The Dreaded Hamstring: Pathophysiology and Rehabilitation Tips

by Joshua J. Stone, MA, ATC, NASM-CPT, CES, PES, FNS
Article originally posted on http://athleticmedicine.wordpress.com/
Follow Josh on Twitter http://twitter.com/JoshStoneATC

How many times are we going to see an athlete suffer from recurrent hamstring strains? How many times are we going to see delayed recovery from a mild hamstring pull? Unfortunately, it’s going to continue, because some health and wellness specialists (ATCs, PTs, and Strength coaches) are looking in the wrong area. Read the following conversation I had between myself and a concerned parent of an athlete (the parent also happened to be a chiropractor).

‘What are you doing? Why are you not treating the hamstring?’

Because it’s not the hamstring.

‘What?!?  When an athlete says “I was running and I felt a pull I the back of my leg…. it feels really tight.” you are going to tell me it is not a hamstring strain? Please! Can you please just treat the hamstring?’ 

Well, technically yes, it is a hamstring strain, but it is not the hamstring – which is why I am doing this.

‘What? techinically it is, but it isn’t? That makes no sense. I evaluated him myself. MMT was 3/5 for knee flexion w/ external rotation, hip extension was 4/5. Passive Hip flexion was -40 degrees when compared bilaterally. There is point tenderness over the proximal musculotendinous junction and you still say its not the hamstring.’  

Well, technically yes, it is but no – its not the hamstring.

‘Fine, enlighten me, what is it?’ 

The hamstring is what hurts and what is injured, but the problem and what needs to be fixed is not the hamstring.

‘My son needs to play and you are not doing your job to help him get back. I am informing the athletic director.’ 

** This actually happened and yes the athletic director was notified. He backed me up (after a conversation). Such is the life of the athletic trainer.**

Now, before I swarmed by an angry mobs of chiropractors trying to beat me with sticks, this is not about chiropractors – this is just one example of the trap that many health care practitioners – Athletic Trainers, PTs, OTs, RKTs, DC, MD, LMTs, etc – fall in to.  Many practitioners are too concerned with ‘the what‘ rather than ‘the how‘ and ‘the why‘. I think Athletic Trainers (especially students) do this too often. Even though I am writing about it today – I do this myself. We keep fixing what hurts – not how and why the injury is occurring. Athletic training rooms are not just first-aid triage and pain-relief centers. Athletic trainers are to relieve pain, prevent pain, and optimize function (amongst other things).

What is the traditional therapeutic approach to patellar tendonitis; Rest, ice, ultrasound, massage, cho-pat strap? All viable and great for triage, but it may not fix the problem. Maybe we should apply MWM to the ankle and improve ankle dorsiflexion, that might fix the problem and relieve pain.

********Back to the dreaded hamstring and my conversation with the parent / medical professional********

This particular parent was upset and did not understand why I was not addressing the what. In my defense, I was dedicating some time to fixing the what – using ultrasound, massage, PROM, etc – to facilitate proper tissue healing. However, I knew this would not fix the problem, thus I was focusing most of my attention on the why and the how. In this particular instance (and most hamstring injuries) I needed to correct human movement dysfunction (poor neuromuscular recruitment, suboptimal arthrokinematics, and altered length-tension relationships). This will fix the problem and go a long way in prevention of re-injury.

Let me explain the breakdown of optimal function – or lack thereof:

Secondary, to pattern overload or prolonged static posturing many individuals suffer from chronic hypertonicity and mechanical shortening of the psoas.  A chronically tight psoas will cause altered reciprocal inhibition of its functional antagonist, the gluteus maximus. What that means is the overactive psoas muscle is telling the nervous system to turn off neural drive to the gluteus maximus.

With this muscle imbalance an abnormal force coupling occurs yielding poor arthrokinematics in the form of an anterior pelvic tilt. Because of the hamstring’s proximal attachment to the ischial tuberosity an anterior pelvic tilt will cause the hamstring to migrate superiorly and posteriorly, essentially lengthening the muscle. If you recall from your applied kinesiology course, muscles have optimal length tension relationships – a zone where maximal muscle force can be produced. The longer or shorter a muscle is, the less the muscular force can be applied or tolerated.

In addition to this, with the glute inactivity caused by altered reciprocal inhibition, a muscle must make up for the glute’s loss of functional ability. So now a synergistic muscle must help with the glutes ability to perform hip extension. Which muscle is going to this? You guessed it – the hamstring.  This is called synergistic dominance – the hamstring (synergist) must dominate the movement of hip extension.

If you recall from above, the hamstring is working in a lengthened and suboptimal position. Coupled with this it is being asked to do more work. So, when we are applying the greatest amount of muscular tension – eccentric contraction near end ROM (such as sprinting) – the hamstring fails. Commonly it fails near the proximal attachment secondary to a line of pull change.

Back to my opening questions:

  • Why do we see so many hamstring injuries? Because health and wellness professionals are not identifying or intervening to correct human movement dysfunctional patterns.
  • Why do we see so many recurrent hamstring injuries? Because we are not fixing what needs to be fixed and allowing the hamstring to work inefficiently.
  • Why are we seeing delayed recovery? Because we are using antiquated rehabilitation techniques. We are focusing on the hamstring when the problem exists elsewhere.

Correcting movement dysfunction and optimizing function will fix the problem. This is so much easier in the long run. I am sure practitioners will disagree with me or have some refuting evidence. Recently there has been a slew of research published discussing the effectiveness of high-intensity eccentric hamstring strengthening on the prevention and rehabilitation of hamstring injuries. Yes, eccentric hamstring exercises work, but why? They work because you are making the hamstring more tolerable and able to function with poor mechanics. Essentially, you are just making the chain a bit stronger. Again, this is not fixing the problem.

2 thoughts on “The Dreaded Hamstring: Pathophysiology and Rehabilitation Tips

  1. I wanted to thank you for this wonderful read!

    ! I absolutely loved every bit of it. I have you book-marked to check out new things you post…

  2. excellent. Josh is an Alumn of SJSU KIN ATC program and a great practitioner. Share this with AT friends.

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