REHABILITATION AND EXERCISE PROGRESSION AFTER GRADE II HAMSTRING STRAIN

Jessica Barrw BSc Physitherapy, SPT1 www.barrwphysitherapy.c.za Cell: 083 256 0434 Rm GF03 Waterfall Hspital Cnr. Magwa Crescent and Mac Mac Avenue Tel: 011 304-7829 Fax: 011 304-7941 REHABILITATION AND EXERCISE PROGRESSION AFTER GRADE II HAMSTRING STRAIN Ntes: Muscle mst cmmnly affected is lng head f the biceps femris, usually just prximal t the muscultendinus junctin 6-16 cm prximal t the knee jint. Immbilisatin if required shuld be in the lengthened psitin and shuld nt last lnger than ne week. The use f NSAIDS is cntrversial in the first few days because f the ptential fr impeding healing; evidence suggests that NSAIDs have n additive effect n the healing rate. Acute Phase (3 t 4 times a day) Rest (immbilisatin in a lengthened psitin fr n lnger than ne week, then relative rest): N antalgia with gait: if antalgic, supplement with assistive device. Gentle stretching (pain less than 3/10). Ice in lengthened psitin (in lng sitting with as much active pain free knee flexin and extensin as pssible). Cmpressin and elevatin until thigh girth stabilises. NSAIDS n sner than 2 t 4 days after injury. Retrgrade massage may be implemented fr swelling cntrl. DTM may begin when girth is stabilised. Mdalities-sensry Estim can be used. Criteria fr prgressin: N increase in thigh girth measured 8cm prximal t the patella; SLR t 80 with an estimatin f 3 r less n a numeric rating scale. Test: The ft is plantar flexed and the examiner slwly (abut 30 /s) raises the leg. Sub-acute Phase: day 3 t >3 weeks Stretching (3 t 4 times per day): Prgressively increase stretch t full ROM (stretched acrss hip and knee) exercises. Page 1 f 18

Self stretching: Begin with standing technique with anterir pelvic tilt. Prgress t aggressive self-stretching and partner stretches. Strengthening prgressin (daily): Ismetric knee flexin: Begin with sub-maximal ismetric hlds at multiple jint angles (0, 30, 60, 90 ) and prgress t maximal hlds. Stl scts: Athlete sits n wheeled stl and plants heel int flr and uses hamstring t prpel frward. Prgress with distance and t single leg. Start with Seated cncentric iskinetic exercises (CON / ECC 50 t 75 /s r istnic). Mve twards higher and lwer speeds with mre frce. Page 2 f 18

S R Seated hamstring curls: Begin at 30% f 1RM (repetitin maximum) f cntralateral hamstring 3 t 4 sets f 10 repetitins prgress t 60%. Deep Tissue Massage (daily): Depth and frcefulness may be increased as the need arises t reach the target tissue that may be deeper. Cardivascular fitness (up t 2 sessins per day): UBE. Statinary biking. Other cntrlled activities. Mdalities. Remdelling Phase: 1 t 6 weeks Stretching prgressin (3 t 4 times per day): Maintain r increase muscle length using aggressive frequent stretching (passive, self and partner stretches) encurage exercise thrugh the full ROM. Strengthening prgressin (daily t every ther) Criteria fr prgressin within this phase: Cmplete the activity with estimatin f 3 r less n a numeric rating scale. Cmplete cncentric seated strengthening prgressin and achieve full ROM with estimatin f 3 r less n a numeric rating scale. Page 3 f 18

Begin mre aggressive cncentric strengthening: Seated hamstring curls: 60% t 80% f 1RM (repetitin maximum) f cntralateral leg. Begin with strength vlume (high weight, lw reps) and mve t pwer vlume (faster speeds). Standing hamstring curls: Can be perfrmed with machine r ankle weights. Begin with strength vlume (high weight, lw reps) and mve t pwer vlume (faster speeds). Prne hamstring exercises (intrduces eccentric cmpnent): Start with prne curls with ankle weights at 30% f 1RM (repetitin maximum) f cntralateral hamstring 3 t 4 sets f 10 repetitins. Prgress t strength and pwer vlumes. Prgress t eccentric cntractin via ankle weights with cncentric assistance r manual resistance. Page 4 f 18

Manual prne eccentric / cncentric hamstring curls. Athlete lays prne while manual resistance is applied distally. He / she cntracts the hamstrings cncentrically against resistance and cntinues t cntract as resistance increases t bring the ft dwn eccentrically. This allws fr the athlete t be strengthened in pain free range and mre fcus can be paid t weakness in certain ranges, especially clser t full extensin. Prne leg drpping: Athlete lies prne with knee flexed and ft in air. Gently mve ft back and frth t stimulate relaxatin. Drp the ft suddenly and have athlete catch the ft as sn as they feel it released. Prgress t 1kg and / r push leg instead f drp t increase lading. This helps the athlete regain their prpriceptive sense that may have been lst secndary t weakness and immbilisatin frm injury. With a heightened prpriceptive sense the athlete may be able t better detect the psitin f the hamstring, which may decrease their risk f reinjury. Page 5 f 18

Prgress t seated eccentric hamstring curl: Lad weights at 120% f 1RM (repetitin maximum) f single leg hamstring curl. Use tw legs fr cncentric mtin. Release ne leg and allw single leg t release weight in a cntrlled fashin. Prgress weights apprpriately. Prgress t prne psitin. Prgress t prne iskinetics (CON/ECC beginning at high speeds (240/240) and gradually decreasing the speed (193, 145, and 96), thrugh pain free range. Prgress t strength and pwer vlumes. Hamstring ball rlls: The athlete lays supine with a ball under his / her leg(s). Rll the ball twards the bdy by flexing the leg while maintaining trunk and hip stabilisatin. This exercise can be prgressed frm: 0.6m using theraball. 0.3m ft using theraball. 0.3m using medball, ther ft in air. Page 6 f 18

Nrdic hamstrings: Athletes are kneeling with feet fixed. Instruct athlete t fall frward and use hamstring t cntrl descent fr as lng as pssible then catch themselves n the table with their hands. Athlete frcefully pushes with hands t return t starting psitin t decrease cncentric lad t the hamstrings. With tw peple begin with maximum assistance using a belt arund the athlete s waist t assist them when they lean frward. With ne persn place theraball in frnt f patient t allw patient t push up and decrease the eccentric lad. Prgress by decreasing assistance, and increasing range until fall. Once patient can withstand whle range f mtin, increase lad by adding speed t the starting phase. The partner can als push n the patient s shulder t increase difficulty. Fr variatin persn can hld dwn legs with different frces t lad ne side mre than anther. Page 7 f 18

Plymetric prgressin In this case, plymetric exercise is used t strengthen the hamstrings while regaining the neurmuscular prperties needed t effectively perfrm sprt specific activities. Plymetric exercise is based n the principle f utilising the muscle s stretch reflex with stres energy thrugh its eccentric phase f cntractin. If utilised quickly, the energy stred can prduce mre frce utput during the cncentric event. This brief mment between the tw phases is the amrtisatin phase. When perfrming plymetric exercise it is essential t perfrm a rapid eccentric phase t decrease the amrtisatin time. They shuld be prgressed systematically fr prper verlad; typically lw intensity with high vlume up t high intensity with lw vlume. It is als imprtant t warm up prperly in a plymetric fashin, which can be incrprated in the dynamic warm up. An apprpriate plymetric warm up fr these particular exercises include: Marching; Jgging; Te jgging t warm up a quick reactin time; Straight leg jgging t prepare fr impact exercises; Butt kicks fr stretching; and Exaggerated skipping. These mtins shuld als be prgressed frm 50% effrt up t 100% effrt t decrease the risk f re-injury. This list is in rder frm easiest t hardest and shuld be prgressed frm ne t anther when cmpleted with 100% effrt while abiding by previusly stated criteria fr prgressin. 1. Cycle split jump a. Athlete stands in half lunge. b. Perfrm jump, switching feet in the air with emphasis n pulling backwards landing with feet ppsite the starting psitin. c. Land and repeat jump with effrt emphasised n decreasing the grund-cntact time. Page 8 f 18

2. Running butt kicks a. Begin running by flexing yur knee and bringing yur heel back and arund t yur buttcks. Maintain a slight frward lean thrughut the drill, and stay n the balls f yur feet. Cmplete 20 kicks within 9 metres. b. Maintain a quick, yet shallw arm swing, keep yur elbws at 90 and drive yur hands frm chest t frnt hip pcket. 3. Running high knees a. Execute prper running frm; keep yur elbws at 90 and drive yur hands up t chin level and back t yur rear pcket. Stay n the balls f yur feet, and drive yur knees up as high as pssible, and then dwn as quickly as pssible. 4. Pg jumps with knees t butt a. Athlete stands erect, feet cmfrtably hips width apart. b. Perfrm straight jump and pulls heels twards the buttcks. c. Land and repeat jump with effrt emphasised n decreasing the grund-cntact time. Page 9 f 18

5. Rllerbard hamstring pulls a. Athlete lays supine with back n rllerbard. b. The athlete s legs are fixed either with a partner hlding them r fixed t a statinary bject. c. The athlete then flexes and pushes away frm his / her feet with emphasis n decreasing the turn-arund time between flexin and extensin. 6. Leg swings (bent knee and straight knee) a. The athlete stands erect with ne hand supprted fr balance. b. The athlete swings his / her leg frwards until he / she feels a slight stretch. c. Quickly and pwerfully push the leg dwn int full hip extensin and let the leg gently swing back int hip flexin with emphasis n decreasing the time between flexin and extensin. Page 10 f 18

d. This can als be dne with the knee flexed t islate the hamstrings. Start by flexing the knee up, then extending it frward, frcefully bend the knee dwnwards until almst straight, and then cntinue t frcefully drive the leg up twards the butt with the knee bent. Then flex the hip t the starting psitin and repeat (Claw). 7. Heel tss with med ball a. Athlete is hanging frm pull up bar with medball squeezed between his / her heels. b. Frm a stand still psitin, the athlete thrws the ball backwards with frceful hip extensin and knee flexin. c. A partner must retrieve the ball and replace it between the athlete s feet. d. This exercise can be prgressed by using a heavier medball. 8. Bx step up and jump a. Place an 18 bx in frnt f yu. Place yur right ft n tp f the bx. Push ff with yur right ft and jump int the air. Land in the same psitin as yu started. Perfrm the set then alternate legs. b. Emphasise the quick cntractin and minimal grund cntact time t get as high as pssible. Use yur arms t help yu explde up. Page 11 f 18

c. Variatins: Perfrm with dumbbells r turn 180 in the air and land n ppsite side f bx. 9. Bx jumps a. Stand facing a 12 t 18 bx. Keeping yur feet tgether, jump up nt the bx. Immediately hp back dwn and then explde back up in ne mvement emphasising minimal grund cntact time. Use yur arms explsively t help prpel yu up and push ff yur tes. b. Variatins: Mve n t higher bxes f 24 t 48. On the higher bxes always step dwn, d nt jump. 10. Depth jumps a. Stand n tp f a 12 bx. Place a 12 t 18 bx abut 1.8 metres in frnt. Drp dwn ff the 12 bx landing with yur feet clse tgether. Explde up nt the 12 t 18 bx and stick yur landing. Step dwn and repeat the jump emphasising rapid change in directin. b. Keep yur feet clse tgether when landing n the grund r n the bx. Bend yur knees when landing n the grund and use yur arms t help yu explde up. Variatins: Prgress t higher bxes. 18 bx n t 24, then 48 bxes. 11. Frward depth jumps in series a. Set up a series f 6 t 8 bxes 12 t 18 high and 1 metre apart. Begin by standing atp the first bx. Drp dwn t the grund and then explde up nt the secnd bx. Cntinue thrugh the series using yur arms explsively decreasing grund cntact time. Page 12 f 18

b. Variatins: Perfrm the depth jump series laterally. Perfrm the depth jump series n single leg. 12. Frward hurdle hps ver and back a. Stand facing a series f 6 t 8 hurdles at 12 t 18 high and 1 metre apart. Hp ver the first hurdle then ver the secnd. As yu land ver the secnd hurdle, immediately hp backwards ver the secnd hurdle, then frwards again decreasing the grund cntact time. Use yur arms explsively and tuck yur knees int yur chest. Maintain yur balance by keeping yur trs upright and yur bdy s centre f gravity ver the hurdle. b. Hpe ver the third hurdle, then the furth, nw repeat ver and back hp n the furth hurdle. (Hp frwards ver dd number hurdles; hp ver and back ver ( even numbered nes). c. Variatins: Explde int a 13.5 metre sprint, g up fr a header ver the last hurdle and explde int a 13.5 metre sprint. Jgging / running prgressin: See attached fr Field and Rad Running Prgressin. Criteria fr prgressin within this phase: cmplete the activity with estimatin f 3 r less n a numeric rating scale where 0 = n pain and 10 = maximal pain. Page 13 f 18

Criteria fr prgressin t next phase: cmplete running prgressin. Able t perfrm 10 Nrdic Hamstring exercises with minimum assist and n pain. Return t activity: 2 weeks t 6 mnths Running activities are increased frm jgging at lw intensity t running and finally sprinting (please see attached running prgressin). High intensity plymetrics. Agility and sprt / psitin specific drills (please see attached agility reference). MAINTAIN FLEXIBILITY AND CONTINUE PROTECTIVE ECCENTRIC PROGRAMME Field Sprts Running Prgressin (Distances based n 91 x 45 metre field) Level 1 Walk ½ field then jg ½ field repeat fr 5 laps ttal Level 2 Walk ½ field then jg full field repeat fr 6 laps ttal (~1.6kms) Level 3 Walk ½ field then jg 2 full fields repeat fr 9 laps ttal (~2.4kms) Level 4 Walk ½ field then jg 3 full fields repeat fr 9 laps ttal (~2.4kms) Level 5 Jg full 12 laps (~3.2kms) Level 6 Jg full 15 laps (~4kms) Level 7 Jg full 18 laps (~4.8kms) ** Levels 8 thught 17 shuld be prgressed t tlerance. Once at maximum level f time suggested cntinue t next level abiding by criteria fr prgressin** Level 8 Alternate between running and jgging every field and a half Level 9 Alternate between running and jgging every 2 fields Level 10 Run full 18 laps (~4.8kms) Level 11 Jg ½ field, then run ½ filed, then sprint fr width f field, then run ½ field and repeat 12 laps (~3.2kms) Level 12 Run ½ field then sprint a width f a field and repeat 10 times Level 13 Run ½ field then sprint a length f a field and repeat 10 times Level 14 Jg ½ field then sprint a width f a field and repeat 10 times Level 15 Jg ½ field then sprint a length f a field and repeat 10 times Level 16 Sprint width f a field then rest 2 minutes and repeat 10 times Level 17 Sprint length f a field then rest 2 minutes and repeat 10 times Sreness rule: (yur pain) If sre during warm-up, take 2 days ff and drp dwn 1 level. If sre during wrkut, take ne ff and drp dwn 1 level. If sre after wrkut, stay at same level. Page 14 f 18

Rad Running Prgressin (Based 12 minute jgging km / 8 minute running km) Level 1 Walk 2 minutes then jg 2 minutes repeat fr ttal f 35 minutes Level 2 Walk 2 minutes then jg 3 minutes repeat fr 32 minutes Level 3 Walk 2 minutes then jg 4 minutes repeat fr 30 minutes Level 4 Walk 2 minutes then jg 5 minutes repeat fr 28 minutes Level 5 Jg full 3.2kms 24 minutes Level 6 Jg full 4kms 30 minutes Level 7 Jg full 4.8kms 36 minutes ** Levels 8 thrugh 17 shuld be prgressed t tlerance. Once at maximum level f time suggested cntinue t next level abiding by criteria fr prgressin** Level 8 Alternate running fr 2 minutes and jgging fr 3 minutes 30 minutes Level 9 Alternate running fr 5 minutes and jgging fr 2 minutes 28 minutes Level 10 Run fr 4.8kms 24 minutes Level 11 Jg 2 minutes then run fr 2 minutes then sprint fr 30 secnds, then run 2 minutes and repeat 30 minutes Level 12 Run 2 minutes sprint 15 secnds and repeat 24 minutes Level 13 Run 2 minutes sprint 30 secnds and repeat 24 minutes Level 14 Jg 2 minutes sprint 15 secnds and repeat 24 minutes Level 15 Jg 2 minutes sprint 30 secnd and repeat 24 minutes Level 16 Sprint 15 secnds then rest 2 minutes 24 minutes Level 17 Sprint 30 secnds then rest 3 minutes 24 minutes Sreness rules: (yur pain) If sre during warm-up, take 2 days ff and drp dwn 1 level. If sre during wrkut, take ne day ff and drp dwn 1 level. If sre after wrkut, stay at same level. Page 15 f 18

Agility Drills Prgressin Backward running: Run backwards, prgressing distance, speed and % effrt. Ladder high knees: Run thrugh ladder with maximal hip and knee flexin increasing speed and % effrt. Back ladder: Run thrugh ladder backwards increasing speed and % effrt Crss ladder: Start n left side f ladder, place right ft in ladder, fllwed by left, place right ft ut f ladder fllwed by left. Place left ft back int ladder, fllwed by right, place left ft ut f ladder fllwed by right. Repeat until end f ladder. Prgress by increasing speed and % effrt. 18.2km square: Start in 2pt stance, sprint 4.5 metres t first cne, make sharp right cut. Shuffle right 4.5 metres, make sharp cut back. Backpedal 4.5 metres t next cne, make sharp cut left. Left shuffle thrugh finish. In and ut shuffle: Start in 2 pt. stance; stand n side f the ladder facing the first bx. Jump with bth feet int first bx, then back t starting psitin, then jump t secnd bx, and jump straight backwards, repeat pattern thrugh ladder. Flip and catch: Start in standing psitin, placing medicine ball tightly between bth feet. Prceed t jump int the air, kicking the ball int the air behind yu. After landing quickly turn and catch the ball befre it hits the grund. Page 16 f 18

Page 17 f 18

These exercises can be mdified t meet sprt and psitins specific demands. Page 18 f 18