from autologous whole blood the re-injury rate, nor were any substantial Actovegin® is a deproteinised hemo-
using a variety of commercially available differences found in pain, muscle strength, dyalisate of calf serum that is believed to
centrifuge separation systems to separate flexibility, muscle function, or imaging9. enhance muscle regeneration11. To date there
the plasma that is rich in platelets from There is even evidence that a PRP is only one non-randomized clinical pilot
other blood components. injection in addition to exercise may be study that examined Actovegin® in muscle
When injected in the injured muscle, detrimental for muscle healing. In the injury12. In this study athletes with grade I
platelets release various growth factors ‘traditional’ animal studies, any effect of injuries that were treated with Actovegin®
like platelet derived growth factor (PDGF), active rehabilitation is neglected. In a recent injections returned to play significantly
insulin-like growth factor (IGF-1), basic ingenious laboratory study, researchers earlier (12 days on average, n=4) than those
fibroblast growth factor (bFGF-2) and accounted for a rehabilitation effect by that only received physiotherapy (20 days
nerve growth factor (NGF). Basic science assigning rats with muscle injuries to 5 on average, n=4). This pilot study is at high
studies have shown that growth factors groups10: risk of bias due to the lack of blinding and
can stimulate myoblast proliferation 1. control group receiving no intervention, randomization. Future larger randomized
and increase muscle regeneration in 2. placebo group receiving a single saline studies, including a placebo-group and
deliberately injured animal muscles8. There injection, assessment of potential side effects, are
are a multitude of autologous platelet-rich 3. PRP group receiving a single PRP necessary to determine whether Actovegin®
blood products commercially available injection, injections are safe and improve muscle
that differ in their preparation procedure 4. exercise group performing daily healing. We do currently not recommend it
and cellular components. Superiority is treadmill running and, as a treatment for hamstring injuries.
often claimed of one PRP product over the 5. PRP + daily exercise group receiving both
others, but it remains unproven whether a single PRP injection and performing Stem cells
the composition of the PRP is relevant for daily treadmill running. There is increasing interest for the use
the efficacy of PRP treatments and this The results revealed that the exercise of stem cell therapy in muscle injuries.
is subject of an ongoing debate in the alone group had the best improvement in Stem cells are undifferentiated cells that
literature. histology and force recovery outcomes. The can renew themselves or differentiate into
Despite these promising results in outcome of this active rehabilitation was cells that are programmed for a certain
animal studies and apparent widespread adversely affected by the PRP injection10. tissue lineage. Stem cells may have the
clinical use, the positive effects of PRP In conclusion, considering the lack of ability to contribute to muscle regeneration
cannot be confirmed in high-level scientific evidence for efficacy, in addition to evidence after injury. Therefore, the concept of
studies on human subjects. A meta-analysis for potential adverse effect on outcome of transplanting stem cells has been explored
with pooled data of six RCTs showed no rehabilitation, we discourage PRP treatment for some time, however the available
superiority of PRP in treating muscle in hamstring muscle injuries. literature focuses mostly on degenerative

Despite these promising results in

animal studies and apparent widespread
clinical use, the positive effects of PRP
cannot be confirmed in high-level
scientific studies on human subjects.

56
muscle disorders, such as muscular Stem cell research that contributes to level several agents known to reduce scar tissue
dystrophies. 1-3 evidence is endorsed. formation through inhibition of TGF-β1,
Evidence for the efficacy of stem cells Despite promising results, we currently such as losartan, decorin, suramin, relaxin
in acute injury is currently limited to do not advocate the use of stem cells in and interferon-γ. In animal studies these
two murine contusion model studies13,14. hamstring injuries, as its safety and efficacy therapies are shown to decrease fibrosis and
These studies found that intramuscular in human use is yet to be determined. increase regeneration of muscle tissue after
transplantation of muscle derived stem injury. Due to (severe) side effect profiles,
cells promoted angiogenesis and increased ANTI-FIBROTIC THERAPY lack of dosing formulations and lack of Food
the number and diameter of regenerative From two to three days after muscle and Drug Administration (FDA) approval for
muscle fibers. Although these findings are injury, connective tissue (fibrosis) starts use in humans, these therapies are currently
promising, it should be explored whether the to appear at the site of the injury. In the not readily applicable in clinical practice,
same results can be found in human muscle following weeks regenerating myofibers and remain experimental for treatment
tissue. Furthermore, concerns have been penetrate the injured area and the fibrous of muscle injury16. The one exception is
raised regarding the potential tumorigenic tissue diminishes in size over time. While Losartan.
risk of stem cells. The Australasian College of formation of fibrous tissue is an essential
Sports and Exercise medicine has released a component of muscle healing, excessive Losartan
formal Position Statement in 2017 regarding scar tissue formation is suggested to impair Losartan is an angiotensine-II (AT-2)
the use of stem cells in sports and exercise recovery of muscle function. This has led to receptor antagonist which is FDA approved
medicine15. In this statement, they currently the idea that pharmacological inhibition for the use in hypertension management.
do not support the use of stem cell treatment of fibrosis may be beneficial for recovery This AT-2 receptor blockade modulates
due to insufficient evidence. As both safety after muscle injury. Transforming Growth TGF- β1. Originally, it was discovered
and efficacy data are lacking, they state that Factor-β1 (TGF-β1) has been identified as as a treatment for cardiac fibrosis in
it is unethical and unprofessional to market a key factor in scar tissue formation by hypertensive disease, but it has also been
stem cell interventions directly to patients. activating fibrotic cascades. There are found to reduce fibrosis after skeletal

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 57

HOW DO WE DEAL WITH IT?

Table 1

Our recommendation for

Pro’s Con’s
hamstring injury

Anti-inflammatory therapy

No effect on pain and muscle

strength compared to a
NSAIDs Analgesic effect placebo Not recommended
Detrimental effect on muscle
healing in animal models
Lack of high-level clinical
Low-level case series
studies
Corticosteroids suggesting a role in muscle Not recommended
Detrimental effect on muscle
injury
healing in animal models
Lack of studies: efficacy and
Traumeel® Not recommended
safety unknown

Muscle regenerating therapy

Level I evidence for no effect

in athletes with hamstring
Promising results in animal
PRP injuries Not recommended
studies
Adverse effect on outcome of
rehabilitation
Lack of high-level clinical
Positive effect in pilot study
Actovegin® studies: efficacy and safety Not recommended
(n=8)
unknown
Promising results in animal Lack of clinical studies:
Stem cells Not recommended
studies efficacy and safety unknown

Anti-fibrotic therapy

Lack of clinical studies

Promising results in animal
Losartan in muscle injury: efficacy Not recommended
studies
unknown

Abbreviations: NSAIDs, Non-steroidal anti-inflammatory drugs; PRP, Platelet rich plasma

Table 1: Summary of medical treatment modalities in hamstring injuries.

muscle injury. In animal models, the oral DISCUSSION should always remember the ‘primum
administration of Losartan was reported to There are currently no medical treatment non nocere’ (‘first do no harm’) dogma
reduce fibrosis and enhance the structural modalities that have proven clinically of Hippocrates. Frankly, it should also be
and functional regeneration of muscle after relevant benefits in acute muscle injuries acknowledged that the popularity of several
laceration and contusion17. (summarized in Table 1). This is either of these therapies is the result of clever
As Losartan is already FDA approved attributable to a lack of evidence for efficacy marketing strategies rather than a solid
for hypertension, and is widely available, or evidence for a lack of efficacy in high-level evidence base. In the continuous pursuit of
it is an interesting accessible intervention clinical trials (e.g. PRP). For some of these accelerated and improved muscle recovery
for treatment of muscle injury. Despite the widely employed therapies, there is even after injury, clinicians must withstand the
promising findings in animal models, there (indirect) evidence that it may adversely pressure to perform interventions that have
are currently no clinical trials in human affect outcome of muscle injury. an insufficient evidence base.
muscle injury. Therefore, it is unknown With a paucity of high-level evidence for Although modifying aspects of muscle
whether Losartan has a clinically relevant safety and efficacy of medical treatment healing may seem reasonable to optimize
effect in hamstring injuries. modalities in muscle injuries, clinicians healing after injury in theory, there is

58
growing insight that muscle healing after of muscle injuries by local administration of angiogenesis. The American journal of
injury is a complex process, resulting in the of autologous conditioned serum: a pilot sports medicine. 2011;39(9):1912-22.
remarkable regenerative capacity of muscle study on sportsmen with muscle strains. 15. Australasian College of Sports and
tissue. Introduction of any treatment that International journal of sports medicine. Exercise Physicians Position Statement.
interferes with this process should be 2004;25(8):588-93. The use of Autologous Mesenchymal
done cautiously and only after a thorough 7. Hamilton B, Knez W, Eirale C, Chalabi Stem Cells in Sport and Exercise Medicine.
assessment of its efficacy in high-quality H. Platelet enriched plasma for acute 2017.
intervention studies. At present, it is often muscle injury. Acta orthopaedica Belgica. 16. Bedair HS, Karthikeyan T, Quintero A, Li Y,
the other way around. 2010;76(4):443-8. Huard J. Angiotensin II receptor blockade
The current available evidence does not 8. Hamilton BH, Best TM. Platelet-enriched administered after injury improves
support any of the available interventions plasma and muscle strain injuries: muscle regeneration and decreases
in addition to active rehabilitation for acute challenges imposed by the burden of fibrosis in normal skeletal muscle. The
muscle injury. Beware to do no harm.  proof. Clinical journal of sport medicine : American journal of sports medicine.
official journal of the Canadian Academy 2008;36(8):1548-54.
of Sport Medicine. 2011;21(1):31-6. 17. Kobayashi T, Uehara K, Ota S, Tobita K,
9. Grassi A, Napoli F, Romandini I, Ambrosio F, Cummins JH, et al. The timing
Samuelsson K, Zaffagnini S, Candrian C, et of administration of a clinically relevant
al. Is Platelet-Rich Plasma (PRP) Effective dose of losartan influences the healing
in the Treatment of Acute Muscle process after contusion induced muscle
Injuries? A Systematic Review and Meta- injury. Journal of applied physiology
Analysis. Sports medicine (Auckland, NZ). (Bethesda, Md : 1985). 2013;114(2):262-73.
2018;48(4):971-89.
References
10. Contreras-Munoz P, Torrella JR, Serres
1. Jarvinen TA, Jarvinen M, Kalimo H. X, Rizo-Roca D, De la Varga M, Viscor G,
Regeneration of injured skeletal muscle et al. Postinjury Exercise and Platelet-
after the injury. Muscles, ligaments and Rich Plasma Therapies Improve Skeletal
tendons journal. 2013;3(4):337-45. Muscle Healing in Rats But Are Not
2. Duchesne E, Dufresne SS, Dumont NA. Synergistic When Combined. The
Impact of Inflammation and Anti- American journal of sports medicine.
inflammatory Modalities on Skeletal 2017;45(9):2131-41.
Muscle Healing: From Fundamental 11. Brock J, Golding D, Smith PM, Nokes L,
Research to the Clinic. Physical therapy. Kwan A, Lee PYF. Update on the Role of Gustaaf Reurink M.D., Ph.D.
2017;97(8):807-17. Actovegin in Musculoskeletal Medicine:
Sports Medicine Physician
3. Reurink G, Goudswaard GJ, Moen MH, A Review of the Past 10 Years. Clinical
Weir A, Verhaar JA, Tol JL. Myotoxicity journal of sport medicine : official journal
of injections for acute muscle injuries: of the Canadian Academy of Sport Anne D van der Made M.D.
a systematic review. Sports medicine Medicine. 2018. Ph.D. Candidate
(Auckland, NZ). 2014;44(7):943-56. 12. Lee P, Rattenberry A, Connelly S, Nokes L.
4. Reynolds JF, Noakes TD, Schwellnus MP, Our experience on Actovegin, is it cutting
Department of Orthopaedic Surgery,
Windt A, Bowerbank P. Non-steroidal edge? International journal of sports
Amsterdam UMC, University of
anti-inflammatory drugs fail to enhance medicine. 2011;32(4):237-41. Amsterdam, Amsterdam Movement
healing of acute hamstring injuries 13. Kobayashi M, Ota S, Terada S, Kawakami Sciences
treated with physiotherapy. South African Y, Otsuka T, Fu FH, et al. The Combined Academic Center for Evidence-based Sports
medical journal = Suid-Afrikaanse Use of Losartan and Muscle-Derived medicine (ACES)
tydskrif vir geneeskunde. 1995;85(6):517- Stem Cells Significantly Improves the
22. Amsterdam Collaboration for Health and
Functional Recovery of Muscle in a Young Safety in Sports (ACHSS), AMC/VUmc IOC
5. Schneider C. Traumeel - an emerging Mouse Model of Contusion Injuries. The Research Center
option to nonsteroidal anti-inflammatory American journal of sports medicine.
Department of Sports Medicine,
drugs in the management of acute 2016;44(12):3252-61. OLVG Hospital
musculoskeletal injuries. International 14. Ota S, Uehara K, Nozaki M, Kobayashi T,
journal of general medicine. 2011;4:225- Terada S, Tobita K, et al. Intramuscular
34. Amsterdam, the Netherlands
transplantation of muscle-derived stem
6. Wright-Carpenter T, Klein P, Schaferhoff P, cells accelerates skeletal muscle healing
Appell HJ, Mir LM, Wehling P. Treatment after contusion injury via enhancement Contact: [email protected]

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 59

HOW DO WE DEAL WITH IT?

SURGICAL
MANAGEMENT
OF PROXIMAL
HAMSTRING RUPTURE
– Written by Navraj Atwal, David Wood and Donald Kuah, Australia

INTRODUCTION Unfortunately, the indications for proximal hamstrings ruptures (450 treated
Proximal hamstring ruptures are a surgical treatment are not entirely clear surgically), we advocate that the decision to
less common injury than muscle and or well supported by Level I or II evidence2. offer surgery be based on both clinical and
musculotendinous strains, but may account Most studies involve small patient numbers radiological findings.
for up to 12% of hamstring complex injuries with differing methodology, treatment Unfortunately, there is even less
and can result in debilitating outcomes in indications and protocols. There are also evidence available on the surgical or non-
active patients if left untreated1. In recent discrepancies in the methods of describing surgical management of partial avulsions/
years, there has been heightened awareness the type of avulsion, differing athletic incomplete injuries and the natural history
of proximal hamstring ruptures allowing requirements of patients and conflicting of this condition remains unclear. What is
more expedient diagnosis and treatment opinions on the need and timing for surgery. clear is that those patients with unremitting
but there remain very few robust scientific Generally, it is accepted that an acute symptoms of sitting pain, inability to run
criteria to aid the decision-making process avulsion of the entire hamstring complex and perform sporting activities at the
as to who will benefit from surgery. As a with retraction should be treated surgically3. desired level can be treated operatively with
result, the management of these serious The surgery becomes technically more symptomatic and functional improvement5.
injuries has typically varied from centre difficult with time due to tendon retraction However, these patients should have
to centre. It has previously been proposed and sciatic nerve tethering within scar exhausted non-operative treatment
that management of proximal hamstring tissue2,4. While predicting who will benefit involving rehabilitation and alternative
ruptures involving 1- or 2-tendons with from surgery is difficult, given the potential therapies such as corticosteroid or Platelet
≤2 cm of retraction be non-operative. By for poor results from chronic repairs, there Rich Plasma (PRP) injections as the results
contrast, surgery is advocated for 2-tendon is an ethical issue in denying surgery in of surgery are not as good as for complete
avulsions with >2 cm of retraction and all the acute phase. Subsequently, from our ruptures. The pathology of partial avulsions
complete 3-tendon tears1. experience of treating over 600 cases of is undoubtedly disparate to acute, complete

60
 1 2

Figure 1: Marked bruising which indicates

3 proximal hamstring rupture.
Figure 2: Extensive bruising indicating proximal
hamstring rupture.
Figure 3: Clinical deformity with prominence of
hamstring muscle belly due to complete tendon
avulsion with retraction.

avulsions and for this reason any surgery similar mechanisms include going into the sciatica-like symptoms, weakness and pain
must be carefully considered. splits (either on purpose as in dancing or with walking, especially up hills or stairs.
This article presents our surgical accidentally) or slipping on a step. Clinical examination in an acute
technique, the review of the literature presentation is difficult to miss, due to the
and proposes a surgical algorithm for the Symptoms history, gross bruising, marked weakness
treatment of this complex injury. Patients report a sudden onset of sharp on hamstring contraction, tenderness at the
pain at the proximal hamstring or buttock. proximal hamstring origin (lateral aspect
HISTORY This is sometimes accompanied by a of the ischial tuberosity) and sometimes
Mechanism of action “pop” or tearing sensation. There is rapid a palpable gap. Chronic presentations or
The most common mechanism of development of severe pain and marked partial tears can be more subtle. There is still
action for this injury is a combined sudden bruising usually, with weakness and an often weakness on hamstring contraction,
hyperflexion of the hip with knee extension. antalgic gait (Figure 1). pain on passive straight leg raise testing,
The most common causative activity In late or chronic presentation patients localised tenderness but no bruising. In
found by the senior author in his series is complain more about sitting pain and an retracted avulsions there may be a palpable
water-skiing. Other common causes with inability to run/sprint. They can also have mass as seen in Figure 3.

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 61

HOW DO WE DEAL WITH IT?

Wood classification of proximal hamstring ruptures

Classification Pathological appearance Preferred Management

Displacement greater than 1 to 2 cm warrants surgical

Type 1 Osseous avulsions reduction and internal fixation to avoid the risk of
symptomatic non-union12.

Difficult to treat surgically. Conservative management is

Type 2 Musculotendinous junction injuries
recommended.

Healing may occur with rehabilitation alone

Some may need adjunctive, non-surgical treatment such
as PRP.
Some will require surgery for ongoing symptoms and
Type 3 Incomplete avulsions
failure to return to pre-injury activity levels. Typically
these present to the surgeon as chronic injuries with
symptomatic patients having undergone a plethora of
investigations and treatments.

Effective treatment prevents excessive scarring and nerve

tethering.
Complete avulsion with no/minimal Surgery nearly always successful.
Type 4
tendon retraction With most patients wanting a guaranteed return to pre-
injury activity levels, there will tend to be an unavoidable
bias towards early surgery.

Complete avulsion with tendon Those with ongoing sitting or driving pain that is
Type 5a retraction with no sciatic nerve impeding normal activities and those unable to return to
involvement desired sporting activities should be offered surgery.

Complete avulsion with tendon These tend to be more chronic cases. Chronic patients tend
Type 5b
retraction and sciatic nerve tethering to self-select for surgery.

Table 1: Wood classification of proximal hamstring ruptures.

If in doubt, MRI scan is the best imaging SURGICAL TECHNIQUE the posterior cutaneous femoral nerve as
modality (Figure 4). If unavailable, The patient is positioned prone under much as possible. The inferior margin of
ultrasound in experienced hands is usually general anaesthesia, with protection of gluteus maximus is identified and retracted
also diagnostic. pressure areas. The leg is prepared and cranially. The avulsed proximal end of the
draped to allow unrestricted knee flexion conjoint hamstring tendon is identified and
WOOD CLASSIFICATION OF PROXIMAL to allow hamstring tendon apposition at mobilised.
HAMSTRING RUPTURES surgery. Bony landmarks are located and a The sciatic nerve is identified and a
In order to obtain more useful longitudinal incision is made from the ischial thorough neurolysis performed. The nerve
information from studies, it is important tuberosity inferiorly over the defect. The is protected throughout the procedure.
that researchers and clinicians are clear on senior surgical author prefers a longitudinal Occasionally, identification of the nerve
the types of avulsions and that a universal incision due to its extensile properties, is extremely difficult due to encasement
classification be accepted so that accurate allowing improved surgical exposure as in scar tissue; a nerve stimulator can be
and comparable literature reviews can required. Some use a transverse incision in useful in such instances. The lateral wall
be performed. Wood et al6 have classified the gluteal crease1, whereas others use a of the ischial tuberosity is exposed using
proximal hamstring injuries in Table 1, combination as required to allow adequate Hohmann retractors and scar tissue cleared.
which is useful for both clinical and research exposure8. The superficial soft tissues are Three Mitek SuperAnchors (DePuy Mitek,
purposes. incised in line with the incision, protecting Raynham, Massachusetts) are inserted into

62
the exposed lateral wall of the tuberosity
and the suture ends are passed through the
tendon end using a modified Mason-Allen Figure 4: Post-surgical
sliding knot technique. The sutures are repair.
then individually tied ensuring the avulsed
conjoint tendon is apposed completely. If
knee flexion is required to relieve tension
on the surgical repair, a hinged knee brace
is required with the knee immobilised in
as much as 90° of flexion for up to 6 weeks.
Unlike other units8,9, we do not feel a knee
brace is necessary for all cases. Some units
routinely use a hip orthosis to prevent strain
on the surgical repair1,3 which we have never
had to use. If full knee extension is attained at
surgery without undue tension on the repair,
there is no requirement for bracing. This can
and should be achieved with diligent sciatic
neurolysis and comprehensive mobilisation
of the hamstrings complex.

POST-OPERATIVE REHABILITATION
During the first 2 weeks, therapy should
concentrate on pain and swelling control, be the aim. Using non-resistance exercises, commence. Full hip and knee motion should
as well as wound care with avoidance full active hip motion with the knee flexed be achieved.
of massage until after 4 weeks (Table 2). greater than 90° and full active knee motion Jogging can be introduced at 16 weeks
Exercises to maintain or improve core with the hip neutral should be the goal. aiming to achieve 60 to 70% strength in
stability may be commenced. Neural During the next 6 weeks, hamstring the injured hamstrings compared to the
mobilisation techniques may be employed strengthening using non-resistance uninjured limb.
ensuring no tension is placed on the repair. methods can begin. Core stability, gluteal After 24 weeks, patients can return
A partial weight-bearing status using strength and proprioceptive work can to sports including sprinting, after
crutches should be maintained. progress at this stage. having achieved greater than 80% of the
During the next 4 weeks, full weight After 3 months, hamstring stretches and contralateral strength.
bearing and a normal gait pattern should strengthening using weight resistance can
RESULTS OF SURGERY
A systematic review of 300 proximal
hamstring injuries from 18 level I-IV studies
Postoperative rehabilitation guidelines indicated that surgical repair is significantly
(P <0.05) associated with better outcomes,
Rehabilitation period Pathophysiology greater rate of return to pre-injury level
of sport and greater strength/endurance
compared to non-surgical management.
0-2 weeks Acute Healing Phase Acute surgical repair (within 4 weeks of
the injury) had significantly better patient
2-6 weeks Continued Healing and Repair Phase satisfaction, subjective outcomes, pain
relief, strength/endurance and higher
6-12 weeks Continued Repair Phase rate of return to pre-injury level of sport
compared to chronic (beyond 4 weeks)
repairs (P <0.001), with reduced risk of
12-16 weeks Remodelling Stage
complications and re-rupture (P <0.05). Non-
operative management is associated with
16-24 weeks Continued Remodelling and Strengthening Stage less patient satisfaction, reduced hamstring
muscle strength and significantly lower
24+ weeks Sport-Specific Stage rates of return to pre-injury sporting level10.
The risk of a moderate/poor result is 28-fold
Table 2: Postoperative rehabilitation guidelines. in patients where surgery has been delayed

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 63

HOW DO WE DEAL WITH IT?

greater than 6 months compared to those

undergoing surgery within 3 months11. This
has been postulated to be due to a number
of reasons including fatty atrophy of the
muscle, adhesions and retraction making
reattachment more difficult or irreversible
damage to branches of the sciatic nerve due
to distal muscle retraction or from surgical
neurolysis
The healing relies on osseotendinous
incorporation, which has not been
investigated for this particular injury, but
in accordance with such healing processes
in other procedures, one should expect this
to be at the very least 6 to 8 weeks. Post-
operative rehabilitation protocols should be
cognizant of this.
Approximately 80% of patients are
able to return to athletic activities after
an average 5 to 6 months postoperatively
and the same number will resume sports Figure 5: Proximal Hamstring rupture and haematoma.
at the same level. However, there are no
known predictive factors to indicate which
individuals will return to the same level of Type 1 the body and conservative management is
activity4. These are typically apophyseal injuries in advocated.
In one of the largest reported single skeletally immature patients. Displacement
centre, single surgeon series, the mean greater than 1 to 2 cm warrants surgical Type 3
post-operative isotonic hamstring strength reduction and internal fixation to avoid the These constitute incomplete hamstring
and the mean postoperative hamstring risk of symptomatic non-union12. avulsion from the ischial tuberosity. MRI
endurance were 84 and 89% respectively, reveals an inflammatory focus between
when compared to the contralateral Type 2 the bone and the partially avulsed tendon,
uninjured side after an average of 2 years These are injuries at the musculo- which most probably represents an
follow-up6. Isokinetic muscle testing studies tendinous junction. Injuries in this zone attempted reparative response. In some,
have shown that an average peak torque of are difficult to treat surgically throughout healing may occur with rehabilitation alone,
nearly 83% can be achieved in the operated
hamstrings muscles compared to the
contralateral side as early as 6 months post-
operatively8.

COMPLICATIONS OF SURGERY

Common causes include

Surgery is not without risk and
complication. Other than general surgical
complications, specific ones include
haematoma, sciatic nerve injury with
consequent paralysis, re-rupture, muscle fat going into the splits on
purpose or accidentally,
atrophy and ongoing symptoms of residual
pain, weakness, cramps, neuralgia and
difficulty walking11.

TREATMENT ALGORITHM or slipping on a step.

Applying the Wood Classification6 a
literature-based treatment algorithm has
been proposed for these injuries.

64
others may respond to adjunctive, non- recommended for complete tears in all 6. Wood DG, Packham I, Trikha SP, Linklater
surgical treatment such as PRP, whereas a athletes who harbour hopes of returning J. Avulsion of the proximal hamstring
third group will require surgery for ongoing to competitive sports, especially those origin. J Bone Joint Surg 2008; 90:2365-
symptoms and failure to return to pre- sports involving sprinting. Identifying 2374.
injury activity levels. Identifying those that that subset of patients that could do well 7. Koulouris G, Connell D. Evaluation of the
will definitely require early surgery remains with non-operative treatment remains hamstring muscle complex following
challenging and has no evidence base. challenging with no obvious predictive acute injury. Skeletal Radiol 2003; 32:582-
Typically then, these present to the surgeon factors. Undoubtedly until it becomes 589.
as chronic injuries with symptomatic possible to identify this group, there is an 8. Konan S, Haddad F. Successful return to
patients having undergone a plethora of ongoing risk of over-operating, but this has high level sports following early surgical
investigations and treatments. to be balanced against the patients desire repair of complete tears of the proximal
to return to sport - as the outcome after hamstring tendons. Int Orthop 2010;
Type 4 delayed repair may not be as good as acute 34:119-123.
These are acute injuries with minimal surgical intervention.
9. Klingele KE, Sallay PI. Surgical repair of
tendon retraction. Expedient treatment
complete proximal hamstring tendon
prevents excessive scarring and nerve
rupture. Am J Sports Med 2002; 30:742-747.
tethering and results of surgery are nearly This paper originally appeared in Aspetar
always successful. Undoubtedly, there Sports Medicine Journal Volume 2, TT 2. 10. Harris JD, Griesser MJ, Best TM, Ellis
will be a group of patients that will do TJ. Treatment of proximal hamstring
well without surgery but, as with Type 3, ruptures - a systematic review. Int J Sports
Med 2011; 32:490-495.
identifying this group is extremely difficult.
With most patients wanting a guaranteed 11. Sarimo J, Lempainen L, Mattila K, Orava S.
return to pre-injury activity levels, there Complete proximal hamstring avulsions:
will tend to be an unavoidable bias towards a series of 41 patients with operative
early surgery. treatment. Am J Sports Med 2008; 36:1110-
1115.
Type 5 References/ further reading 12. Servant CT, Jones CB. Displaced avulsion
These are complete avulsions with of the ischial apophysis: a hamstring
1. Cohen SB, Rangavajjula A, Vyas D, Bradley
tendon retraction. This group is divided injury requiring internal fixation. Br J
JP. Functional results and outcomes after
depending on sciatic nerve involvement. Sports Med 1998; 32:255-257.
repair of proximal hamstring avulsions.
Those with sciatic nerve tethering tend to
Am J Sports Med 2012; 40:2092-2098.
be more chronic cases but nerve tethering
can still occur in the acute phase after 2. Askling CM, Koulouris G, Saartok T,
injury8. Chronic patients tend to self-select Werner S, Best TM. Total proximal
for surgery. Those with ongoing sitting hamstring ruptures: clinical and
or driving pain that is impeding normal MRI aspects including guidelines for
postoperative rehabilitation. Knee Surg
activities and those unable to return to
Sports Traumatol Arthrosc 2013; 21:515-533.
desired sporting activities should be offered
surgery. They should be appropriately 3. Birmingham P, Muller M, Wickiewicz
Navraj S Atwal F.R.C.S. (Tr&Orth), M.B.,
counselled regarding expectancy of T, Cavanaugh J, Rodeo S, Warren R.
CH.B., B.Sc.
outcomes. As with Type 4 injuries, Functional outcome after repair of
proximal hamstring avulsions. J Bone Orthopaedic Surgeon
determining which patients with an acute
injury will benefit from surgery remains Joint Surg Am 2011; 93:1819-1826.
elusive and needs to be investigated further. 4. Lefevre N, Bohu Y, Naouri JF, Klouche David G Wood M.B., B.S., F.R.A.C.S.
S, Herman S. Returning to sports after Orthopaedic Surgeon
CONCLUSION surgical repair of acute proximal
North Sydney Orthopaedic and Sports
A proximal hamstring rupture is a hamstring ruptures. Knee Surg Sports Medicine Centre
significant injury, which can permanently Traumatol Arthrosc 2013; 21:534-539.
impede return to high level sporting 5. Aldridge SE, Heilpern GNA, Carmichael
activity. It is important to be vigilant and Donald Kuah M.B., B.S., F.A.C.S.P.
JR, Sprowson AP, Wood DG. Incomplete
maintain a high index of suspicion in order avulsion of the proximal insertion of the Sports Physician
to obtain a prompt and accurate diagnosis hamstring outcome two years following Sydney Sports Medicine Centre
and to expedient definitive treatment. surgical repair. J Bone Joint Surg Br 2012; Sydney, Australia
Acute surgical repair within 4 weeks is 94:660-662.

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 65

WHEN WILL I BE READY TO PLAY?

REHABILITATION AND
RETURN TO SPORT
AFTER HAMSTRING
INJURY
BE WARY OF ANYONE WHO TELLS YOU THEY
HAVE A SIMPLE AND EFFECTIVE SOLUTION
FOR HAMSTRING INJURY
– Written by Rod Whiteley, Qatar, Arnlaug Wangensteen, Norway, Nicol van Dyk and Philipp Jacobsen, Qatar

INTRODUCTION more who weren’t involved in randomised in managing these problems, then we feel
If there was a simple rehabilitation trials but formed part of our daily practice. that a principal contributor to this has
approach which “cured” all hamstring In our rehabilitation department at been the approach that the RTS process is a
injuries and prevented their recurrence Aspetar we’re lucky to be regularly visited series of daily steps which involve “gaining
in a timely manner, then chances are, it by many practitioners from around the right” to progress to more challenging
would’ve been found by now. We might the world covering many sports. And a loading by proving competence at a lower
cheekily suggest that often in this area recurring, almost ubiquitous question has level of loading. Viewed through this lens,
the strength of opinions held are nearly been: “what do you use as your return to it’s easier to appreciate that each player will
inversely proportional to the scientific sport (RTS) criteria for hamstring injury?” be considered individual in terms of their
evidence of effectiveness. We therefore enter The question itself seems fair enough – ultimate requirements for load tolerance.
this space cautiously, mindful that we are but we think it belies a fundamental error In the players we see, this is commonly
adding just another opinion, albeit backed in the overall management of hamstring repeated sprinting, kicking, and direction-
with some evidence of outcomes in over injury – specifically that there are separate change. This apparent simplicity allows
200 carefully controlled cases of hamstring “rehabilitation” and then later “RTS testing” for the clinical complexity of tailoring
injury rehabilitation1, and perhaps as many components. If we have had any success your daily rehabilitation to both the daily

66
 RETURN TO RETURN TO RETURN TO A TYPICAL PRESENTATION AFTER A
PARTICIPATION SPORT PERFORMANCE RUNNING-RELATED HAMSTRING INJURY
Let’s set the scene – a 24-year-old
Figure 1: The three elements of the return to sport (RTS) continuum. Clare L Ardern et al Br J professional football player presents to
Sports Med 2016. Recreated with permission. your clinic one day after he suffered a
posterior thigh injury during a league
game. The injury occurred without contact
examination findings – which are viewed the changes in volume and intensity are in the 80th minute while he was sprinting
as a response to the previous day’s loading sensible, any given individual is going to towards the ball with a slight change in
– and the abilities and requirements of the adapt to their mechanics whether they be direction. He was not able to continue
player at hand. “optimal” or not. For these reasons, other playing and felt immediate severe localised
There are some aspects for which we than attempting to address any obvious pain in his posterior thigh when walking.
have allowed theoretical considerations “limping”, little if any attention is placed on Initial care was removal from the field,
to enter the management: specifically, the an individual’s running mechanics, and this walking with assistance followed with
notion that high-speed running is likely the aspect is left to a qualified sprint coach, if it ice, compression, and elevation as well as
most potent strengthening stimulus for the is addressed at all. appropriate immobilisation ensuring no
muscles which require rehabilitation, and The 2016 Consensus statement on return pain provocation was provided.
that eccentric overload exercise of these to sport from the First World Congress in A comprehensive initial clinical
same muscles confers local changes which Sports Physical Therapy, Bern has provided examination is performed by the sports
are likely beneficial. Where high speed an evidence-based framework for clinicians medicine physician. The typical clinical
running is not clinically indicated, a range to plan their management of injuries2. RTS signs are identified – pain on palpation,
of relative overload exercises are suggested is described as “…a continuum paralleled decreased strength and flexibility, and pain
to be performed in lieu of running until with recovery and rehabilitation – not with functional movements. No previous
running forms the majority of clinical simply a decision taken in isolation at the history of a hamstring injury or any other
loading. end of the recovery and rehabilitation major injuries in the past five years is
process2”. The overall RTS process should be reported, and there were no signs of any
WHY WE THINK ATTENTION TO RUNNING considered as continuous, where the player neural involvement, or any other adverse
MECHANICS IS A WASTE OF CLINICAL TIME returns to participation, then return to findings from the initial examination. and
AND ATTENTION sport, and eventually, return to performance the clinical examination is supplemented
Currently, we remain unconvinced of the (Figure 1)2. with a magnetic resonance imaging (MRI)
usefulness of more complicated attention In this article, we hope to present the scan. The MRI revealed positive signs of
to individual gait analyses and therefore reader with a criteria-based progression injury, corresponding with a Grade II biceps
“biomechanical” contributors. This stems rehabilitation protocol, as well as clinical femoris muscle tear, located at the proximal
from several lines. Firstly, we are unaware of predictors used in RTS decision making. musculotendinous junction.
any evidence of good predictive association
of any “bench” measures (e.g. posture,

The central tenet of the

flexibility, strength, movement patterns)
with actual overground high speed running
mechanics, and we don’t yet know how to
measure high speed running mechanics
in someone who is currently injured. rehabilitation protocol
is a requirement for set
Secondly, we suggest that the magnitude
of any differences is likely to be small in
comparison to the possibility for overload
through simple changes in the volume and
intensity of running which players regularly criteria (specific physical
testing) to be proven prior
encounter as part of normal training and
match variability. We are unaware of any

to allowing progression to
evidence that physiotherapy interventions
can meaningfully change high speed
running mechanics and therefore loads.
Finally, we suggest that a fundamental
aspect of training principles is that
individuals adapt to (over)load. Provided
the next stage.
HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 67
WHEN WILL I BE READY TO PLAY?

Table 1

SOME THINGS TO CONSIDER STAGE 1: PROMOTE HEALING AND EARLY OPTIMAL LOADING OF THE INJURED TISSUE
The central tenet of the rehabilitation
protocol is a requirement for set criteria 1. Protect scar tissue development
(specific physical testing) to be proven prior
2. Minimise muscle atrophy and pain
to allowing progression to the next stage.
Daily measurements of subjective pain,
pain with palpation, range of movement or STAGE 2-3: REGAIN FULL MUSCLE FUNCTION
flexibility, and strength allows the clinician
to adapt the protocol for the player on the 1. Regain full voluntary control over the injured muscle
particular day of treatment depending on 2. Regain pain-free hamstring strength, initially in inner range progressing to
the presentation of the individual, as well as longer hamstring lengths
identify the response to the previous day’s 3. Develop appropriate control of trunk and pelvis with progressive movement
treatment. speed and increasing load on the hamstrings
Since loading healing tissue beyond
4. Pain free running up to maximal speed and with changing directions,
its elastic limit might result in further
performed under fatigue
exacerbations, signaled by the presence of
pain with this loading, we advocate that
generally all exercises should be performed STAGE 4-6: INTEGRATE FULL SPORTS SPECIFIC PARTICIPATION
close to pain free limit3. If the exercise or
movement elicits pain from the injured 1. Symptom-free during all activities
area, the exercise is immediately adjusted or 2. Complete 3 progressive sports specific sessions with no pain (at the time of the
terminated. exercise or later) and full effort.
Arbitrarily the rehabilitation protocol
consists of six stages; three “physiotherapy” Table 1: Rehabilitation goals for each stage.
stages and three “sport specific” stages. The
main feature of the protocol repeated in CRITERIA FOR PROGRESSION TO STAGE 2 running mechanics. It is performed under
each stage is the early, but safe resumption Progression to stage 2 is allowed when the supervision to ensure these components
of repeated high-speed running, and player can perform a pain free single leg are executed well, and adjustments can be
direction change movements. The extended squat, as well as stationary bike for five made where necessary.
basic description of the daily measurements minutes, maintaining power output (in Before running, the player performs
and rehabilitation protocol was released for Watts) of 150% of their bodyweight (in kg). an appropriate warm up routine, such
information purposes, and is freely available as stationary cycling, slow running, or
online (https://t.co/TkXOehNLm). Stage 2 other lower limb cardio-type exercise. The
Exercises are performed with increased player performs the sprinting technique
THE CRITERIA-BASED PROGRESSION load. Importantly, the practitioner monitors “A” and “B” drills which emphasise the
REHABILITATION PROTOCOL the exercises to ensure they are executed late swing, and triple extension phases of
We present the six stages within appropriately. running, respectively. During these drills
the rehabilitation protocol and the The running progression protocol is intro- observations of symmetry and ranges of
corresponding criteria for progression into duced in this stage. Lengthening exercises4 motion are observed, and corrections can be
each of the stages (Figure 2). The goals for can be introduced if appropriate. If there made as appropriate.
each stage is summarised in Table 1. is a worsening in the patient’s strength or Importantly, when the running
range of movement measurements, or an programme is introduced, the loading
Stage 1 increase in pain reported, then the loading during running is progressively and
The main aim is to promote healing is reduced. Here the clinician needs to carefully increased. For this reason, we
and simultaneously avoid any provocative clinically reason what component of the ask the player to rate their perceived effort
activities which might delay the RTS previous session was the likely culprit, and during running. This allows us to ensure
process. Low load exercises during the modify this accordingly. In this regard we that similar loads are maintained within
early phase of healing are used. Functional can be guided by EMG studies, the player’s sessions and enables careful increases in
exercises aimed at retaining and even reported perception of the load during the loading (running speed).
improving movement patterns are also exercise, and the observed performance Typically, the player is presented with a
utilised. Typically, active movements in during rehabilitation. line marked from 0% to 100%, explaining
mid and inner range (of knee- and hip that a 100% run would equal a maximum
flexion), specific soft tissue mobilisation, RUNNING PROGRESSION effort sprint, while 0% would be the slowest
and isometric or easy concentric exercises The running progression programme possible speed that the player could run at
are performed. addresses volume, intensity, and to an extent (see Figure 3c). We perform the running

68
 2
Physio On-field

Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 Stage 6

Pain-free single leg squat

Light football
Pain-free bike 150W,
training session
5 minutes

Run > 70% In-between football

ROM SLR & HS Θ>75% training session
Figure 2: Criteria
based progression
algorithm.
100% running
Heavy football Figure 3: Running
pain free direction
training session progression and
change
direction change.

3a 3b 2

3
4 laps = 8 ‘sprints’ × 3 sets 4
~ 700m
11s → 3.1s
10% → 100% 3 reps
5 12s → 9s
60% → 100%

3c

0 10 20 30 40 50 60 70 80 90 100

on an oval track with approximately During each session, if the player can of sprinting an elite football player would
30m straights, and approximately 100m complete a set without any increase in sprint in a professional match5. 
around (see Figure 3a). The players begin pain, he is allowed to increase the speed by
from a walking start into the “run” at the 5-10%. If any discomfort is experienced, if CRITERIA FOR PROGRESSION TO STAGE 3
beginning of the straight and decelerate the player does not feel confident or displays The player must be able to run more
on the corners. Each time the player lack of adequate mechanics or control, the than 70% of maximal speed (self-rated).
completes three sets of four laps they are player is instructed to return to the previous Additionally, we are guided by strength
asked to rate their speed compared to their set’s percentage running. If any discomfort and flexibility, where 75% painless range
fastest speed during each set. We also or pain is reported during the running, the of mo-tion as well as 75% of the players
record their times across the 30m track player is instructed to stop, and no further maximum strength was required to
using a hand-held stop watch. In practice running is attempted for that session. progress. This may still be a good guideline,
0-10% usually equates to approximately At Aspetar, the typical amount of running however, in our players this was almost
13-15 seconds, while a full sprint (100%) (3 sets of 4 laps or 8 “runs”) is approximately always the case when they were able to
might be as fast as 2.9 seconds. 700m.This compares well to the amount run at 70%.

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 69

WHEN WILL I BE READY TO PLAY?

/ /20___ DAYS POST:

Sign:_____________________________
Stage 3 INJURED UNINJURED
Further progression of strengthening- Average pain today VAS /10
and lengthening exercises4 are now
included. Eccentric strengthening exercises Walking No P NA
are introduced, specifically the Nordic Jogging No P NA
hamstring exercise6. Load and speed are
added to the lengthening exercises to
2 leg squat × 3 No P NA
increase difficulty. 1 leg squat × 3 No P NA
Daily measurements of the player’s Trunk flexion No P NA
response to training allows us to monitor the
player’s response to the loading, and if the Total palp. length cm P
player is ready for progression. If necessary, Mid range kg P | no kg
a “rest day” may be implemented to allow
recovery between treatment sessions.
Outer range kg P | no kg
Strengthening exercises may now SLR º P| no º
include more specific modifications for the
MHFAKE º P| no º
individual player. Lengthening exercises are
performed with added weights, and/or with Bent leg bridge × 3 No P NA
increased speed to continue increasing the Straight leg bridge × 3 No P NA
overall loading.
The player will also start with changes in
Comments:
direction during running and progression
of running to 100% self-reported effort.
Changes in direction is performed through Figure 4: Daily assessments form.
a modification of the T-drill (Figure 3b). The
player is asked to run from a standing start
and touch each of the cones continuously over three to four days. Depending on treating physiotherapist as well as team
in a forward motion. Change in direction the player’s response, we may allow for doctor or sport medicine physician involved
is without any side stepping or backwards a recovery day between sessions. These with the management of the player.
running. The goal is to allow changes in sessions include running, sprinting, change
direction in a forward motion which would in direction, multiple skill sets, such as Isokinetic Assessment
more accurately reflect football specific passing and kicking, and perturbation. If Knee flexion and extension muscle
demands. In this sense, there is a low the player is not able to meet the criteria or strength were tested using an isokinetic
impact transfer to the on-field part of the experiences any pain or discomfort in this dynamometer (Biodex Multi-joint System 3).
rehabilitation. stage, the programme is adapted in terms of Testing comprises three different modes and
The player starts with the direction the load. If the symptoms persist, the player speeds. First, the players were tested over
changes only when the running is self- returns to the previous stage in the protocol. five repetitions of concentric knee flexion
reported at 70%. The player is asked to start and extension at 60°/s. This was followed by
at 60% with the directional changes, and to RTS ASSESSMENT AND RECOMMENDATION 10 repetitions of concentric knee flexion and
increase the speed progressively as with the After completion of all three sport specific extension at 300°/s. Finally, they performed
running. The total time is measured from rehabilitation stages (stages 4-6), the final five repetitions of eccentric knee extension
the start of the drill to the end of the drill. re-assessments (clinical examinations) are at 60°/s. The highest peak torque value
performed before the player is discharged observed from all repetitions performed
CRITERIA FOR PROGRESSION TO STAGES 4-6 from rehabilitation. for each of the three different tests were
When the player can run at 100% (self- Initial measurements of strength and recorded.
rated) and perform the modified T-drill flexibility are repeated, as well as the func-
test at maximum speed (self-rated), he tional movement tests as seen in the daily Askling H-test
progresses to stages 4-6. assessment form (Figure 4). Additionally, The patient is in supine with the
we perform an isokinetic assessment and, contralateral leg and the upper body fixed.
Stage 4-6 On-field rehabilitation the Askling H-test7. and the patient is asked On the tested leg, a knee braces ensures
After completion of stage 3, the player to rate his own perceived readiness to RTS. full extension of the knee (0°). The H-test
progress to the on-field phase of the Importantly, this information is not used session begins with the passive flexibility
rehabilitation protocol. This requires as set criteria for RTS, but forms part of the test where the clinician slowly raises the
completing three 30 – 45 min sessions of shared decision-making process8, which examined leg towards maximal hip flexion
sport specific training, typically performed ideally includes the player, the coach, and range of motion. Endpoint is reached when

70
the patient reports a strong, but tolerable
stretching in the hamstring muscle.
The active flexibility test consists of
one practice trial followed by a set of three
consecutive test trials.
The patient is firstly instructed to
perform the practice straight leg trial
with submaximal effort, followed by the
three active test trials, where the patient is
instructed to perform a straight leg as fast as
possible to the highest point without taking
any risk.
After the three active trials, the patient is
asked to estimate experience of insecurity
and pain on a VAS-scale from 0 to 1007.
When the player is discharged from
rehabilitation, and deemed ready to return
to training or match play, we recommend to
the player and the coaching team to make a
progressive RTS:
1. 1 X 50% training session Figure 5: Palpation. Note the length of pain (in cm).
2. 2 X full training sessions
3. Reduced 1st match return to play (50% FLEXIBILITY Outer-range strength (Figure 8)
or 30min) Active knee extension range of motion The player is positioned in supine with
4. Full Match return to play is measured in maximal hip flexion, a fixating belt over the pelvis in line with
named the Maximal Hip Flexion Active the anterior superior iliac spine (ASIS). The
OUTCOME BASED REHABILITATION Knee Extension (MHFAKE) test9 (Figure 6). clinician passively flexes the player’s knee on
THROUGH DAILY ASSESSMENTS Keeping the hip in maximal flexion with the testing leg to 90° while the contralateral
We used the daily measurements to the elbows locked, the player is instructed leg remains flat. Standing at the side of the
assist in the clinical reasoning of how to actively extend the knee until reaching examination table, holding a HHD with
to progress or adapt the treatment the point of maximal tolerable stretch of both arms and vertically positioned against
session of the player on a specific day. the hamstring muscle. The contralateral leg the player’s posterior heel, the clinician
When the association between daily is fixed by the clinician. The absolute knee resists an isometric maximum voluntary
clinical measures and the progression of extension angle is measured as the endpoint contraction against the HHD for three
rehabilitation was analysed, we found of maximal tolerable stretch with the hand- seconds, before a break is performed.
the daily measures was seen to be non- held inclinometer placed on the anterior
linear, meaning that the change in the tibial border mid shin. We have found the RUNNING
RTS time was not proportional to the MHFAKE test to be a better measure of Lower perceived running effort (below
different measures. The main clinical flexibility than the traditional straight leg 50%) was quite variable between different
outcome measures that forms part of the raise test, or other "usual" hamstring tests. players. which measures correlate well with
decision making during rehabilitation is the progression through rehabilitation.
monitoring pain, strength, flexibility, and STRENGTH Clinically, we have found that outer
running. Mid-range strength (Figure 7) range strength tracked well with beyond
The player is positioned in prone and the approximately 50%. 
PAIN clinician passively flexes the player’s knee
Our daily assessments include subjective to one foot distance above the examination CLINICAL IMPLICATIONS
pain using the visual analogue scale (VAS) table (plinth). Standing behind the player, Asking the patient about pain during
and pain on palpation/tenderness (Figure 5). holding the hand-held dynamometer their daily activities (such as a numeric
The player reports the overall pain for (HHD) with both arms against the posterior pain rating scale), measuring strength in
that day, and the length of pain on palpation heel in a comfortable position, the clinician the outer range position, the maximal hip
is measured. If pain worsens (either resists an isometric maximum voluntary flexion active knee extension flexibility
reported by the player or the length of pain contraction from the player against the test, as well as length of pain on palpation
on palpation) reduce the amount of load in HHD for three seconds, before performing were the most useful daily examinations
that session. break movement. to inform the progression during different

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 71

WHEN WILL I BE READY TO PLAY?

6a 6b

Figure 6: Maximal hip flexion active knee extension (MHFAKE) test.

7a 7b

Figure7: Mid-Range strength test.

8a 8b

Figure 8: Outer Range strength test.

stages of rehabilitation through to return to The important subjective features • Outer range strength at day 7 expressed
participation (Box 1). associated with RTS time were: as a percentage of the uninjured leg,
• Maximum pain (VAS scale 1-10) reported • Peak isokinetic strength of knee flexion
CLINICAL PREDICTORS FOR RETURN TO at the time of injury of the uninjured leg.
SPORT (RTS) • A delay in starting physiotherapy Careful attention to these measurements
There is still lack of consensus regarding • Time taken to walk pain free. might provide the clinician with greater
which clinical measurements are useful to The physical findings that were found insights into the duration of RTS for an
predict time to RTS. useful were strength testing related injured football player.
A combination of clinical findings at the variables:
day 7 follow up clinical examination could • Change in pain on the mid-range SUMMARY
provide some reasonable predictive ability strength test over the first week In the literature, several different
in the duration of RTS9. For this investigation, • Pain during the outer range strength rehabilitation protocols have been
RTS was 23 (±5) days. test and single leg bridge at day 7 described; these approaches have been

72
 Box 1: Clinical implications for daily outcome
measurements during rehabilitation
valuable in growing our knowledge and
understanding of what constitutes an
• If pain worsens (either reported by the player or the length of pain on palpation)
appropriate rehabilitation protocol. The
reduce the amount of load in that session
difficulty remains in understanding
how and when they will benefit an • When the length of pain on palpation is half (reduced by 50% from the initial
individual player. We have presented examination), it is likely that the rehabilitation process is 50% completed.
our rehabilitation protocol for a football • The maximal hip flexion active knee extension (MHFAKE) is the best measure of
player with a typical running related flexibility more so than straight leg raise (SLR), but it normalises half way through
hamstring injury, where criteria-based the rehabilitation process.
progression is followed throughout the • Outer range strength seems to be the best measure to guide strength progression,
rehabilitation process. If we integrate and normal outer range strength should be approximately 50% of the player’s
objective measures as well as subjective bodyweight
measures into the clinical reasoning • Players can estimate their running effort in a meaningful way, but only above
process, we can provide a rehabilitation approximately 50% of their perceived maximum.
program that is aligned with our RTS • The percentage perceived running effort roughly correlates to the outer
goals. range strength (measured as a percentage of the uninjured side at the initial
At Aspetar, we value of a multi- examination)
disciplinary team approach, and shared
decision making as described in the
literature, has been a valuable feature 4. Askling CM, Tengvar M, Thorstensson performance health management and
in our experience2,10-11. During the A. Acute hamstring injuries in Swedish coaching model. Br J Sports Med. 2014
rehabilitation process, the communication elite football: a prospective randomised Apr;48(7):523–31.
with the player, the team doctor, and controlled clinical trial comparing two 11. Ardern CL, Bizzini M, Bahr R. It is time for
especially the coaching, is critical if we rehabilitation protocols. Br J Sports Med. consensus on return to play after injury:
want to achieve successful outcomes for 2013 Oct;47(15):953–9. five key questions. Br J Sports Med. 2016
our players.
5. Bangsbo J, Mohr M, Krustrup P. Physical May;50(9):506–8.
and metabolic demands of training and
match-play in the elite football player. J
Sports Sci. 2006 Jul;24(7):665–74.
6. Petersen J, Thorborg K, Nielsen MB, Budtz-
Jorgensen E, Holmich P. Preventive Effect
of Eccentric Training on Acute Hamstring Rod Whiteley Ph.D.
Injuries in Men’s Soccer: A Cluster-
Rehabilitation Department, Aspetar
Randomized Controlled Trial. Am J Sports
Orthopaedic and Sports Medicine Hospital
Med. 2011 Nov 1;39(11):2296–303.
Doha, Qatar
7. Askling CM, Nilsson J, Thorstensson A.
A new hamstring test to complement
the common clinical examination Arnlaug Wangensteen Ph.D.
References before return to sport after injury. Knee Oslo Sports Trauma Research Center,
1. Whiteley R, van Dyk N, Wangensteen A, Surg Sports Traumatol Arthrosc. 2010 Department of Sports Medicine,
Hansen C. Clinical implications from daily Dec;18(12):1798–803. Norwegian School of Sport Sciences
physiotherapy examination of 131 acute 8. Dijkstra HP, Pollock N, Chakraverty R, Oslo, Norway
hamstring injuries and their association Ardern CL. Return to play in elite sport:
with running speed and rehabilitation a shared decision-making process. Br J
progression. Br J Sports Med. 2017 Oct Sports Med. 2017 Mar;51(5):419–20. Nicol van Dyk Ph.D.
30;bjsports-2017-097616. 9. Jacobsen P, Witvrouw E, Muxart P, Tol JL, Aspetar Orthopaedic and Sports Medicine
Hospital
2. Ardern CL, Glasgow P, Schneiders A, Whiteley R. A combination of initial and
Witvrouw E, Clarsen B, Cools A, et al. 2016 follow-up physiotherapist examination Doha, Qatar
Consensus statement on return to sport predicts physician-determined time to
from the First World Congress in Sports return to play after hamstring injury, Philipp Jacobsen
Physical Therapy, Bern. Br J Sports Med. with no added value of MRI. Br J Sports
Liverpool Football Club
2016 Jul;50(14):853–64. Med. 2016 Apr;50(7):431–9.
Liverpool, United Kingdom
3. Glasgow P, Phillips N, Bleakley C. Optimal 10. Dijkstra HP, Pollock N, Chakraverty
loading: key variables and mechanisms. R, Alonso JM. Managing the health
Br J Sports Med. 2015;49(5):278–279. of the elite athlete: a new integrated Contact: [email protected]

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 73

WILL IT INFLUENCE MY PERFORMANCE?

DEFINING
PERFORMANCE
AFTER HAMSTRING
STRAIN INJURY
– Written by Darren Paul, Qatar and Joao Brito, Portugal

INTRODUCTION is expected that the coach will have a squad running/sprinting exposure, as beneficial to
"I was petrified of running into a channel. ready and capable to perform on the field. performance5,6.
I just knew I was going to tear a muscle… the Unfortunately, most teams will encounter
worst thing about it is that your instinct players being lost through injury during FUNCTIONAL PERFORMANCE
tells you to do what you have done all your crucial times of the season, for extended Although not impossible, a hamstring
life but you start thinking: oh no, don't… periods of time, and/or on repeated strain is unlikely to be a career ending injury.
for six or seven years I hated it… I couldn't occasions. The outcome of this will likely However, while an athlete should eventually
wait to retire… mentally I could do it, but have significant implications on morale, be able to return to the field without any
physically I couldn't". This was Michael finances, and the team’s chances of success. complications, there may be lingering
Owen’s recent admission of the impact the Hamstring strain injurie (HSI) remains morphological, physical, or psychological
hamstring injuries that plagued a large part common in team sports and one of the most concerns which individually or collectively
of his footballing career had on himself and challenging issues facing sports medicine may negatively impact performance7. It
the team1. practitioners2. In elite European football, is suggested that players may return to
the incidence of HSI has increased annually competition after hamstring injury having
HAMSTRING IMPORTANCE AND by 4% between 2001 and 20143 with high developed maladaptation’s that predispose
PERFORMANCE reinjury rates. The hamstrings play a them to subsequent injury8. In addition,
Coaches, players and supporters are for significant role during important match following the initial trauma, players may
the most part, concerned with their team winning actions such as sprinting past an worry about whether the muscle will fully
winning. The medical and sport science opposing defender4. Accordingly, there is a return to its previous capacity, the potential
staff play an important role towards this growing body of research demonstrating effect on their physical ability, and the likely
objective by mitigating the risk of injury measures of hamstring function, notably impact of being absent for any forthcoming
and enhancing performance. In doing this it eccentric strength, as well as high speed important matches.

74
 cises, notably the Nordic hamstring exercise
and high-speed running, have gained
support as being effective to mitigate injury
risk as well as improving performance13,14.
Specifically, improvements in peak
eccentric hamstring strength and force
capacity, sprint and change of direction
performance have also been found with
the introduction of the Nordic hamstring
exercise and/or high-speed running
training5,15. Interestingly, the gains in change
of direction performance were shown to be
maintained despite an approximate 10%
decrease in eccentric hamstring strength
following a detraining period. This has led
to inferences regarding several adaptations
that may occur in response to training,
such as: increased fascicle length16 and/
or enhanced neuromuscular parameters15.
Practically, this indicates that performance
improvements may still be maintained
even when the Nordic hamstring exercise
is removed or reduced during specific
periods, such as the winter break and
congested match schedules. These findings
are valuable to aid practitioners in their
programming.
The implementation of hamstring
strengthening exercises is likely to differ
between sports teams and clubs, based on a
myriad of factors such as match schedules,
player and coach perceptions; and education
around such interventions. Accordingly,
teams may adopt a different model of
The force producing capabilities of nerve branches at the site of injury, shifts training that represents an experience-
the muscle have also shown to be altered in the knee flexor torque-joint angle based approach. This approach might not
during tasks such as running, which may relationship and associated neuromuscular resemble general recommendation, but
further contribute to reinjury risk9. Players activity deficits. These changes may induce conforms with these circumstances. For
returning from an injury have shown to be potentially injurious kinematics8,12. For example, performing the Nordic hamstring
moderately slower compared to uninjured example, sagittal asymmetry in hip flexion, exercise before training attenuated sprint
players2, although this does improve over pelvic tilt, and medial rotation of the knee performance declines but decreased
time. There is also evidence of a horizontal, have also been reported following an injury, eccentric hamstring peak torque during
but not vertical, force application deficit effectively altering certain movement football-specific exercise17. More recently,
in the injured limb during running10. patterns. The concern is that these may be Lovell and colleagues18 showed biceps
Such a scenario may resonate more with moderating factors of future hamstring femoris fascicle length increases were more
those ‘chronic rehabbers’ (i.e. players with function. likely to increase when performing the
persistent symptoms, or subsequent injuries Nordic hamstring exercise before, compared
of the same type and nature), particularly TRAINING PERFORMANCE to after, training. However, increases in
since the relevance of previous injury is Regaining hamstring function early and biceps femoris muscle thickness and
perceived differently for injured than non- safely, while minimizing any detraining pennation angle were found when Nordics
injured players11. induced decline in physical performance, were performed after, compared to before,
Following a HSI, changes may also occur is an important part of the rehabilitation training. As inadequate eccentric strength
in the connective tissue content of the scar process. While there is no single intervention and fatigue are both risk factors for HSI,
tissue. This may include selective residual which optimally re-conditions the injured strength training should be considered
atrophy, damage to the intramuscular hamstring, performing strengthening exer- along with the development of peak

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 75

WILL IT INFLUENCE MY PERFORMANCE?

Coaches, players and supporters are,

for the most part, concerned with their
team winning. The medical and sport
science staff play an important role
towards this objective by mitigating
the risk of injury and enhancing
performance.

eccentric strength, as a component of It is believed that a criteria-based rather Deficits in eccentric and concentric
programmes aimed at reducing injury risk than a time-based approach will objectify strength and strength ratios have been
in multiple-sprint sports19. Such findings all physical variables involved in the return shown to persist beyond the return to sport
demonstrate there may be benefits to to sport, allowing for a decision to be less process23. Worryingly, the ability to perform
performing these exercises both before and subjective or experience dependent. While a repeated sprints may also be impaired as long
after a training session, perhaps reducing returning athlete may achieve the specified as two years after returning to competition24
the negative influence of fatigue. performance outcomes, there may still be while greater reductions in isokinetic knee
gaps within the rehabilitation programme flexor torque and the concentric hamstring:
RETURN TO SPORT PERFORMANCE that may not fully prepare them to perform quadriceps peak torque ratio have been
The return to sport (RTS) criteria are on the field. Blanch and Gabbett22 noted that observed after repeated-sprint running
suggested to represent a key component of most protocols for ascertaining RTS clearance only in the injured (kicking) leg, and only
the rehabilitation process. It is considered focused on healing status and functional in the previously injured subjects25. Such
a vital part in order to fully address and tests, with little information pertaining to findings are insightful to the long-term
prepare the player. Recently, van der Horst the completion of an appropriate volume care and management of players, even after
and colleagues20 published an expert of training. This is consistent with some returning to competition.
consensus on the RTS after HSI. Consensus potential concerns of a mismatch between Sport teams are investing heavily into
(defined as agreement of >70%) was what is currently performed in training and staff, facilities, and equipment to better
only reached for repeated sprint ability, what is expected in match play. their understanding and advance current
single leg bridge, deceleration drills and Targeting a set performance criterion practice of athlete care and performance.
position specific global positioning system (e.g. time to complete a sprint test) may Daily subjective and objective measures,
targeted match specific rehabilitation, offer an appealing framework; however, monitoring training and match activity,
highlighting the disparity in approaches. judging an athlete’s capacity solely on some as well as calculating workloads, seem to
The RTS decision-making process is based isolated measures of performance has its be daily duties within sports science and
on the evaluation of the relevant health limitations. medicine teams. Commonly, teams do
(medical and injury-specific factors) and some form of benchmarking, identifying
activity (performance factors) risks, but MATCH PERFORMANCE ‘red flags’, and comparing pre- and post-
is also influenced by contextual factors There is a level of acceptance that an injury data to aid the decision-making
known as decision modifiers (e.g., timing athlete may return to the competition even during the rehabilitation process. While
of the season, competitive level, coach and though they may not have fully completed such data may offer a reference point, it
/or stakeholder pressure)21. Considering the the final stages of the rehabilitation should also be interpreted with a sense
multidimensional nature of HSI, the return process. However, simply returning to the of caution when considering a player’s
to sport criteria should not be validated as field does not mean that the player can return. Classifying a post-injury drop in
univariate factors, but interaction of context achieve optimal performance, as there is a match workload (e.g. sprints), compared to
dependent criteria that also includes significant distinction between fit to play pre-injury data, as being solely a physical
different weighting. and fit to perform. limitation is a reductionist viewpoint, and

76
ignores the context and complexity of impact on team performance30. This also it is suspected that RTS may impact
sports performance. suggests that some players may return to performance, particularly during the earlier
A reluctance to sprint may be attributed sport prior to complete resolution of the stages of rehabilitation. It is important that
to several factors, including a general fear injury and in a suboptimal state31. If this the process of returning to performance
of reinjury (psychological reservations), occurs, consider the effect it may have on is a shared decision making and that the
or conserving oneself for selection of the the coach and the player’s teammates. The player plays a significant role throughout
national team (environmental contextual difficulty is establishing whether this is a the process.
factors). It may even be a player’s (non) normal part of the RTS process, or whether
subliminal action of pacing themselves, it is indicative of some shortfalls in the
constituting part of a self-determined final player’s physical preparation and overall
phase of their rehabilitation. Indeed, it rehabilitation process. If it is communicated
would seem intuitive for some players to to the coach that they are unlikely to be
‘ease their way back’ into the competitive receiving back the same player (in terms
environment. A player taking this approach of performance) that was in the team prior
may be cognizant of their injury history, to the injury, it then may impact upon the
playing age and/or experience; it may even coach’s selection process. However, coaches
have been recommended by a teammate may be willing to take the risk, and should
whom has previously had a similar injury. clearly be made aware of the potential
References available at
Such context specific details cannot be impact on team performance, and the
www.aspetar.com/journal
captured solely from the physical workloads increased risk of reinjury. Since team sports
presented from time and motion analyses. can be multimillion-dollar industries, and
Nonetheless, if the returning player the difference between winning and losing
produces a significant action (scoring a games hold enormous financial impact,
goal) or match winning performance, the coaches need to be mindful that certain
relatively low match workloads may simply decisions regarding players can prove very
be a distant secondary consideration for the costly.
coach! There are many challenges to losing a
player - possibly a repositioning of players
TEAM PERFORMANCE in the team, a different playing style or
HSI carries a high burden and sub- selecting a substitute player who has had
stantial financial implications26,27. For very little game time over recent weeks
the professional player, an average of 18 or months. However, following the loss of
days and three matches are missed per influential team members, the support
season, and cumulatively, this equates to staff have an important role in providing a
a club average of 15 matches and 90 days strategy that will not adversely impact on
missed per season28. The inability to play the team. Rather than seeing the situation
and prolonged absence from play during as a threat to success, players should
rehabilitation affects both the individual be encouraged to see the situation as a
player and the team. Losing the star player challenge they are capable of overcoming.
Darren Paul M.Sc.
can have an impact on winning impor-
tant games/competitions, marketing, and SUMMARY Exercise physiologist
even ticket sales, which may produce an HSI can impact muscle morphology, an Exercise Sport Science Department,
unwanted burden to the finances of a club. athlete’s capacity to perform optimally, Aspetar Orthopaedic and Sports Medicine
While this is relevant to any injury, the high and the team’s chances of success, which Hospital
frequency of reinjury suggests this may be may not go unnoticed by the coach and Doha, Qatar
particularly pertinent to HSI. support staff. Establishing reference
It is well established that player points may be useful but should not be
availability is highly important for success29. the sole focus of a rehabilitation process, Joao Brito Ph.D.
However, even when a player has returned rather a holistic approach should be the Physiologist
to the team following a HSI, the coach’s objective. Appropriate strategies such as Performance and health unit,
opinion of player performance appears strengthening exercises and performing
Portuguese Football Association,
to be lower than pre-injury. Statistics sprinting activities as part of training
Portugal
show that staff (coaches, medical) and a should provide some reinjury protection as
large percentage of players (67%), believe well as increasing functional performance.
a lower limb injury to have a negative The coach should be informed when Contact: [email protected]

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 77

CONCLUSION

THE COMPLEXITY OF
BEES, BICYCLES, AND
INJURIES
AN OVERVIEW OF THE PREVENTION
PARADIGM SHIFT AND ADVICE FOR
CLINICAL PRACTICE
– Written by Nicol van Dyk, Qatar and Erik Witvrouw, Belgium

INTRODUCTION defined by van Mechelen et al6, creating a of the injury mechanism during the inciting
Those working in the sport and exercise framework for injury prevention. The model event as a component of the causal path-
medicine community are continuously suggests three steps: way8. The causation model was later updated
trying to improve and refine ways to protect 1. identify the magnitude of the problem to capture the non-linearity of sports injury
the health of athletes and minimise the (incidence or severity), in the dynamic recursive model9. This allows
risk of injury. We are experiencing a shift 2. ascertain the aetiological risk factors for the potential of the inciting event to cha-
in general healthcare from curative disease or injury mechanism responsible, and nge the athlete’s intrinsic risk factors and
management to practicing preventative based on these findings their predisposition to injury. This model
evidence based medicine1. And although 3. introduce a preventative measure moved beyond the simple identification of
this focuses on chronic health diseases such to address the injury occurrence. extrinsic and intrinsic factors that might
as diabetes, arthritis, and cancer, the shift Finally, the effect of the intervention is be associated with injury. Finch et al
towards prevention is also evident in sports evaluated by repeating the first step. advanced this model further by addressing
medicine2,3. Unfortunately, injury rates The causation model proposed by implementation and effectiveness of such
across different sports have not changed4,5, Meeuwisse et al further developed our interventions, through the Translating
and we are in need of a radical paradigm understanding of injury risk by accounting Research into Injury Prevention Practice
shift in our approach to injury prevention. for the interaction of multiple risk factors, (TRIPP) framework10. In this framework,
It has been over 30 years since the both intrinsic and extrinsic7. Bahr and two important steps were added before
injury prevention research model was first Krosshaug expanded on the characteristics repeating step one - determining the ideal

78
 Multifactorial model of Complex model for sport injury
athletic injury etiology TRIPP framework Application of complex system
Account for interaction of Addressing factors related theory that allows for interactions
multiple risk factors to effectiveness and between variables that determines
(intrinsic and extrinsic factors) implementation emerging pattern (adaptation or injury)

Dynamic recursive model of

Comperhensive model etiology in sport injury
Injury prevention model for injury causation Account for repeated participation
Fundamental four Account for interaction of in sport and adaptation/
step model for multiple risk factors alteration/interaction of known
injury prevention (intrinsic and extrinsic factors) risk factors

1992 1994 2005 2006 2007 2016

Van Mechelen el al32 Meeuwisse el al21 Bahr and Krosshaug3 Finch el al10 Meeuwisse el al20 Bittencourt el al (2016)6

Figure 1: Temporal development of injury prevention models, with key characteristics for each model highlighted (with permission).

conditions to perform the preventative ineffectiveness of our current approach to that needs 21 days to recover. In addition,
measure, and evaluating the effectiveness risk factor identification and analysis. it would be very difficult to determine a
of the prevention programme in an The purpose of this article is to present clear cut-off point for significant eccentric
implementation context. A summary of examples of simple injury prevention weakness that effectively separates the
these injury prevention models and their programmes that work, highlight some high risk (will be injured) athletes from the
key characteristics can be found in Figure 1. reasons for the inefficiencies within these low risk (will not be injured) athletes15. The
A vital part of all these models is the programmes, and propose the paradigm lack of clinical utility demonstrated in these
identification of risk factors that may shift needed in our understanding of injury tests highlight the difficulty we face when
predispose the athlete to injury. However, risk. interpreting these significant findings.
risk factor analysis is still presented as the This type of analysis and interpretation
breakdown of the big problem (injury) into WHY OUR CURRENT MODELS DON’T of risk factors still relies heavily on the
smaller units (risk factors), which resolved WORK - THE (LACK OF) CLINICAL UTILITY statistical p-value, which conceal other
through analyses and rational deduction. IN STATISTICALLY SIGNIFICANT RESULTS relevant analyses, such as effect size or
This represents an oversimplified, reducti- When statistically significant results clinically meaningful differences. Although
onist view of the problem. What is required are reported, we need to establish how p-values are useful to determine probability
is greater awareness of the complexity well these findings translate into clinical in hypothesis testing, it is not valuable in
involved in sports injuries, with newer practice. To illustrate, let us consider the assigning clinical meaning to a finding16.
models outlining how these factors incidence for hamstring injuries in Qatar, Despite this obvious limitation, we quickly
mediate, moderate, and interact with each reported as 11%13. This is known as the “base assign the “importance” of a particular
other11. rate” for hamstring injury in this population. finding based almost entirely on this one
In 2009, the International Olympic Eccentric hamstring strength is often found component of an analytic assessment. At
committee (IOC) released a consensus to be a significant risk factor for hamstring its root level, a p-value is the probability
statement regarding the use of periodic injury; in this population reported with an of obtaining a result that is as extreme as
health evaluations, commonly referred to as odds ratio of 1.37 (CI 1.01-1.85, p=0.04)14. If we the one that was actually observed, using
“screening.” It suggested screening to be set apply this odds ratio of 1.37 to the base rate the assumption that the null hypothesis is
up as research projects, and called for future for hamstring injury, the risk of injury for the of actual value17. Consequently, statistical
research to perform large-scale population- athlete changes from 11% to 14.6% (Figure 2). significance is not the same as clinical
based studies to “evaluate the components Is this change meaningful enough to change significance18.
of history and examination that can be used your clinical practice? Furthermore, consider This highlights the important issue of
to identify athletes at risk, intervene, and the burden and severity of the injury, such applying appropriate statistical modelling to
change outcome12.” In agreement with this as the time to return to play (for hamstring answer research questions comprehensively,
recommendation, the Aspetar Injury and injury, reported as 21 days on average). We which might include Bayesian probability,
Illness Prevention Programme (ASPREV) was might take very different clinical decisions aggregated decision tree, or stochastic time-
initiated at Aspetar, with similar projects when the 37% increase in relative risk (as series methods19. Even though two groups
performed all over the world. The results the odds ratio indicates) is translated into a might be statistically different (and when
from these studies regrettably highlight the 3.5% increase in absolute risk, for an injury using p-values, this might merely reflect the

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 79

CONCLUSION

Table 1

power of chance or a function of the sample Prevention programme Description Effectiveness

size), clinically they would appear almost
exactly the same. Therefore, risk factor Nordic hamstring
Nordic hamstring 51% reduction in
findings are not always in agreement. exercise in weekly
exercise23 hamstring injuries
prevention programme
OPPOSING RISK FACTOR FINDINGS A inclusive soccer specific
Many risk factor studies have delivered programme including
exercises for running,
contrasting results. Hamstrings injuries FIFA 11+ prevention 25% reduction in
strength, plyometrics,
provide evidence for this, where strength is programme22 overall injuries
balance, acceleration/
often identified as a risk factor for hamstring deceleration, and change
injury. In fact, the most comprehensive in direction
meta-analysis to date could only identify
Table 1: Examples of injury prevention programmes and their effectiveness.
three factors associated with increased
risk of injury, with increased quadriceps
strength being the only modifiable risk
factor (the two non-modifiable risk factors
being age and previous injury)20. Yet two
Lower eccentric
recent publications on strength as a risk
factor for hamstring injury - from the largest
strength
37%
prospective risk factor study performed to
date - produced somewhat contradicting
results14,21.
The first study reported two statistically
significant results. A decrease in isokinetic
increased risk
concentric quadriceps strength and
eccentric hamstring strength were
significantly associated with an increased Pre-test Post-test
risk (approximately 40%) of injury. The
second study reported that an increase in odds odds
isokinetic concentric quadriceps strength
@300°/s was associated with hamstring
1 to 8 1.37 to 8
injury when categorised into strong (two
standard deviations above the mean) and
11% 14.6%
weak (two standard deviations below the
mean) groups; while athletes with stronger
quadriceps being twice as likely to suffer
a hamstring injury21. So in these studies, Figure 2: An illustration of how to apply a specific odds ratio to the base rate of an injury to
performed in two similar study populations interpret the clinical value of the finding (with permission).
with exactly the same methodology and
design, both increased and decreased Therefore, predicting the outcome is made intervention studies using prevention
quadriceps strength were associated with possible by accounting for the sum of the exercises implemented at the group level
an increased risk of injury? Confounding system’s units by identifying these direct have consistently been successful.
factors such as age and previous injury were relationships. This reductionist approach
accounted for in both studies, yet these assumes a linear relationship exists SIMPLE SOLUTIONS TO A COMPLEX
opposing results suggest that we have not between these factors and the outcome, not PROBLEM?
accounted for how the different variables accounting for the complexity rooted within Currently, low-cost, non-invasive ham-
might influence, or even alter, the direct these findings11. As shown in our example, string injury prevention programmes exist,
effect of another specific variable. we must appreciate that a multitude of such as the Nordic hamstring exercise and
These examples demonstrate a faulty factors (modifiable and non-modifiable) the FIFA 11+ programme in soccer22,23. The
reductionist view. Reductionism focuses on may affect the influence of one specific effectiveness of these programmes are
the identification of one or more risk factors variable. often limited by poor compliance or lack
in isolation, such as quadriceps strength, Although risk factor studies continue to of implementation, influenced by team
that is directly associated as the causes for deliver contradicting results20,we observe culture, attitudes and beliefs, as well as
the outcome, whether the outcome is injury a puzzling paradox within the literature. stakeholder involvement24,25. However,
or the development of a specific pathology. Regardless of risk factor identification, apart from these difficulties that we need to

80
 O
organisation. A large number of interacting
x individual agents form an emergent
y θf behaviour (not derivable for the sum of
the activity of these agents alone)28. Our
traditional screening prevention models
θr δ include the assumption that we are dealing
with a static, non-dynamic closed system,
which includes predictors that are too

Rear frame Front frame refined and restrictive to translate to the

“real world” setting19. Similar to beehives
and bicycles, athletes also have a multitude
of different agents (previous injury, age,
technique, playing style, motivation,
strength, neuromuscular control, emotional
health) acting and interacting to form the
emergence of injury. These systems are
robust and can easily adapt to change,
but when the balance between order and
disorder is disrupted, it fails.
A complex systems approach has been
O head angle suggested to better reflect the dynamic
nature of sports injuries11. This new approach
would require investigations of interactions
x Φ trail between different (risk) factors, how these
z interactions might influence, or even alter
each other to form different emergent
wheel base patterns of injury. Unpredictability and
contradiction are ingrained in complex
Ψ systems, and some things will remain
unknowable32. However, by moving away
Figure 3: The complex dynamics of how bicycles remain upright. from a list of risk factors towards developing
risk profiles, we might be able to better
manage the emergence of sports injuries, and
address, the positive preventative effect of queen bee, the system would merely adapt protect our athletes. This approach considers
these programmes are undeniable (Table 1). - other workers would take over the tasks of the interconnected and multidirectional
Such programmes are important tools the missing bees, or the hive would breed interaction between all factors.
for clinicians; they will continue to form a new queen26. The interaction between
part of prevention efforts as our ability to different variables are also evident in the STRATEGIES FOR CLINICAL PRACTICE
monitor the athlete improves. Yet we are “simple” task of riding a bicycle. Explaining Predictive modelling and complex
unable to consistently identify risk factors how bicycles stay upright requires about approaches may not be available in our
that support the results of these successful 25 mathematical variables (Figure 3). But clinics yet. However, we propose three
interventions. Understanding how injuries even after altering a key element needed take-away strategies from the themes
occur, and identifying patterns that might for balance and motion (such as the discussed here to assist the clinician in
refine and optimise these interventions, gyroscopic force of the wheel) that would better translation of risk factor findings into
requires something else - an appreciation of technically make them “unrideable”, it meaningful action.
complexity. remains stable and on track27. This is due to
an understanding of the interaction of the 1) Apply risk factor findings reported in large
THE COMPLEXITY OF BEES, BICYCLES, AND various parts, as well as the complex action prospective cohorts to base rates
HOW IT APPLIES TO INJURY PREVENTION of the human riders to intuitively keep the When the odds ratio findings are applied
First, let’s consider some examples of bicycles stable and upright. So what do bees to base rates of the injury, we can better
complexity. Healthy beehives with many and bicycles have to do with injury? They understand how these findings translate
different elements (thousands of bees) are all examples of complex systems. to our clinical setting. This approach, often
produce highly functional, ordered patterns. Complex systems are dynamic, open referred to as Bayesian thinking, allows us
They may consist of up to 70,000 bees; if systems with inherent non-linearity to adapt our conclusions as new evidence
you remove a few hundred, or even the and unpredictability that exhibit self- emerges. Starting with our pre-test odds

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 81

CONCLUSION

It is time to leverage
our collective strength
THE WAY FORWARD
To challenge current paradigms, we

and share our

need to understand how a complex
system functions, interacts and adapts.
Specialist knowledge of the system we

resources to advance
are investigating is crucial. We need,
in addition to statistics, mathematical

the management and

modelling and machine learning; new
ways of analysis which are already used
in other areas of science and medicine30.

prevention of hamstring This approach may reduce the number of

studies with limited subjects and isolated

injury, and indeed all

variables, and stimulate the emergence
of qualitative research projects including
large subject populations and a multitude

sports injuries. of interacting variables. More importantly it

will require collaboration between sporting
organisations, their affiliated teams, re-
searchers and practitioners, to allow for the
appropriate scientific and clinical veracity
(prior probability), we apply an odds ratio, use, and is occasionally necessary to needed to make meaningful conclusions. It
and end up with post-test odds (posterior fulfil medico-legal requirements12. This is time to leverage our collective strength
probability) (Figure 2). Now this post-test information is valuable in a shared decision and share our resources to advance the
result becomes our new prior, and we making process, where different members management and prevention of hamstring
can apply another piece of information of the management team can review the injury, and indeed all sports injuries.
to further shape our clinical reasoning. information as permitted, and act together
These factors also change in the context to improve the health and performance of
of different athletes. Comparing an older the athlete29.
athlete competing in the final season of a
long career to a young draft pick just starting, 3) Large group-based prevention strategies
who may represent a multi-million-dollar As illustrated in our discussion of
investment to the organisation, the level of complexity, it is likely that several different
acceptable risk and decision to play might be factors combine to produce a specific References
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2007;17(3):215–219.
21. Van Dyk, N N, Bahr R, Whiteley R, et al. meat discriminating metabolites. Sci Rep.
10. Finch C. A new framework for research
Hamstring and Quadriceps Isokinetic 2017;7:42514.
leading to sports injury prevention. J Sci
Strength Deficits Are Weak Risk Factors
Med Sport. 2006;9(1-2):3-9.
for Hamstring Strain Injuries: A
11. B
ittencourt NFN, Meeuwisse WH, 4-Year Cohort Study. Am J Sports Med.
Mendonça LD, Nettel-Aguirre A, Ocarino 2016;44(7):1789-1795.
JM, Fonseca ST. Complex systems
22. Thorborg K, Krommes KK, Esteve E,
approach for sports injuries: moving from
Clausen MB, Bartels EM, Rathleff MS.
risk factor identification to injury pattern
Effect of specific exercise-based football
recognition—narrative review and new
injury prevention programmemes on
concept. Br J Sports Med. 2016;50(21):1309-
the overall injury rate in football: a
1314.
systematic review and meta-analysis of
12. Ljungqvist A, Jenoure P, Engebretsen L, et the FIFA 11 and 11+ programmemes. Br J
al. The International Olympic Committee Sports Med. 2017;51(7):562-571.
(IOC) Consensus Statement on periodic
23. Al Attar WSA, Soomro N, Sinclair PJ,
health evaluation of elite athletes March
Pappas E, Sanders RH. Effect of Injury
2009. Br J Sports Med. 2009;43(9):631–643.
Prevention Programmes that Include
13. Eirale C, Farooq A, Smiley FA, Tol JL, the Nordic Hamstring Exercise on
Chalabi H. Epidemiology of football Hamstring Injury Rates in Soccer Players:
injuries in Asia: A prospective study in A Systematic Review and Meta-Analysis.
Qatar. J Sci Med Sport. 2013;16(2):113-117. Sports Med. 2017;47(5):907-916.
Nicol van Dyk, Ph.D.
14. Van Dyk, N N, Bahr R, Whiteley R, et al. 24. McCall A, Davison M, Andersen TE, et
Hamstring and Quadriceps Isokinetic Physiotherapist & Clinical Researcher
al. Injury prevention strategies at the
Strength Deficits Are Weak Risk Factors FIFA 2014 World Cup: perceptions and Aspetar – Orthopaedic and Sports
for Hamstring Strain Injuries: A practices of the physicians from the 32 Medicine Hospital
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2016;44(7):1789-1795. Med. 2015;49(9):603-608.
15. Bahr R. Why screening tests to predict 25. Bahr R, Thorborg K, Ekstrand J. Evidence- Erik Witvrouw, Ph.D.
injury do not work—and probably never based hamstring injury prevention is not
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football teams: the Nordic Hamstring Physiotherapy, Ghent University
Stovitz SD, Verhagen E, Shrier I.
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survey. Br J Sports Med. 2015;49(22):1466- Ghent, Belgiu
Misinterpretations of the ‘p value’: a brief
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Sports Med. 2017;51:1176-1177. 26. Naeger NL, Peso M, Even N, Barron AB, Contact: [email protected]

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 83

INTERVIEW

CLAUDE
MAKELELE
– Interview by Nebojsa Popovic

Myriam Mzali

84
 © Pascal Le Segretain/Getty Images

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 85

INTERVIEW

CLAUDE CAREER HIGHLIGHTS

MAKELELE 2017 Head coach of K.A.S Eupen

Technical director of Monaco AC

2016
Head coach of Bastia FC
2014
Claude Makelele tells the story of his Retired as a player and was appointed as
2010
splendid career, from the perspectives of an Assistant Manager to Carlo Ancelotti in PSG

elite player and then of a leading coach.

Joined Paris Saint Germain and in 2010 won
2008
Makelele was regarded as one of the best the French Cup

midfielders in Premier League history.

Joined Chelsea FC, and in five years, won two
As he undeniably redefined the game of 2003 English Premier Leagues, two English League
football, the position of defensive midfield Cups, FA Cup, FA Community Shield and the
Carabao Cup
became known as the “Makelele role”.
Highlights of his career includes being 2000 Joined Real Madrid and in three years, won
two Spanish Championships and Spanish
a key player of Galacticos Real Madrid, Super Cup, Champions League, European
the leading heart of Chelsea FC’s and Super Cup, Intercontinental Cup
player, then assistant coach-of Paris Saint-
Germain. He played a fundamental role in 1995 French Champion with FC Nantes

winning league titles in France, Spain and

England.
Makelele’s playing career ended with Paris
Saint-Germain after winning the ‘Coupe
de France’ in 2010. With enthusiasm,
Makelele then started on a new journey
in coaching with his great personality
and experience. He vowed to teach the
younger generations all he had learnt
Hello Claude, how are you? Are you satisfied with your stay in
throughout his outstanding playing career. Aspire?
He currently holds the position of Football Very well, thank you. Aspire is a great place for winter football
camp. The facilities are amazing and the people are so professional
Manager for the Belgian club K.A.S. Eupen, and kind. I feel like it is the world’s finest relaxation and sports
as he continues to aid players achieve their destination, the weather was astonishing with an eye catching
ambience.
maximum potential. A lot of players have
changed the game over the years, but it is And how did you get involved in sports?
Just like most kids, I started playing different types of sports in
only Makelele who has ever had a position school, such as karate, kayak, basketball, handball and table tennis.
named after him. This allowed me the opportunity to develop different skills that

86
 © Vincent Van Doornick/Isosport /MB Media/Getty Images

helped me significantly at a later stage, when I started playing adaptability. Moreover, a coach needs to understand the players,
football. learn their strengths and weaknesses to be able to motivate them.
Being a coach is very similar to being the CEO of a global enterprise.
What’s more difficult, being a football coach or a player? It is essential there is also open communication with the technical
When you transition from playing to coaching, you have to staff (assistant and Sports & Conditioning coaches) as well as
completely change your perspective. As a player, you are more medical staff (doctors and physiotherapists) these relationships are
self-centred and only focus on your personal well-being and very important for athletes’ success. A coach also needs to be fully
performance. As a coach, it is the complete opposite, as you need to in touch with the environment in the football federation. After all,
move the focus from yourself to the team. A coach’s job is to make we should always keep in mind that the players are the essence of
sure that everything is prepared and in place; from the players the club.
to the technical and medical teams, as well as the management Football is a complex sport. In the sense that you need to integrate
and media. It requires a 24-hour availability, anticipation and two parts that are highly significant for the successful functioning

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 87

INTERVIEW

of the club. The first part consists of the players and the staff on the
pitch, and the second part involves the administrative and logistic
staff that are office based. Both parties must not only co-exist but
also demonstrate a high level of cooperation. In the beginning of
my coaching career, I soon realised that I was not fully prepared,
and was unaware of the importance of media in the football
world. Today, media consumes nearly 50% of your daily attention
because journalists have a significant influence in many fields,
including marketing. Therefore, it is very important to have a good
relationship with the representatives of media in order to enhance
feedback and reputation.

When did you start with your specialization in football?

At the age of 17 - after discussing with my father who was ex-

© Philippe Perusseau/Icon Sport/Getty Images

professional football player - I chose the path of professional football.
My dad told me that there will be great, but also tough, times to be
expected but respected my choice.

Let’s talk about your opinion on early specialisation in football.

So many academies for young talents are opening up globally.
Do you see this as an advantage for the future stars of the new
generation?
Personally, I think that young people should try different sports at
a young age and should only start specialisation at the age of 15.
Otherwise you risk burning your talents and becoming disillusioned.

Image above: Claude Makelele

playing for Paris Saint-Germain
(PSG) against Valenciennes FC
at Stade Nungesser in France,
2009.
Image left: President of PSG
Nasser Al-Khelaifi and Claude
Makelele attend the French
Ligue 1 match between PSG and
AS Monaco at Parc des Princes
stadium in Paris, France, March
2016.
Image right: Makelele during a
Premier League match between
Chelsea and Arsenal at Stamford
Bridge football stadium,
England, March 2008.
© Jean Catuffe/Getty Images

88
What do you think the profile of the 21st century football player? always vigilant that it would not affect the time to heal human
Football players should be role models for the youth on and off the injury and that’s where for me the medical team could really
pitch and show a professional attitude and behaviour. In reality help me.
they are the CEO of their own enterprise and we should learn from
individual sports like tennis on how to manage “these teams within What should be for you the ideal profile and set of qualities that
the team”. Best examples are Messi and Ronaldo who have taken a Sports Medicine Physician should have?
this to the next level and are true chiefs of their company. First of all, he or she should be a very good medical educator and
spend the time to discuss all related matters with the player first on
Let’s talk about your own career and the great clubs that you injury prevention and treatment. The doctor is the best person to
played for (Chelsea, Real Madrid, and the French National Team). inform us on this in the best way and direct our decision making as
What should be the role of a Medical Commission in high-level a player on treatment options.
clubs and teams and what is your experience with them? Players should be receptive to medical advice since most players
Luckily in my career I didn’t have too many encounters with medical see the doctor only when injured and then it’s already sometimes
issues, but I believe that the players themselves have a responsibility too late. However, the true champions are the ones that take the
to prepare his/her body in the best way possible since we know our medical advice before an injury occurs.
body best of all. Medical club doctors have specific confidentiality protocols and
I only took medication when I was really sick; in my career I never inability to discuss injuries that have to be reported, this gives
used vitamins and supplements or iron injections. I was always the confidence to the player. Still, open discussion is helpful and
worried about potential doping issues and I didn’t want to risk the opinion of my doctor on return to play is crucial as player and
my career. So much effort and sacrifice are made to reach a high coach. This allows for the player and coaching staff to fine tune an
professional level, so I didn’t want any external factor to destroy appropriate reconditioning schedule. The relationship with your
this. Therefore, I used to avoid contact with the medical staff at the club doctor is very important with mutual respect and confidence.
club as much as possible (laughs) but for me the most important This can bring the individual player to a higher level of performance
medical encounter was to know about the severity of my injury. physically and mentally. This confidence should go both ways, of
I could take a lot of pain anyway and could resist well but I was course.

© CARL DE SOUZA/AFP/Getty Images

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 89

INTERVIEW

Choosing to play at a high level is a

very difficult choice, as it comes with
significant risks and sacrifices. In
the beginning, we don’t really know
the kind of sacrifices we will have
to make to play professionally, that
comes with experience.
The current issue of this Journal is all about injuries. Did you Is overload the main reason for hamstring injury nowadays?
ever suffer from hamstring injuries during your active career? There are several reasons. First of all, it is the lack of experience
Yes of course, as does any great player (laughs). I was lucky to have a and knowledge of the player on these types of injury. Second, the
few mild hamstring sprains that recovered relatively fast. I believe lifestyle of the player can also affect this since professional players
that excessive energy accumulation due to overload is detrimental need enough rest and recovery to cope with the fast pace and high
to hamstring injuries and therefore physical effort should be number of matches and training. I remember as a player, I slept a lot
disseminated equally throughout match and training. and I believe my body needed it to recover in the best way.

During your long career, did you ever play, or was forced to play,
while having a hamstring injury?
-Of course if you are selected to play in a Champion’s League final,
you want to play at all stakes, even if this requires specific conditions.
I remember having a small hamstring injury a few days before our
Champion’s League final. I discussed openly with my doctor on my
body’s risk management and we evaluated the options. I took the
risk, knowing I could make my injury more severe and along with
that my rehabilitation time. Since it was the last game of the season,
I taped up well and played. Ten minutes before the end whistle, I
asked to be substituted but it worked out very well for me. This is
where the value of your team doctor is essential so that the player
knows what to decide and also what to avoid.

Today, we talk a lot about the prevention of sports injuries in

football. Who is the most responsible for you to prevent injury?
The player!
He/she should know his/her body the best. You can compare it with
the maintenance and necessary checks of your car. If you diligently
© Leon Neal/AFP/Getty Images

follow the guidelines that are put at the time you buy it, you can
already avoid or minimise many issues with it.
Players should learn at early age how to protect and nourish their
body in the best way to prolong the chance of a long career. Football
is a contact sports where there will always be injuries that you
cannot prevent. Still, injury prevention in professional football lies
mainly in the minimisation of the risk to get badly injured.
This can be done through anticipation both physically, visually and
Image: Claude Makelele playing for French national team at mentally - since the great players are able to reduce severe contact
Euro 2008 Championships match France vs. Romania. Zurich, with their opponents. Contact is necessary but requires skill to
Switzerland, 2008. manage. Sometimes a tackle comes too late and these milliseconds

90
 © Vincent Van Doornick/Isosport/MB Media/Getty Images
Image: Makelele as the head coach of Kas Eupen talking to Yuta Toyokawa during the Jupiler Pro League match Cercle Brugge KSV vs. KAS
Eupen. Brugge, Belgium, 2018.

can decide on days versus months of recovery. I believe my Did I miss anything? Do you have to say something that I haven’t
anticipation and training helped me a lot to avoid severe injuries already asked you about?
during my long career. By all means send my greetings to Professor Gerard Saillant. I
I was lucky, at a young age, to meet big stars who advised me on this worked with him for four years in Paris Saint Germain and learned
and it’s our task now to inform the next generation. a lot in discussions, with him. He is one of the most excellent people
I have met and worked with throughout my entire life and that is
Are you going to push your kids to be elite athletes? why I am ending this interview with the warmest regards to him.
I have two kids; my daughter is a dancer and my son plays basketball.
I try to encourage them into playing sport but it does not interest
them. I push them because I think sports positively impacts the
human body by generating energy that reflects on a person’s
mental health and emotional well-being. That is why more often
than not I encourage them to play sport, but not at a high-level,
because at the end it’s their choice and only theirs. Choosing to play
at a high level is a very difficult choice, as it comes with significant
risks and sacrifices. In the beginning, we don’t really know the kind
of sacrifices we will have to make to play professionally, that comes
with experience. When I made the choice to become a professional
football player, I had the greatest coach - my dad. It was he who
taught me everything about the game. At the time, my dad sat me
down and explained to me every aspect of the game, then said: “Ok,
if you think you can do it, go ahead. But if, at any stage, you feel
like you’re not capable anymore, you have to stop”. I did not fully Nebojsa Popovic M.D., Ph.D.
understand that statement until later on in my career. Myriam Mzali

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 91

ASPETAR RESEARCH
UPDATES
– Moderated by Gavin McClean PhD,
Qatar

Examination of Physical Characteristics and

Positional Differences in Professional Soccer
Similar Isokinetic Strength Preinjury and at Players in Qatar
Return to Sport after Hamstring Injury
Football practitioners often rely on
Side-to-side strength differences are often normative values from a range of
used in return to sport decision making musculoskeletal and performance
following hamstring injury. In football tests to identify deficiencies and in
(soccer), there is little consensus, and a turn for talent identification, fitness
side-to-side difference of <10% is often or rehabilitation programming, and
suggested as a criterion. To date, no study identification of injury risk factors.
has determined whether differences Physical characteristics have been
exist when comparing the strength of shown to vary between playing
the injured limb at return to sport to the positions in other professional
pre-injury level. Therefore, we aimed to leagues, but has not previously
compare the isokinetic strength at return to sport to pre-injury been reported for the Qatar Stars League. Therefore, we examined
strength in the injured limb. positional differences in commonly used clinical and performance
tests among 195 professional players in Qatar.
Side-to-side differences in isokinetic strength at return to sport were
similar to pre-injury levels. Overall, 63.4% of the players had a >10% Significant differences were apparent for anthropometric and
negative strength difference (i.e. the injured limb being weaker) strength variables, while jump performance and range of motion
and 57.9% of the players had a >10% positive strength difference (i.e. was similar between playing positions. Goalkeepers were taller and
the injured limb being stronger) in at least one of the five isokinetic heavier than the other positions and also stronger in absolute terms.
variables. When expressed relative to body mass, defenders were generally the
strongest, followed by midfielders. Compared to results from other
The distribution of isokinetic strength differences when comparing professional leagues, players in the Qatar Stars League were shorter
strength at return to sport to pre-injury measures were similar, and lighter, and although direct comparisons are difficult due to
urging clinical caution when interpreting these results. Small methodological differences, they appeared to display inferior jump
changes in isokinetic strength of the injured limb at return to sport and strength performance while range of motion was similar.
compared to pre-injury strength suggest that isokinetic cut-off
values are not useful to guide restoration of strength as a criterion These results highlight the importance of tailoring training and
for return to sport after hamstring injury. rehabilitation programs to the specific playing position and league
in which the athletes compete.
Van Dyk, N., Wangensteen, A., Vermeulen, R., Whiteley, R., Bahr, R., Tol,
J. and Witvrouw, E., 2019. Similar Isokinetic Strength Preinjury and at Wik, E.H., Mc Auliffe, S. and Read, P.J., 2019. Examination of Physical
Return to Sport after Hamstring Injury. Medicine and science in sports Characteristics and Positional Differences in Professional Soccer
and exercise. Publish Ahead of Print():, JAN 2019, PMID: 30640285, Issn Players in Qatar. Sports, 7(1), p.9.
Print: 0195-9131.
Eirik Halvorsen Wik is a PhD candidate with Aspetar and the
Dr. Nicol van Dyk is a physiotherapist and clinical researcher at Norwegian School of Sport Sciences. His research interests are in
Aspetar. His research interests include injury prevention and risk training load management, growth and maturation, and injury
management. Twitter: @nicolvandyk. prevention. Twitter: @eirikwik.

92
 Poor agreement between ultrasound and inbuilt
diffusion tensor MRI measures of biceps femoris
Chronic lateral ankle instability increases long head fascicle length
the likelihood for surgery in athletes with os Short muscle fascicles in the biceps femoris long head are associated
trigonum syndrome with an increased risk of hamstring muscle injury. Ultrasound
Imaging (UI) has been the imaging method utilised in the majority
The os trigonum ankle syndrome is of this previous research. Recent advancements in Diffusion
characterised by posterior ankle pain in Tensor Imaging (DTI) have demonstrated promising results in the
plantar flexion, prevalent in as many as determination of fascicle length in various lower limb muscles,
50% of footballers. Understanding why but the accuracy of
some athletes evolve towards surgery, and biceps femoris long head
others not, will significantly aid strategies assessment remains
for prevention, diagnosis, therapy and unknown. Therefore,
rehabilitation of os trigonum syndrome. we aimed to 1) assess
Therefore, we aimed to ascertain if chronic if DTI using magnetic
lateral ankle instability increases the risk resonance imaging (MRI)
of necessary surgical intervention in the methodology inbuilt
athlete with os trigonum syndrome. within manufacturer
software can reliably
Pre-operative magnetic resonance images of 80 professional measure biceps femoris
athletes who were referred for surgical consultation at the Aspetar long head fascicle
Orthopaedic and Sports Medicine Hospital, between 2013–2017, length and 2) assess the
were evaluated for the presence of chronic or acute lateral ligament agreement between UI,
complex injury. All 40 professional athletes whom required os and DTI for measures of
trigonum surgery had some involvement of lateral ligament injury biceps femoris long head
to the ankle on magnetic resonance images. Specifically, thirty-seven fascicle length.
(94.1%) had a chronic and three (5.9%) had an acute lateral ligament
injury, respectively. Biceps femoris long head fascicle length of both legs of 20 males
were assessed utilising UI and diffusion tensor MRI. Reliability of DTI
Risk of surgical intervention is approximately 10-fold greater in measures was ‘acceptable’ but minimal detectable change values
the professional athlete with os trigonum syndrome and a chronic were ‘unacceptable’. Furthermore, ‘poor’ agreement was found
than an acute lateral ligament ankle injury. Understanding why between UI and DTI measures of biceps femoris long head fascicle
some athletes evolve towards surgery has significant implications length.
regarding strategies for prevention, diagnosis, therapy and
rehabilitation for elite athletes with os trigonum syndrome. DTI measures inbuilt within manufacturer software do not display
‘acceptable’ clinical reliability and do not agree with validated
D’Hooghe, P., Alkhelaifi, K., Almusa, E., Tabben, M., Wilson, M.G. and ultrasound methods. Clinicians should continue to use ultrasound
Kaux, J.F., 2018. Chronic lateral ankle instability increases the likelihood measures of the biceps femoris long head fascicle length or
for surgery in athletes with os trigonum syndrome. Knee Surgery, algorithm-based DTI measures when the expertise is available.
Sports Traumatology, Arthroscopy, 2018, https://doi.org/10.1007/
s00167-018-5183-0. Behan, F.P., Vermeulen, R., Smith, T., Arnaiz, J., Whiteley, R., Timmins,
R.G. and Opar, D.A. Poor agreement between ultrasound and inbuilt
Dr. Pieter D'Hooghe is an Orthopedic Sports Surgeon at Aspetar. diffusion tensor MRI measures of biceps femoris long head fascicle
He holds an MBA in Sports Management and is President of the length. Transl Sports Med. 2019;2:58–63.
International Foot and Ankle ISAKOS Committee. His research
mainly focusses on the impact of Bio Surgery on Ankle injuries in Fearghal Behan, is a Research Scientist at Aspetar. His research
Sports. Twitter : @PdHooghe. focuses on neuromuscular function and musculoskeletal injury.

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 93

LETTERS FROM

A LETTER FROM
PARIS, FRANCE

Hamstring injury
prevention in

© Pixabay.com/Ronile
elite football –
a contemplative
walk through the
City of Lights are confident that our colleagues working
in our rival teams at all latitudes, just like
ourselves, are up to date with the latest
photographed by tourists from all over the
world.

– Written by Cristiano Eirale, France literature on prevention of this common “May the increasing hamstring injuries’
and Qatar injury. In fact, the rate of hamstring injuries rate during training sessions be due to
increased only during training sessions, an increased intensity during training,
while there was no significant increase of aimed to better prepare the players for the
these injuries during matches1. In reality, match?” Maybe. However, our performance
considering that high-intensity running and technical staff are so meticulous when
demands in football over the same periods preparing the training programme that
have moderately-to-largely increased, this seems unlikely. The conditioning and
it appears that match injury risk has in preparation of our players always take
fact slightly decreased (≈20%) during this individual load profiles into account, and
Working in an elite football team, here in time3. We can therefore be proud of the the sessions are tailored according to the
the “Ville de Lumiere (City of Lights)*”, we effectiveness of our prevention protocols for medical and performance indicators of each
are well aware of the high risks of hamstring reducing match hamstrings injuries. athlete. In addition, technological advances
injuries in our elite footballers. These injuries are constantly improving our ability to track
sometimes disturb the ‘La Belle Epoque” of “Hamstrings injuries increase during and monitor our players. In summary: how
our club. Just like the French period starting trainings but not during matches; I would come injuries are increasing when we can
in the 1870s and lasting until World War have bet the opposite… but what could be control the composition, load and intensity
I. Since the arrival of the Qatar ownership the reason for this strange discrepancy?” of the football activities?
in 2011, our club has been characterised by This question taunted me while I was
economic prosperity, science, technology, walking along the beautiful streets of Paris As these thoughts were taking shape,
culture of modernisation and an overall filled with its inspiring monuments, many I was in view of Notre Dame, the most
optimism. For that reason, we were quite of them due to the Baron Georges-Eugène admirable example of French Gothic
surprised to learn that, despite our daily Haussmann, the man responsible for architecture consecrated in the literature by
efforts since 2001, hamstring injuries have the major renovation of Paris that began Victor Hugo. It was built on the famous “Île de
increased by 4% annually among the elite halfway through the 19th century. Thanks la Cité”, one of the remaining natural islands
European teams we are part of1. to this enlightened Prefect and his mentor, along the Seine, where in the years between
Napoleon III, Paris was transformed to what 250-225 BC the tribe of Parisii established,
We don’t think the reason could be that it looks like today, with buildings that have giving the name to the city. Inspired by this
evidence based preventive measures are the same uniformed architectural style. This architectural wonder, I considered another
only partially implemented at the elite lev- unique style has become synonymous with explanation for the hamstring injury
el2, as hypothesised by some scientists. We city of Paris itself, captured on postcards and increase. Could it be possible that the reason

94
of this negative trend is paradoxically the and recovery. This preventative measure researchers state that this name origins from
result of a prevention strategy too4? that can only really be implemented during the XVIII century when, due to the rising
trainings (because this kind of precaution is criminality in the streets of the city, the
Paris Saint Germain Football Club not realistic during matches)and is recorded Prefect asked the population to put lamps on
participates in the UEFA Elite Clubs Injury as a hamstring injury in epidemiological their windows.
Study (ECIS), where a time loss definition studies. From a statistical point of view, it
of injury is utilised5. This definition implies doesn’t matter if it is an effective method
the recording of all injuries that force the for avoiding the progression of more serious
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pain free. But there is pain and then there their work gave life to the intellectual and in men's professional football:every
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overlooked. the prosperity of the city. We know that Med. 2018 Dec;52(23):1489. doi: 10.1136/
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Thanks to the prevention strategies multiple (and alternative) ways to face 5. Fuller CW, Ekstrand J, Junge A, Andersen
based on the education of players and problems. Sometimes, this allows them to TE, Bahr R, Dvorak J, et al. Consensus
staff, club clinicians are nowadays able flourish. Perhaps the same can be true for statement on injury definitions and
to identify footballers with hamstrings our view of hamstring injuries. Perhaps our data collection procedures in studies of
overuse symptoms early. This often leads prevention efforts are actually protecting football (soccer) injuries. Br J Sports Med.
to the prudent removal of a player from our players, which is not captured by the 2006 Mar;40(3):193–201.
the team training sessions for treatment epidemiological data.
6. Bahr R. No injuries, but plenty of pain? On
the methodology for recording overuse
Of course, this is an optimistic hypothesis.
symptoms in sports. Br J Sports Med. 2009
And I cannot hold back my optimism
Hamstring walking around the most beautiful city
Dec;43(13):966–72.

prevention efforts in the world (which I admit reluctantly,

considering my Italian origins), but as Oscar
are actually Wilde quipped “When good Americans die,
Cristiano Eirale M.D., Ph.D.
they go to Paris.” As a scientist, this optimism
protecting our might be a limitation. But, inspired to think Sports Medicine Physician

players, which is differently by this beautiful city, I have

accepted that.
PSG Football Club
Paris, France
not captured by the Aspetar – Qatar Orthopaedic and Sports
*There is a debate on the origin of this
epidemiological surname. Hypotheses were gained thanks
Medicine Hospital
Doha, Qatar
data. to perfect illuminations during the period
of 1820-30 granted by Philippe Lebon, the
inventor of gas lightening. However, other Contact: [email protected]

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 95

INDUSTRY
NEWS
– Written by Nathan Riding PhD, Qatar

Could fatigue induced inter-limb asymmetry

predict future hamstring injury?

Previous hamstring injury is commonly cited as the greatest risk

factor to future susceptibility. While its explanation is multi-
factorial, hamstring fatigue may be one such influencing factor,
particularly when we consider risk of injury is highest in the last 15
minutes of a football match. This fatigue has been shown to alter
running mechanics possibly due to altered muscle propriocenption
and was the focus of a recent study from a research team based at
the Edith Cowan University in Australia. Published in the Journal
of Science and Medicine in Sport the study required 40 Australian
soccer players to perform a 10 x 6 second repeated sprint test.
Half the players included had a previous unilateral hamstring
injury, with key measurements being the difference in horizontal
and vertical force production, as well as contact and flight times
© Jon Candy/Flickr.com (Cropped)

between legs. The main findings from the study indicated

that there is a 10% greater decrease in mean horizontal force
production in the dominant leg of the injured group, however this
did not carry over to vertical force production or contact and flight
times. In identifying a large inter-limb asymmetry of the mean
horizontal force in the injured players the authors suggest that
there is an association between the rate of fatigue and previous
hamstring injury and the need for future prospective studies is
emphasised.

Added resistance key to improving the effect of

Nordic Hamstring Exercises

Eccentric knee flexor strength and biceps femoris long head (BFlh)
fascicle length are seen as modifiable risk factors to hamstring injury
susceptibility, and in turn have gained significant attention in the
academic and applied field. The Nordic hamstring exercise has been at
the forefront of interventions to improve these factors, however, despite
promising results, adherence remains poor. The prominent Australian
research team at the Australian Catholic University recently set out to
investigate the effect of Nordic hamstring exercise with and without
additional weight versus an alternative weighted razor hamstring curl
exercise upon the two modifiable risk factors of eccentric knee flexor
strength and BFlh fascicle length. After six weeks of performing a total
of 128 reps of one of the three exercises, it was shown that with a mean
difference of 1.57cm, the 10 males in the weighted Nordic hamstring
exercise group demonstrated the greatest fascicle lengthening,
compared to nearly no changes in the bodyweight Nordic group and the
razor hamstring curl group (both also with 10 participants). A similar
trend was observed for Nordic hamstring strength, while change in razor
hamstring curl strength was greatest among those performing the razor
hamstring curl. These adaptations showed reversal just one-week post
training. The authors conclude that although lower volume Nordics can
result in positive adaptation, added resistance is needed.

96
 © Steven Pisano/Flickr.com (Cropped)

© Roger Mommaerts/Flickr.com (Cropped)

Are physicians and physiotherapists at greater risk of
having a proximal hamstring tendon avulsion injury?

The publication rate of hamstring injury research has increased 3 fold in the
past decade, and has likely led to an increased understanding and awareness
The 5-point strategy for hamstring injury
of such injuries. However, a recent letter published in the British Journal of prevention
Sports Medicine suggests there may be notable gaps in the knowledge. The
authors, from the University of Amsterdam, emphasise that among patients What do Lionel Messi, Cristiano Ronaldo, Neymar, and
enrolled in an ongoing prospective study and diagnosed with a full-thickness Luka Modric all have in common? These top football
proximal hamstring tendon avulsion, twenty percent were medical doctors and players have all had a hamstring injury. As noted above,
physiotherapists. In representing just 0.8% of the general population it begs the hamstring injuries are consistently the most common
question of whether they are at higher risk or just happen to be more adequately setback within the game. However, a recent review
assessed. Among these professionals there was also no substantial delay in in the British Journal of Sports Medicine suggests that
diagnosis through MRI, suggesting that the injury may be underrepresented the high rate of hamstring injuries are in part due to
within the normal population; an important finding considering the described the recommendation of a simple single component
poor clinical outcome if it is left untreated. approach to a complex multifactorial problem. They
argue that practitioners must adopt a 5-point strategy
to their prevention. The authors, led by Dr Buckthorpe
from the Isokinetic Medical Group at their FIFA Medical
Centre of Excellence in London (UK), suggest these 5 key
© Kane Brooker/Flickr.com (Cropped)

points for athletes to focus on:

1. strengthening the hamstrings,
2. optimising their training balance,
3. implementing a lumbopelvic hip stability
programme,
4. developing the players physical conditioning and
5. incorporating a focus on movement quality.
The strategy is based upon anecdotal evidence rather
than a truly evidence based approach but is believed
by the authors to be the most sensible approach in the
ultimate aim of hamstring injury prevention.

The price of a Premier League injury

The English premier league is big business. While the bottom team will take
IN NUMBERS

16%
home around £100 million in prize money, each subsequent position is worth
an extra £2 million. With this comes the ever present demands on the team’s Reported hamstring
medical staff to keep their players fit, and for the third year specialist insurance re-injury rate in
broker and risk consultant JLT have put a price on it. In their analysis they
determined that the cost of injuries last season had rose by 21% to £217 million,
professional football
despite a 10% drop in injury prevalence. English Premier League champions players.

59%
Manchester City suffered the second lowest amount of injuries with 24, while
Brighton topped this ranking with just 15, costing the club £3.1 million. Arsenal Percentage of
had the most injuries throughout the season with 54, costing them £19.3 million. recurring hamstring
The average cost of injured players per club was £10.7 million, and as expected, injuries within one
hamstrings topped the list of injury type, accounting for 21% of the total injuries
and a cool £34.5 million.
month of return to play.

HAMSTRING INJURIES – ASPETAR EXPERIENCE TARGETED TOPIC 97

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