What we ll cover... Two types of hamstring injury! What type of athletes tear hamstrings!

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Craig Ranson PhD Programme Director MSc Sports

University Wales Rugby Team Physiotherapist

.. Likely hamstring function & pathomechanics

1 What s'new'in'hamstring'strain' injury'prevention'&'rehabilitation? Craig Ranson PhD Programme Director MSc Sports & Exercise Medicine Cardiff Metropolitan University Wales Rugby Team What we ll cover... Likely hamstring function & pathomechanics Running technique Approaches to rehabilitation & prevention What type of athletes tear hamstrings! Sprinters Cricketers/Baseballers Footballers NFL AFL Rugby Soccer Hockey Two types of hamstring injury!

2 Over-stretch Fast Running Are these the sites of strain injury? Hams tendon to muscle ratio...

3 Tears are of fascial origin... Koularis & Connell 2004 Symptoms 1. Acute onset (stretch or sprint) 2. Localised posterior thigh 3. Pull or pop Signs 1. Localised pain on palpation 2. Pain on stretch 3. Pain with resistance Differential diagnoses Lumbar disc - trunk flexion - Slump/SLR Lumbar stress fracture - Stork test (trunk extension)

The known and potential risk factors include.

4 The known and potential risk factors include... Previous Injury Psychology Spine & Pelvis Co-ordination Hamstring Tear Strength Technique Fatigue Endurance Nutrition & Hydration Strength Benchmarks Predict Injury... Isokinetics Ecc Hams > Conc Quads Croisier 2008 AJSM Eccentric Hamstring Strength

Programme Australian Hockey/Football Progressive Agility &

5 Strength Benchmarks Predict Injury... Single leg bridge test (25 reps) Freckleton et al., 2013 BJSM Rehab mostly empirical.. POLICE - Length - Strength - Running Accelerated Running Programme Australian Hockey/Football Progressive Agility & Trunk Stabilisation (PATS) 2004 Early Mobility Lateral Running PATS Fwd & Back Running Little or no hamstring load

6 End stage rehab often based on prevention studies.. BJSM 2013

Conclusions: A rehabilitation protocol emphasising lengthening type of exercises is more effective than a protocol containing conventional exercises in promoting time to return in Swedish elite

7 Conclusions: A rehabilitation protocol emphasising lengthening type of exercises is more effective than a protocol containing conventional exercises in promoting time to return in Swedish elite football. BJSM 2013 but return to sport process was long Lengthening protocol 7 weeks (49 days) Conventional 12 weeks (86 days)!! Welsh Professional Rugby Return to Play - XX Days

8 Rehab should reflect Stages of healing 2. Mechanism of injury 3. Hamstring function and forces Running Gait Cycle Float 1. Forward Swing 2. Reversal 3. Backward Swing Running Gait Cycle Support 1. Front 2. Mid 3. Rear Fast running, eccentric or isometric?

extension Hamstrings tear due to... Over-stretch? Muscle strength imbalance - Q:H ratios?

9 Hamstring functions as a spring? Isometric muscle action Swing - Elastic elements (tendon/fascia) stretch Stance - Stored energy returned - hip extension Hamstrings tear due to... Over-stretch? Muscle strength imbalance - Q:H ratios? Strain during swing phase?...or, hamstrings tear due to... High force at the wrong time Rotated lower limb during stance e.g. biceps when leg externally rotated Mistimed foot placement Trunk flexion Higashihara 2014 JSS

Pelvic Lock position optimises trunk, pelvic, thigh function Pelvic

Anterior pelvic tilt Stance side hip internal rotation Maximal Forces

Targeted hamstring rehabilitation Programme Principles Rehab Phases

Acute phase protection 2. Single source of stress during each phase 3.

10 Pelvic Lock position optimises trunk, pelvic, thigh function Pelvic posture at moment of maximal force Swing side of pelvis raised Anterior pelvic tilt Stance side hip internal rotation Maximal Midstance Hamstring extending the: hip knee! Targeted hamstring rehabilitation Programme Principles Rehab Phases Return to Play Prehab Rehab Principles Reflect Function 1. Acute phase protection 2. Single source of stress during each phase 3. Early maximal isometric hamstring recruitment appropriate load, muscle action and ROM 4. Running is Final Phase

Phase 1 Acute Protection Days 1-3 POLICE* PWB

Double Leg Bridge Start days 2-3 Heel on

11 Phase 1 Acute Protection Days 1-3 POLICE* PWB crutches Dynamic or K-Taping No stretching or direct STT Bike *Bleakely 2011 Double leg bridge test to exit to Phase 2 Phase 2 - Double Leg Bridge Start days 2-3 Heel on 30-45cm box 2 sec isometric hold x 4-6 reps Exit to next stage

12 Double leg bridge perturbation test Single leg bridge test Phase 2 - Single Leg Bridge Start days 3-5 Heel on 30-45cm box 2 sec isometric hold x 4-6 reps Single leg bridge perturbation test to exit to Phase 3

Phase 3 Roman Chair Isometric Hamstring Loading Start Days 4-8 Aim for

position Pain free & no DOMS Single leg isometric hip extension 1.

Elastic bounces - mimics spring Trunk flexion-extension pertubations

13 Phase 3 Roman Chair Isometric Hamstring Loading Start Days 4-8 Aim for maximal isometric hamstring activation Mid-stance (lock) pelvic position Pain free & no DOMS Single leg isometric hip extension 1. Manual Resistance (rotation) 3 reps x 2s hold 2. Elastic bounces - mimics spring Trunk flexion-extension pertubations Elastic recoil (isometric) 6-8 bounces x 3 reps Barbell provides high load... Goal > 50% BW 3 reps x 2 sec

Plate rotations isolate medial & lateral hams.

Straight-leg pretension high for distance 3.

14 Plate rotations isolate medial & lateral hams... 2 reps each direction for bends, cutting, drive outs Phase 4 Box Jumps Start days Pretension jump for height 2. Straight-leg pretension high for distance 3. Single leg step jumps Box Jumps Pretension squat jump for distance & height Single Leg Box Jumps 3 sets of 7 Stance phase hip & knee extension

Phase 5 Running Progression 1. Stair Running 2. Sub-Max Speed (60-70%) Accelerations 3. Accelerations on uneven surface 4. Lateral runs & side-steps on uneven surfaces 5. Non-contact rugby drills 6.

15 Phase 5 Running Progression 1. Stair Running 2. Sub-Max Speed (60-70%) Accelerations 3. Accelerations on uneven surface 4. Lateral runs & side-steps on uneven surfaces 5. Non-contact rugby drills 6. Endurance Stair Running 5-20 steps 1. one step at a time 2. two steps at a time Single leg bridge perturbation and rotation Running test Accelerations 20-40m 60-80% x 6 reps (build to 10 reps) Gradually reduce deceleration distance 15m down to 5m

16 Fast curves & Unplanned cuts Sports Specific drills AFL & Hockey Sprinting Rugby Bent-over running Drive phase, bends Down-ups & drive Summary Progression 1. Acute phase protection 2. Single source of stress during each phase Bridge - Isometric Hip Ext - Jumps - Run 3. Early maximal isometric hamstring recruitment 4. Stair running before sub-max horizontal runs (5-7ms) 5. Uneven surface running 6. Sport specific running drills Prevention Regular fast running - inoculation Robust hamstring conditioning Training an effective technical model Thorough rehab and RTP

17 Injury Prevention Process Injury Surveillance Optimal Management Musculo-Skeletal Risk Factor Profiling Pre-habilitation & Injury Prevention Education Hamstring'injury'prevention'&'rehabilitation Craig Ranson PhD with thanks to Frans Bosch & The Wales Rugby Team

HIP CASESTUDY 3. Body Chart-Initial Hypothesis: Property of VOMPTI, LLC. For Use of Participants Only. No Use or Reproduction Without Consent 1

HIP CASESTUDY 3. Body Chart-Initial Hypothesis: Property of VOMPTI, LLC. For Use of Participants Only. No Use or Reproduction Without Consent 1 Body Chart-Initial Hypothesis: HIP CASESTUDY 3 Orthopaedic Manual Physical Therapy Series Charlottesville 2017-2018 Eric Magrum DPT OCS FAAOMPT Hamstring Strain HS Tendinopathy Lumbar Radiculopathy Lumbar