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1.  TREATMENT OF HAMSTRING STRAIN IN A COLLEGIATE POLE‐VAULTER INTEGRATING DRY NEEDLING WITH AN ECCENTRIC TRAINING PROGRAM: A RESIDENT'S CASE REPORT 
Background:
Hamstring strain injuries are among the most common injuries seen in sports. Management is made difficult by the high recurrence rates. Typical time to return to sport varies but can be prolonged with recurrence. Eccentric strength deficits remain post‐injury, contributing to reinjury. Eccentric training has shown to be an effective method at prevention of hamstring injury in multiple systematic reviews and prospective RCTs but limited prospective rehabilitation literature. Functional dry needling is a technique that has been reported to be beneficial in the management of pain and dysfunction after muscle strains, but there is limited published literature on its effects on rehabilitation or recurrence of injury.
Purpose:
The purpose of this case report is to present the management and outcomes of a patient with hamstring strain, treated with functional dry needling and eccentric exercise.
Case Description:
The subject was an 18‐year‐old collegiate pole‐vaulter who presented to physical therapy with an acute hamstring strain and history of multiple strains on uninvolved extremity. He was treated in Physical Therapy three times per week for 3 weeks with progressive eccentric training and 3 sessions of functional dry needling.
Outcomes:
By day 12, his eccentric strength on the involved extremity was greater than the uninvolved extremity and he reported clinically meaningful improvement in outcome scores. By Day 20, he was able to return to full sports participation without pain or lingering strength deficits.
Discussion:
The patient in this case report was able to return to sport within 20 days and without recurrence. He demonstrated significant decreases in pain and dysfunction with dry needling. He had greater strength on the injured extremity compared to contra‐lateral previously injured extremity.
Conclusions:
This case illustrates the use of functional dry needling and eccentric exercise leading to a favorable outcome in a patient with hamstring strain.
Level of Evidence:
Level 4
PMCID: PMC3679638  PMID: 23772348
Functional Dry Needling; Hamstring; Eccentric Exercise
2.  Hamstring Strain Injuries: Recommendations for Diagnosis, Rehabilitation and Injury Prevention 
Synopsis
Hamstring strain injuries remain a challenge for both athletes and clinicians given the high incidence rate, slow healing, and persistent symptoms. Moreover, nearly one-third of these injuries recur within the first year following a return to sport, with subsequent injuries often being more severe than the original. This high reinjury rate suggests that commonly utilized rehabilitation programs may be inadequate at resolving possible muscular weakness, reduced tissue extensibility, and/or altered movement patterns associated with the injury. Further, the traditional criteria used to determine the readiness of the athlete to return to sport may be insensitive to these persistent deficits, resulting in a premature return. There is mounting evidence that the risk of reinjury can be minimized by utilizing rehabilitation strategies that incorporate neuromuscular control exercises and eccentric strength training, combined with objective measures to assess musculotendon recovery and readiness to return to sport. In this paper, we first describe the diagnostic examination of an acute hamstring strain injury, including discussion of the value of determining injury location in estimating the duration of the convalescent period. Based on the current available evidence, we then propose a clinical guide for the rehabilitation of acute hamstring injuries including specific criteria for treatment progression and return to sport. Finally, we describe directions for future research including injury-specific rehabilitation programs, objective measures to assess reinjury risk, and strategies to prevent injury occurrence. Level of evidence: Diagnosis/therapy, level 5.
doi:10.2519/jospt.2010.3047
PMCID: PMC2867336  PMID: 20118524
functional rehabilitation; muscle strain injury; radiology/medical imaging; running; strength training
3.  Clinical and Morphological Changes Following 2 Rehabilitation Programs for Acute Hamstring Strain Injuries: A Randomized Clinical Trial 
STUDY DESIGN
Randomized, double-blind, parallel-group clinical trial.
OBJECTIVES
To assess differences between a progressive agility and trunk stabilization rehabilitation program and a progressive running and eccentric strengthening rehabilitation program in recovery characteristics following an acute hamstring injury, as measured via physical examination and magnetic resonance imaging (MRI).
BACKGROUND
Determining the type of rehabilitation program that most effectively promotes muscle and functional recovery is essential to minimize reinjury risk and to optimize athlete performance.
METHODS
Individuals who sustained a recent hamstring strain injury were randomly assigned to 1 of 2 rehabilitation programs: (1) progressive agility and trunk stabilization or (2) progressive running and eccentric strengthening. MRI and physical examinations were conducted before and after completion of rehabilitation.
RESULTS
Thirty-one subjects were enrolled, 29 began rehabilitation, and 25 completed rehabilitation. There were few differences in clinical or morphological outcome measures between rehabilitation groups across time, and reinjury rates were low for both rehabilitation groups after return to sport (4 of 29 subjects had reinjuries). Greater craniocaudal length of injury, as measured on MRI before the start of rehabilitation, was positively correlated with longer return-to-sport time. At the time of return to sport, although all subjects showed a near-complete resolution of pain and return of muscle strength, no subject showed complete resolution of injury as assessed on MRI.
CONCLUSION
The 2 rehabilitation programs employed in this study yielded similar results with respect to hamstring muscle recovery and function at the time of return to sport. Evidence of continuing muscular healing is present after completion of rehabilitation, despite the appearance of normal physical strength and function on clinical examination.
LEVEL OF EVIDENCE
Therapy, level 1b–. J Orthop Sports Phys Ther 2013;43(5):284-299. Epub 13 March 2013. doi:10.2519/jospt.2013.4452
doi:10.2519/jospt.2013.4452
PMCID: PMC3751188  PMID: 23485730
MRI; muscle; return-to-sport criteria
4.  At return to play following hamstring injury the majority of professional football players have residual isokinetic deficits 
British Journal of Sports Medicine  2014;48(18):1364-1369.
Background
There is an ongoing debate regarding the optimal criteria for return to sport after an acute hamstring injury. Less than 10% isokinetic strength deficit is generally recommended but this has never been documented in professional football players after rehabilitation. Our aim was to evaluate isokinetic measurements in MRI-positive hamstring injuries.
Methods
Isokinetic measurements of professional football players were obtained after completing a standardised rehabilitation programme. An isokinetic strength deficit of more than 10% compared with the contralateral site was considered abnormal. Reinjuries within 2 months were recorded.
Results
52 players had a complete set of isokinetic testing before clinical discharge. There were 27 (52%) grade 1 and 25 (48%) grade 2 injuries. 35 of 52 players (67%) had at least one of the three hamstring-related isokinetic parameters that display a deficit of more than 10%. The percentage of players with 10% deficit for hamstring concentric 60°/s, 300°/s and hamstring eccentric was respectively 39%, 29% and 28%. There was no significant difference of mean isokinetic peak torques and 10% isokinetic deficits in players without reinjury (N=46) compared with players with reinjury (N=6).
Conclusions
When compared with the uninjured leg, 67% of the clinically recovered hamstring injuries showed at least one hamstring isokinetic testing deficit of more than 10%. Normalisation of isokinetic strength seems not to be a necessary result of the successful completion of a football-specific rehabilitation programme. The possible association between isokinetic strength deficit and increased reinjury risk remains unknown.
doi:10.1136/bjsports-2013-093016
PMCID: PMC4174121  PMID: 24493666
Hamstring injuries; Isokinetics; Soccer
5.  Outcome of Grade I and II Hamstring Injuries in Intercollegiate Athletes 
Sports Health  2011;3(6):528-533.
Background:
Hamstring muscle strains represent a common and disabling athletic injury with variable recurrence rates and prolonged recovery times.
Objectives:
To present the outcomes of a novel rehabilitation protocol for the treatment of proximal hamstring strains in an intercollegiate sporting population and to determine any significant differences in the rate of reinjury and time to return to sport based on patient and injury characteristics.
Study Design:
Retrospective case series.
Methods:
A retrospective review was performed of 48 consecutive hamstring strains in intercollegiate athletes. The rehabilitation protocol consisted of early mobilization, with flexible progression through supervised drills. Athletes were allowed to return to sport after return of symmetrical strength and range of motion with no pain during sprinting. Primary outcomes included time to return to sport and reinjury rates.
Results:
All patients returned to their sports, and 3 sustained repeat hamstring strains (6.2% reinjury rate) after a minimum follow-up of 6 months. The average number of days missed from sport was 11.9 (range, 5-23 days). There was no statistically significant difference for time to return to sport between first-time and recurrent injuries and between first- and second-degree injuries (P > 0.05).
Conclusions:
Grade I and II hamstring strains may be aggressively treated with a protocol of brief immobilization followed by early initiation of running and isokinetic exercises—with an average expected return to sport of approximately 2 weeks and with a relatively low reinjury rate regardless of injury grade (I or II), injury characteristics (including first-time and recurrent injuries), or athlete characteristics.
doi:10.1177/1941738111422044
PMCID: PMC3445226  PMID: 23016054
hamstring muscle; injury; athletes; rehabilitation; return to sports
6.  RECURRENT HAMSTRING INJURY: CONSIDERATION FOLLOWING OPERATIVE AND NON‐OPERATIVE MANAGEMENT 
Purpose/Background:
Hamstring injuries are common at all levels of sport, however recurrence rates are disproportionate compared to other soft tissue injuries. Age and previous injury are supported in the literature as risk factors for hamstring injury; nonetheless, debate exists regarding modifiable risk factors. Restoration of peak torque length using lengthening eccentrics and core stability interventions appear to reduce incidence of re‐injury. The purpose of this clinical commentary is to review examination techniques and rehabilitation considerations in order to identify important risk factors to reduce recurrence after hamstring strain and total rupture.
Discussion/Relation to Clinical Practice:
Novel clinical examination techniques both at time of acute injury and prior to return to sport may provide valuable prognostic information. Restoration of core stability, neuromuscular control and lengthening eccentric hamstring interventions are proposed key components to reduce hamstring re‐injury.
Levels of Evidence:
Level 5
PMCID: PMC4223289  PMID: 25383248
Eccentrics; hamstring injury; recurrence risk factors
7.  Influence of Hip-Flexion Angle on Hamstrings Isokinetic Activity in Sprinters 
Journal of Athletic Training  2012;47(4):390-395.
Context
Hamstrings strains are common and debilitating injuries in many sports. Most hamstrings exercises are performed at an inadequately low hip-flexion angle because this angle surpasses 70° at the end of the sprinting leg's swing phase, when most injuries occur.
Objective
To evaluate the influence of various hip-flexion angles on peak torques of knee flexors in isometric, concentric, and eccentric contractions and on the hamstrings-to-quadriceps ratio.
Design
Descriptive laboratory study.
Setting
Research laboratory.
Patients and Other Participants
Ten national-level sprinters (5 men, 5 women; age = 21.2 ± 3.6 years, height = 175 ± 6 cm, mass = 63.8 ± 9.9 kg).
Intervention(s)
For each hip position (0°, 30°, 60°, and 90° of flexion), participants used the right leg to perform (1) 5 seconds of maximal isometric hamstrings contraction at 45° of knee flexion, (2) 5 maximal concentric knee flexion-extensions at 60° per second, (3) 5 maximal eccentric knee flexion-extensions at 60° per second, and (4) 5 maximal eccentric knee flexion-extensions at 150° per second.
Main Outcome Measure(s)
Hamstrings and quadriceps peak torque, hamstrings-to-quadriceps ratio, lateral and medial hamstrings root mean square.
Results
We found no difference in quadriceps peak torque for any condition across all hip-flexion angles, whereas hamstrings peak torque was lower at 0° of hip flexion than at any other angle (P < .001) and greater at 90° of hip flexion than at 30° and 60° (P < .05), especially in eccentric conditions. As hip flexion increased, the hamstrings-to-quadriceps ratio increased. No difference in lateral or medial hamstrings root mean square was found for any condition across all hip-flexion angles (P > .05).
Conclusions
Hip-flexion angle influenced hamstrings peak torque in all muscular contraction types; as hip flexion increased, hamstrings peak torque increased. Researchers should investigate further whether an eccentric resistance training program at sprint-specific hip-flexion angles (70° to 80°) could help prevent hamstrings injuries in sprinters. Moreover, hamstrings-to-quadriceps ratio assessment should be standardized at 80° of hip flexion.
PMCID: PMC3396298  PMID: 22889654
injury prevention; eccentric exercises; length-tension relationship; hamstrings-to-quadriceps ratio; muscle strains
8.  Concentric Versus Enhanced Eccentric Hamstring Strength Training: Clinical Implications 
Journal of Athletic Training  1998;33(3):216-221.
Objective:
Hamstring injuries can be quite debilitating and often result in chronic problems. Eccentric muscle actions are often the last line of defense against muscle injury and ligament disruption. Traditionally, the focus of hamstring strength rehabilitation has been on concentric muscle actions. The purpose of our study was to compare hamstring muscle strength gains in concentric and eccentric hamstring strength training.
Design and Setting:
A randomized-group design was used to examine differences in 1-repetition maximum (1 RM) and isokinetic strength values among 3 groups of subjects. Subjects were tested in a biomechanics laboratory using an isokinetic dynamometer, while training was carried out in a physical therapy outpatient clinic.
Subjects:
Twenty-seven healthy male subjects (age = 22.9 ± 3.1 years, wt = 81.8 ± 12.9 kg, ht = 178.6 ± 7.2 cm) participated in this study. Subjects were randomly assigned to 1 of 3 treatment groups: eccentric training, concentric training, or control.
Measurements:
Subjects performed hamstring curls using an isotonic weight training device. Pretest 1 RM weight values were determined for all subjects using a standardized 1 RM protocol. In addition, maximum concentric and eccentric isokinetic strength values for knee-flexion strength were determined. Control group subjects refrained from weight training for 6 weeks. Subjects in the training groups trained 2 days per week for 6 weeks (12 sessions). After 6 weeks of training, all subjects returned for 1RM and isokinetic posttesting.
Results:
The concentric group improved 19%, while the eccentric group improved 29%. The control group subjects did not show any significant change over the 6 weeks. In addition, there were improvements in eccentric isokinetic peak torque/ body weight ratios at both 60 °s and 180° from pretesting to posttesting in the eccentric training group only.
Conclusions:
Our results demonstrate the effectiveness of isotonic strength training on the development of hamstring muscle strength. More important is the dramatic effect of eccentric strength training on overall hamstring muscle strength, both isotonic and isokinetic. Clinicians should consider using eccentric hamstring strengthening as part of their rehabilitation protocols for hamstring and knee injuries.
Images
PMCID: PMC1320426  PMID: 16558513
1RM; peak torque/body weight ratios; enhanced eccentrics; isotonic; isokinetic
9.  Evaluation and Imaging of an Untreated Grade III Hamstring Tear: A Case Report 
Background
Muscle strains are one of the most common complaints treated by physicians. High-force lengthening contractions can produce very high forces resulting in pain and tissue damage; such strains are the most common cause of muscle injuries. The hamstring muscles are particularly susceptible as they cross two joints and regularly perform lengthening contractions during running. We describe a patient with return to full function after a large hamstring tear.
Case Description
We report the case of a 26-year-old man who presented 1 year after a noncontact, left-sided proximal hamstring tear incurred while sprinting. He received no medical treatment or formal rehabilitation. He was able to return to all sports and activities 1 to 2 months after injury, but noted a persistent deformity of the proximal thigh, which led him to seek evaluation. Physical examination, MRI functional tests, and specific muscle tests 1 year after his injury documented a major hamstring tear at the musculotendinous junction with muscle retraction, but no avulsion of the proximal tendon attachment.
Literature Review
Surgery often is recommended for major proximal hamstring tendon tears, especially when more than one tendon of origin is ruptured from the ischial tuberosity. Myotendinous tears are treated nonoperatively, but may be associated with decreased strength, prolonged recovery, and recurrence.
Purpose and Clinical Relevance
We describe the case of a young man who sustained a hamstring tear, with retraction, at the proximal myotendinous junction, where the biceps femoris and semitendinosus arise from the conjoint tendon. He achieved full functional recovery without medical attention, but had a persistent cosmetic deformity and slight hamstring tightness. This case suggests a benign natural history for this injury and the appropriateness of noninvasive treatment.
doi:10.1007/s11999-011-2027-3
PMCID: PMC3183192  PMID: 21850562
10.  Functional and Neuromuscular Changes in the Hamstrings After Drop Jumps and Leg Curls 
The purpose of this study was to use a holistic approach to investigate changes in jumping performance, kinaesthesia, static balance, isometric strength and fast stepping on spot during a 5-day recovery period, following an acute bout of damaging exercise consisted of drop jumps and leg curls, where specific emphasis was given on the hamstring muscles. Eleven young healthy subjects completed a series of highly intensive damaging exercises for their hamstring muscles. Prior to the exercise, and during the 5-day recovery period, the subjects were tested for biochemical markers (creatine kinase, aspartate aminotransferase, and lactate dehydrogenase), perceived pain sensation, physical performance (squat jump, counter movement jump, maximal frequency leg stamping, maximal isometric torque production and maximally explosive isometric torque production), kinaesthesia (active torque tracking) and static balance. We observed significant decreases in maximal isometric knee flexion torque production, the rate of torque production, and majority of the parameters for vertical jump performance. No alterations were found in kinaesthesia, static balance and fast stepping on spot. The highest drop in performance and increase in perceived pain sensation generally occurred 24 or 48 hours after the exercise. Damaging exercise substantially alters the neuromuscular functions of the hamstring muscles, which is specifically relevant for sports and rehabilitation experts, as the hamstrings are often stretched to significant lengths, in particular when the knee is extended and hip flexed. These findings are practically important for recovery after high-intensity trainings for hamstring muscles.
Key PointsHamstring function is significantly reduced following specifically damaging exercise.It fully recovers 120 hours after the exercise.Prevention of exercise-induced muscle damage is cruicial for maintaining normal training regime.
PMCID: PMC3772585  PMID: 24149148
Isometric strength; stamping; balance; kinaesthesia; DOMS; EIMD
11.  Hamstring Musculotendon Dynamics during Stance and Swing Phases of High Speed Running 
Introduction
Hamstring strain injuries are common in sports that involve high speed running. It remains uncertain whether the hamstrings are susceptible to injury during late swing phase, when the hamstrings are active and lengthening, or during stance, when contact loads are present. In this study we used forward dynamic simulations to compare hamstring musculotendon stretch, loading and work done during stance and swing phases of high speed running gait cycles.
Methods
Whole body kinematics, EMG activities and ground reactions were collected as 12 subjects ran on an instrumented treadmill at speeds ranging from 80% to maximum (average of 7.8 m/s). Subject-specific simulations were then created using a whole body musculoskeletal model that included fifty-two Hill-type musculotendon units acting about the hip and knee. A computed muscle control algorithm was used to determine muscle excitation patterns that drove the limb to track measured hip and knee sagittal plane kinematics, with measured ground reactions applied to the limb.
Results
The hamstrings lengthened under load from 50% to 90% of the gait cycle (swing), and then shortened under load from late swing through stance. While peak hamstring stretch was invariant with speed, lateral hamstring (biceps femoris) loading increased significantly with speed, and was greatest during swing at the fastest speed. The biarticular hamstrings performed negative work on the system only during swing phase, with the amount of negative work increasing significantly with speed.
Conclusion
We concluded that the large inertial loads during high speed running appear to make the hamstrings most susceptible to injury during swing phase when compared to stance phase. This information is relevant for scientifically establishing effective muscle injury prevention and rehabilitation programs.
doi:10.1249/MSS.0b013e3181f23fe8
PMCID: PMC3057086  PMID: 20689454
Acute strain injury; motion analysis; forward dynamic simulation; musculoskeletal model; muscle mechanics
12.  Comparison of hamstring transfer with hamstring lengthening in ambulatory children with cerebral palsy: further follow-up 
Background
Overactivity or contractures of the hamstring muscles in ambulatory children with cerebral palsy (CP) can lead to either a jump gait (knee flexion associated with ankle plantar flexion) or a crouch gait (knee flexion associated with ankle dorsiflexion). Hamstring lengthening is performed to decrease stance knee flexion. However, this procedure carries the potential risk of weakening hip extension power as well as recurrence over time; therefore, surgeons have adopted a modified procedure wherein the semitendinosus and gracilis are transferred above the knee joint, along with lengthening of the semimembranosus and biceps femoris.
Purpose
The purpose of our study is to evaluate the differences between hamstring lengthening alone (HSL group) and hamstring lengthening plus transfer (HST group) in the treatment of flexed knee gait in ambulatory children with CP. We hypothesized that recurrence of increased knee flexion in the stance phase will be less in the HST group at long-term follow-up, and hip extensor power will be better preserved.
Methods
Fifty children with CP who underwent hamstring surgery for flexed knee gait were retrospectively reviewed. All subjects underwent a pre-operative gait study, a follow-up post-operative gait study, and a long-term gait study. The subjects were divided into two groups; HSL group (18 subjects) or HST group (32 subjects). The mean age at surgery was 9.9 ± 3.3 years. The mean follow-up time was 4.4 ± 0.9 (2.7–6.3) years.
Results
On physical examination, both groups showed improvement in straight leg raise, knee extension, popliteal angle, and maximum knee extension in stance at the first post-op study, and maintained this improvement at the long-term follow-up, with the exception of straight leg raise, which slightly worsened in both groups at the final follow-up. Both groups improved maximum knee extension in stance at the initial follow-up, and maintained this at the long-term follow-up. Only the HST group showed significant (p < 0.05) improvement in the peak hip extension power in stance at the first post-op study, and this increased further at the final follow-up. In the HSL group, there was an initial slight decrease in the hip extension power, which subsequently increased to pre-operative values at the long-term study. Only the HST group showed increase of the average anterior pelvic tilt at the long-term follow-up study, although this was small in magnitude. There were two subjects who developed knee recurvatum at the post-op study, and both were in the HST group.
Conclusions
There is no clear benefit in regards to recurrence when comparing HST to HSL in the long term. In both HSL and HST, there was reduction of stance phase knee flexion in the long term, with no clear advantage in either group. Longer follow-up is needed for additional recurrence information. There was greater improvement of hip extension power in the HST group, which may justify the additional operative time of the transfer.
Significance
This study helps pediatric orthopedic surgeons choose between two different techniques to treat flexed knee gait in patients with CP by showing the long-term outcome of both procedures.
doi:10.1007/s11832-014-0626-8
PMCID: PMC4252270  PMID: 25430874
Cerebral palsy; Hamstring lengthening; Hamstring transfers; Motion analysis; Long-term study
13.  How Joint Torques Affect Hamstring Injury Risk in Sprinting Swing–Stance Transition 
ABSTRACT
Purpose
The potential mechanisms of hamstring strain injuries in athletes are not well understood. The study, therefore, was aimed at understanding hamstring mechanics by studying loading conditions during maximum-effort overground sprinting.
Methods
Three-dimensional kinematics and ground reaction force data were collected from eight elite male sprinters sprinting at their maximum effort. Maximal isometric torques of the hip and knee were also collected. Data from the sprinting gait cycle were analyzed via an intersegmental dynamics approach, and the different joint torque components were calculated.
Results
During the initial stance phase, the ground reaction force passed anteriorly to the knee and hip, producing an extension torque at the knee and a flexion torque at the hip joint. Thus, the active muscle torque functioned to produce flexion torque at the knee and extension torque at the hip. The maximal muscle torque at the knee joint was 1.4 times the maximal isometric knee flexion torque. During the late swing phase, the muscle torque counterbalanced the motion-dependent torque and acted to flex the knee joint and extend the hip joint. The loading conditions on the hamstring muscles were similar to those of the initial stance phase.
Conclusions
During both the initial stance and late swing phases, the large passive torques at both the knee and hip joints acted to lengthen the hamstring muscles. The active muscle torques generated mainly by the hamstrings functioned to counteract those passive effects. As a result, during sprinting or high-speed locomotion, the hamstring muscles may be more susceptible to high risk of strain injury during these two phases.
doi:10.1249/MSS.0000000000000404
PMCID: PMC4323551  PMID: 24911288
RUNNING BIOMECHANICS; MUSCLE STRAIN; LOAD CONDITION; JOINT TORQUE; INTERSEGMENTAL DYNAMICS
14.  A NOVEL APPROACH TO TREATMENT FOR CHRONIC AVULSION FRACTURE OF THE ISCHIAL TUBEROSITY IN THREE ADOLESCENT ATHLETES: A CASE SERIES 
Background and Incidence:
Ischial tuberosity fracture and its associated complications are an under recognized diagnosis in the adolescent athlete. Apophyseal injuries of the pelvis in the skeletally immature athlete can occur in multiple locations but are most common at the ischial tuberosity, affecting males more commonly than females.
Description of Injury and Current Management:
The most common cause of ischial tuberosity avulsion fracture is a quick eccentric load to the proximal hamstrings, occurring with kicking as in soccer, football, or dance. Signs and symptoms are similar to a proximal hamstring injury but avulsion injuries often go undiagnosed, as radiographs are not frequently obtained. In acute cases, rest and relative immobilization are the recommended course of care. In chronic cases, including those with delayed diagnosis, or those that remain symptomatic after initial care due to non‐union or associated sciatic nerve adhesions, surgery is often performed in order to restore normal anatomy, alleviate symptoms, and help return the athlete to full activity.
Purpose:
The authors' share a novel treatment approach consisting of ultrasound guided percutaneous needle fenestration for the treatment of three adolescent athletes with symptomatic delayed diagnoses of ischial tuberosity fractures. Needle fenestration was followed by a physical therapy progression which was developed based on tissue healing rates, symptom presentation, and the available literature related to proximal hamstring injuries.
Outcomes:
Two athletes reported elimination of pain, full functional recovery and return to sport without limitations as measured by use of the Numeric Pain Rating Scale, the Global Rating of Change Scale, and the Lower Extremity Functional Scale. One athlete reported elimination of pain and full functional recovery and chose to return to a new sport. Symptoms of possible concurrent hamstring syndrome are discussed as well the management of this condition.
Discussion/Conclusions:
This case series introduced a novel approach for treatment of symptomatic delayed union ischial tuberosity fractures in three adolescents prior to consideration of surgical intervention. Percutanous needle fenestration and the described subsequent rehabilitation provided positive treatment outcomes in the presented cases, including full return to athletic and recreational endeavors.
Level of Evidence:
Level 5
PMCID: PMC4275201  PMID: 25540712
Adolescent apophyseal injury; ischial tuberosity avulsion; percutaneous fenestration; percutaneous tenotomy
15.  Eccentric and concentric isokinetic moment characteristics in the quadriceps and hamstrings of the chronic isolated posterior cruciate ligament injured knee 
OBJECTIVE: Functional strength deficits associated with chronic isolated posterior cruciate ligament (PCL) insufficiency have received limited attention in the literature. The purpose of this study was to determine the eccentric and concentric isokinetic moment characteristics of the quadriceps and hamstrings in a sample of patients with isolated PCL injury. METHODS: Eccentric and concentric mean average and average peak moments were measured for 17 patients with a history of conservatively treated isolated PCL injury using an isokinetic dynamometer. Quadriceps and hamstring isokinetic moments were recorded from 10 degree to 90 degree of knee flexion. Strength ratios were calculated and compared with those reported in the literature for healthy subjects. RESULTS: The hamstrings of the involved side (eccentric/concentric (E/C) ratio = 1.06) were significantly weaker (p<0.05) eccentrically than those of the contralateral side (E/C ratio = 1.29). All hamstrings/quadriceps (H/Q) ratios were less than the universally accepted value of 0.60 and the eccentric H/Q ratio for the injured extremity was significantly lower than the non-injured (p<0.05). In a bilateral comparison, the injured/non-injured (I/N) ratio was less than 1.00 for concentric quadriceps, eccentric quadriceps, and hamstring isokinetic moments. Calculation of the E/C ratio showed that, for the quadriceps, it was 1.08 on the injured side and 1.07 on the non-injured extremity. CONCLUSIONS: Eccentric strengthening should be an integral part of functionally rehabilitating the quadriceps and hamstrings of athletes who suffer from the complications associated with chronic isolated PCL insufficiency. 



PMCID: PMC1756212  PMID: 10597850
16.  The relationship between previous hamstring injury and the concentric isokinetic knee muscle strength of irish gaelic footballers 
Background
Hamstring injury is one of the most common injuries affecting gaelic footballers, similar to other field sports. Research in other sports on whether residual hamstring weakness is present after hamstring injury is inconsistent, and no study has examined this factor in irish gaelic footballers. The aim of this study was to examine whether significant knee muscle weakness is present in male Irish gaelic footballers who have returned to full activity after hamstring injury.
Methods
The concentric isokinetic knee flexion and extension strength of 44 members of a university gaelic football team was assessed at 60, 180 and 300 degrees per second using a Contrex dynamometer.
Results
Fifteen players (34%) reported a history of hamstring strain, with 68% of injuries affecting the dominant (kicking) limb. The hamstrings were significantly stronger (p < 0.05) on the dominant limb in all uninjured subjects. The previously injured limbs had a significantly lower (p < 0.05) hamstrings to quadriceps (HQ) strength ratio than all other non-injured limbs, but neither their hamstrings nor quadriceps were significantly weaker (p > 0.05) using this comparison. The previously unilaterally injured hamstrings were significantly weaker (p < 0.05) than uninjured limbs however, when matched for dominance. The hamstring to opposite hamstring (H:oppH) strength ratio of the previously injured players was also found to be significantly lower (p < 0.05) than that of the uninjured players.
Conclusion
Hamstring muscle weakness was observed in male Irish gaelic footballers with a history of hamstring injury. This weakness is most evident when comparisons are made to multiple control populations, both within and between subjects. The increased strength of the dominant limb should be considered as a potential confounding variable in future trials. The study design does not allow interpretation of whether these changes in strength were present before or after injury.
doi:10.1186/1471-2474-9-30
PMCID: PMC2289821  PMID: 18325107
17.  The Influence of Prior Hamstring Injury on Lengthening Muscle Tissue Mechanics 
Journal of biomechanics  2010;43(12):2254-2260.
Hamstring strain injuries often occur near the proximal musculotendon junction (MTJ) of the biceps femoris. Post-injury remodeling can involve scar tissue formation, which may alter contraction mechanics and influence re-injury risk. The purpose of this study was to assess the affect of prior hamstring strain injury on muscle tissue displacements and strains during active lengthening contractions. Eleven healthy and eight subjects with prior biceps femoris injuries were tested. All previously injured subjects had since returned to sport and exhibited evidence of residual scarring along the proximal aponeurosis. Subjects performed cyclic knee flexion-extension on an MRI-compatible device using elastic and inertial loads, which induced active shortening and lengthening contractions, respectively. CINE phase-contrast imaging was used to measure tissue velocities within the biceps femoris during these tasks. Numerical integration of the velocity information was used to estimate two-dimensional tissue displacement and strain fields during muscle lengthening. The largest tissue motion was observed along the distal MTJ, with the active lengthening muscle exhibiting significantly greater and more homogeneous tissue displacements. First principal strains magnitudes were largest along the proximal MTJ for both loading conditions. The previously injured subjects exhibited less tissue motion and significantly greater strains near the proximal MTJ. We conclude that localized regions of high tissue strains during active lengthening contractions may predispose the proximal biceps femoris to injury. Furthermore, post-injury remodeling may alter the in-series stiffness seen by muscle tissue and contribute to the relatively larger localized tissue strains near the proximal MTJ, as was observed in this study.
doi:10.1016/j.jbiomech.2010.02.038
PMCID: PMC2922492  PMID: 20472238
phase contrast velocity; magnetic resonance imaging; hamstring muscle; muscle strain
18.  The Football Association Medical Research Programme: an audit of injuries in professional football—analysis of hamstring injuries 
Objective: To conduct a detailed analysis of hamstring injuries sustained in English professional football over two competitive seasons.
Methods: Club medical staff at 91 professional football clubs annotated player injuries over two seasons. A specific injury audit questionnaire was used together with a weekly form that documented each clubs' current injury status.
Results: Completed injury records for the two competitive seasons were obtained from 87% and 76% of the participating clubs respectively. Hamstring strains accounted for 12% of the total injuries over the two seasons with nearly half (53%) involving the biceps femoris. An average of five hamstring strains per club per season was observed. A total of 13 116 days and 2029 matches were missed because of hamstring strains, giving an average of 90 days and 15 matches missed per club per season. In 57% of cases, the injury occurred during running. Hamstring strains were most often observed during matches (62%) with an increase at the end of each half (p<0.01). Groups of players sustaining higher than expected rates of hamstring injury were Premiership (p<0.01) and outfield players (p<0.01), players of black ethnic origin (p<0.05), and players in the older age groups (p<0.01). Only 5% of hamstring strains underwent some form of diagnostic investigation. The reinjury rate for hamstring injury was 12%.
Conclusion: Hamstring strains are common in football. In trying to reduce the number of initial and recurrent hamstring strains in football, prevention of initial injury is paramount. If injury does occur, the importance of differential diagnosis followed by the management of all causes of posterior thigh pain is emphasised. Clinical reasoning with treatment based on best available evidence is recommended.
doi:10.1136/bjsm.2002.002352
PMCID: PMC1724733  PMID: 14751943
19.  Muscle Activity Response to External Moment During Single-Leg Drop Landing in Young Basketball Players: The Importance of Biceps Femoris in Reducing Internal Rotation of Knee During Landing 
Internal tibial rotation with the knee close to full extension combined with valgus collapse during drop landing generally results in non-contact anterior cruciate ligament (ACL) injury. The purpose of this study was to investigate the relationship between internal rotation of the knee and muscle activity from internal and external rotator muscles, and between the internal rotation of knee and externally applied loads on the knee during landing in collegiate basketball players. Our hypothesis was that the activity of biceps femoris muscle would be an important factor reducing internal knee rotation during landing. The subjects were 10 collegiate basketball students: 5 females and 5 males. The subjects performed a single-leg drop landing from a 25-cm height. Femoral and tibial kinematics were measured using a 3D optoelectronic tracking system during the drop landings, and then the knee angular motions were determined. Ground reaction forces and muscle activation patterns (lateral hamstring and medial hamstring) were simultaneously measured and computed. Results indicated that lower peak internal tibial rotation angle at the time of landing was associated with greater lateral hamstring activity (r = -0.623, p < 0.001). When gender was considered, the statistically significant correlation remained only in females. There was no association between the peak internal tibial rotation angle and the knee internal rotation moment. Control of muscle activity in the lateral to medial hamstring would be an important factor in generating sufficient force to inhibit excessive internal rotation during landing. Strengthening the biceps femoris might mitigate the higher incidence of non-contact ACL injury in female athletes.
Key pointsLower activity of the external rotator muscle of the knee, which inhibits internal rotation of the knee, may be the reason why females tend to show a large internal rotation of the knee during drop landing.Externally applied internal rotation moment of the knee during landing would not be expected to explain why female athletes tend to show excessive internal knee rotation.Biceps femoris strength training might help decrease the incidence of non-contact ACL injury in female athletes.
PMCID: PMC3737861  PMID: 24149198
ACL injury; risk factors; knee moment; muscle activation
20.  Isokinetic strength testing does not predict hamstring injury in Australian Rules footballers 
OBJECTIVE: To determine the relation of hamstring and quadriceps muscle strength and imbalance to hamstring injury using a prospective observational cohort study METHOD: A total of 102 senior male Australian Rules footballers aged 22.2 (3.6) years were tested at the start of a football season. Maximum voluntary concentric and eccentric torque of the hamstring and quadriceps muscles of both legs was assessed using a Kin-Com isokinetic dynamometer at angular velocities of 60 and 180 degrees/second. Twelve (11.8%) players sustained clinically diagnosed hamstring strains which caused them to miss one or more matches over the ensuing season. RESULTS: There were no significant differences for any of the isokinetic variables comparing the injured and non-injured legs in players with unilateral hamstring strains (n=9). Neither the injured nor the non-injured leg of injured players differed from the mean of left and right legs in non-injured players for any isokinetic variable. The hamstring to opposite hamstring ratios also did not differ between injured and non-injured players. A hamstring to opposite hamstring ratio of less than 0.90 and a hamstring to quadriceps ratio of less than 0.60 were not associated with an increased risk of hamstring injury. A significantly greater percentage of players who sustained a hamstring strain reported a history of hamstring strain compared with non-injured players (p=0.02). However, this was not related to muscle weakness or imbalance. CONCLUSIONS: Isokinetic muscle strength testing was not able to directly discriminate Australian Rules football players at risk for a hamstring injury. 



PMCID: PMC1756115  PMID: 9865403
21.  A survey of flexibility training protocols and hamstring strains in professional football clubs in England 
Objectives: To investigate the relation between current flexibility training protocols, including stretching, and hamstring strain rates (HSRs) in English professional football clubs.
Method: Questionnaire based data on flexibility training methods and HSRs were collected from 30 English professional football clubs in the four divisions during the 1998/99 season. Data were coded and analysed using cross tabulation, correlation, and multiple regression.
Results: Flexibility training protocols were characterised by wide variability, with static stretching the most popular stretching technique used. Hamstring strains represented 11% of all injuries and one third of all muscle strains. About 14% of hamstring strains were reinjuries. HSRs were highest in the Premiership (13.3 (9.4)/1000 hours) with the lowest rates in Division 2 (7.8 (2.9)/1000 hours); values are mean (SD). Most (97%) hamstring strains were grade I and II, two thirds of which occurred late during training/matches. Forwards were injured most often. Use of the standard stretching protocol (SSP) was the only factor significantly related to HSR (r = –0.45, p = 0.031) in the correlation analysis, suggesting that the more SSP is used, the lower the HSR. About 80% of HSR variability was accounted for by stretching holding time (SHT), SSP, and stretching technique (STE) in the multiple regression equation: HSR = 37.79 – (0.33SHT – 10.05SSP + 2.24STE) ± 2.34. SHT (negatively correlated with HSR) was the single highest predictor, and accounted for 30% of HSR variability, and an additional 40% in combination with SSP.
Conclusions: Flexibility training protocols in the professional clubs were variable and appeared to depend on staffing expertise. Hamstring stretching was the most important training factor associated with HSR. The use of SSP, STE, and SHT are probably involved in a complex synergism which may reduce hamstring strains. Modification of current training patterns, especially stretching protocols, may reduce HSRs in professional footballers.
doi:10.1136/bjsm.2002.000044
PMCID: PMC1724868  PMID: 15273168
22.  CONSERVATIVE REHABILITATION OF SCIATIC NERVE INJURY FOLLOWING HAMSTRING TEAR 
Study Design:
Resident's case report
Background:
There have been only a few case reports in the literature mentioning sciatic nerve injury following a hamstring tear. In previous cases surgical intervention was performed to debride scar tissue around the sciatic nerve with the goal of full return to function for the patient.
Objectives:
The purpose of this case report is to describe the conservative interventions that allowed for recovery from a hamstring tear with sciatic nerve involvement.
Case Description:
The subject was a 53 year old female who developed foot drop and weakness in the common fibular nerve distribution following a grade 3 hamstring injury sustained during Nordic skiing. Nerve function and strength gradually returned over the course of several months of conservative rehabilitation which included on neural gliding and strengthening exercises.
Outcomes:
At 18 months post injury, the subject had returned to 95% of full sport function and 98% of full function with activities of daily living, as rated by the Hip Outcome Scale, and had full strength with manual muscle testing. Isokinetic testing revealed strength deficits of 11–23% in knee flexion peak torque at 60 degrees/second and 180 degrees/second respectively.
Discussion:
Sciatic nerve injury is a rare, but important potential consequence of severe hamstring strains. Clinicians should be cognizant of the potential injury to the nerve tissue following hamstring strains, so they may be dealt with in a prompt and appropriate manner. The use of neural gliding may be worth considering for a prophylactic effect following hamstring strains.
PMCID: PMC2971645  PMID: 21589670
foot drop; nerve glide; sciatic nerve; hamstring strain
23.  Hamstring Strength and Morphology Progression after Return to Sport from Injury 
Hamstring strain re-injury rates can reach 30% within the initial two weeks following return to sport (RTS). Incomplete recovery of strength may be a contributing factor. However, relative strength of the injured and unaffected limbs at RTS is currently unknown. PURPOSE: Characterize hamstring strength and morphology at the time of RTS and six months later. METHODS: Twenty-five athletes that experienced an acute hamstring strain injury participated, following completion of a controlled rehabilitation program. Bilateral isokinetic strength testing and magnetic resonance imaging (MRI) were performed at RTS and 6-months later. Strength (knee flexion peak torque, work, angle of peak torque) and MRI (muscle and tendon volumes) measures were compared between limbs and over time using repeated measures ANOVA. RESULTS: The injured limb showed a peak torque deficit of 9.6% compared to the uninjured limb at RTS (60°/s, p<0.001), but not 6-months following. The knee flexion angle of peak torque decreased over time for both limbs (60°/s, p<0.001). MRI revealed that 20.4% of the muscle cross-sectional area showed signs of edema at RTS with full resolution by the 6-month follow-up. Tendon volume of the injured limb tended to increase over time (p=0.108), while muscle volume decreased 4–5% in both limbs (p<0.001). CONCLUSION: Residual edema and deficits in isokinetic knee flexion strength were present at RTS, but resolved during the subsequent six months. This occurred despite MRI evidence of scar tissue formation (increased tendon volume) and muscle atrophy, suggesting that neuromuscular factors may contribute to the return of strength.
doi:10.1249/MSS.0b013e3182776eff
PMCID: PMC3580023  PMID: 23059864
magnetic resonance imaging; knee flexion torque; rehabilitation; muscle volume
24.  Update on rehabilitation following ACL reconstruction 
As anterior cruciate ligament (ACL) reconstruction has evolved to less invasive, more anatomical approaches, rehabilitation of the injured athlete has likewise become more progressive and innovative, with a sound understanding of graft and fixation strength and biologic healing-remodeling constraints. This review discusses these innovations including specific considerations before surgery, when planning rehabilitation timetables, and the importance of reestablishing nonimpaired active and passive knee range of motion and biarticular musculotendinous extensibility in positions of function. Concepts of self-efficacy or confidence and reestablishing the “athlete role” are also addressed. Since ACL injury and reinjury are largely related to the influence of structure-form-function on dynamic knee joint stability, the interrelationships between sensorimotor, neuromuscular, and conventional resistance training are also discussed. Although pivot shift “giving way” relates to function loss following ACL injury, anterior translational laxity often does not. Although there is growing evidence that progressive eccentric training may benefit the patient following ACL reconstruction, there is less evidence supporting the use of functional ACL knee braces. Of considerable importance is selecting and achieving a criteria-based progression to sports-specific training, reestablishing osseous homeostasis and improved bone density, blending open and closed kinetic chain exercises at the appropriate time period, and appreciating the influence of the trunk, upper extremities, and sports equipment use on knee loads. We believe that knee dysfunction and functional recovery should be considered from a local, regional, and global perspective. These concepts are consolidated into our approach to prepare patients for return to play including field testing and maintenance training.
PMCID: PMC3781865  PMID: 24198553
knee; arthroscopy; neuromuscular reeducation; sport-specific training
25.  Type of acute hamstring strain affects flexibility, strength, and time to return to pre‐injury level 
Objectives
To investigate possible links between aetiology of acute, first time hamstring strains in sprinters and dancers and recovery of flexibility, strength, and function as well as time to return to pre‐injury level.
Methods
Eighteen elite sprinters and 15 professional dancers with a clinically diagnosed hamstring strain were included. They were clinically examined and tested two, 10, 21, and 42 days after the acute injury. Range of motion in hip flexion and isometric strength in knee flexion were measured. Self estimated and actual time to return to pre‐injury level were recorded. Hamstring reinjuries were recorded during a two year follow up period.
Results
All the sprinters sustained their injuries during high speed sprinting, whereas all the dancers were injured while performing slow stretching type exercises. The initial loss of flexibility and strength was greater in sprinters than in dancers (p<0.05). At 42 days after injury, both groups could perform more than 90% of the test values of the uninjured leg. However, the actual times to return to pre‐injury level of performance were significantly longer (median 16 weeks (range 6–50) for the sprinters and 50 weeks (range 30–76) for the dancers). Three reinjuries were noted, all in sprinters.
Conclusion
There appears to be a link between the aetiologies of the two types of acute hamstring strain in sprinters and dancers and the time to return to pre‐injury level. Initially, sprinters have more severe functional deficits but recover more quickly.
doi:10.1136/bjsm.2005.018879
PMCID: PMC2491922  PMID: 16371489
hamstrings; injury; sprinters; dancers; recovery

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