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Hamstring Injuries in Swedish Elite Football. Askling Et Al. 2013
Hamstring Injuries in Swedish Elite Football. Askling Et Al. 2013
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BJSM Online First, published on March 27, 2013 as 10.1136/bjsports-2013-092165
Original article
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Askling CM, et al. BrArticle author
J Sports Med (or their
2013;00:1–8. employer) 2013. Produced
doi:10.1136/bjsports-2013-092165 by BMJ Publishing Group Ltd under licence. 1
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Original article
Inclusion/exclusion criteria addition, the perpendicular distance between the level of the
To be included, the player had to have had an acute sudden most proximal pole of the oedema and the level of the most
pain in the posterior thigh when training football or playing a distal part of the ischial tuberosity was measured.4
match. The initial clinical examination had to reveal localised
pain when palpating the hamstring muscles, localised pain while Rehabilitation protocols
performing a passive straight leg raise test and increased pain The time from the date of injury to the date of rehabilitation
when adding an isometric hamstring contraction during that protocol initiation was 5 days for both protocols. Overall, exer-
test.3 Exclusion criteria included verified or even suspected, cises were chosen that could be performed in any place and
earlier hamstring injuries in the same leg during the last without the use of advanced equipment. The exercises of the
6 months, extrinsic trauma to the posterior thigh, ongoing or L-protocol specifically aimed at loading the hamstrings during
chronic lower back problems and pregnancy. extensive lengthening, mainly during eccentric muscle actions.
In contrast, the C-protocol consisted of conventional exercises
Injury situation—type of injury for the hamstrings with less emphasis on lengthening. Each
At the first visit, the players were interviewed about the injury rehabilitation protocol consisted of three different exercises,
situation, that is, the movements or exercises during which the where exercise 1 was aimed mainly at increasing flexibility, exer-
acute injury occurred. As the majority of the players came from cise 2 was a combined exercise for strength and trunk/pelvis sta-
the two highest football divisions in Sweden, video clips of the bilisation and exercise 3 was more of a specific strength training
injury situation were available in many cases (46 of 75). The exercise. All exercises were performed in the sagittal plane. The
video was used to confirm if the injury was a sprinting-type intensity and volume of training were made as equal as possible
injury, that is, occurred at high-speed running and/or acceler- between the two protocols. The training sessions were super-
ation or a stretching-type injury, that is, occurred during move- vised, at least once every week, during the whole rehabilitation
ments with large joint excursions, that is, high kicking, split period, and the speed and load were increased over time. No
positions and glide tackling. pain provocation was allowed at any time when performing the
exercises. All exercises included in the two rehabilitation proto-
Clinical examination cols are explained in figures 1–6 and shown in online supple-
All players were examined within 2 days after the injury. The mentary videos 1–6.
clinical examination included manual assessment of flexibility
and strength of the injured and uninjured legs. The point of Outcome
peak palpation pain was recorded and the distance between that The main outcome is time to return, that is, time needed from
point and the ischial tuberosity was measured.3 The same the incidence of injury to full participation in football team
test-leader (CMA) performed this clinical examination weekly training and availability for match selection. Also occurrence of
until there were no signs of remaining injury. The last decision reinjuries was registered during a 12 months period after return.
by the CMA had to be confirmed by an independent colleague If a reinjury occurred, the responsible medical team was to
before being finalised. immediately contact the study leader so that the same procedure
as for the original injury could be repeated. The full 1-year
Askling H-test follow-up period was completed by all players in the study.
When the clinical examination showed no signs of remaining
injury, the Askling H-test was performed.15 If the player experi- Statistical analyses
enced insecurity during this dynamic test, he/she was not All statistical analyses were conducted with SPSS V.19.0 software
allowed to go back to full team training and/or match. Instead, (SPSS Inc, Chicago, Illinois, USA). Shapiro-Wilk W tests showed
the rehabilitation period was extended and the H-test repeated that the data were not normally distributed. The Mann-Whitney
with an interval of 3–5 days until insecurity was eliminated. U test was performed to investigate differences in age, height
and mass as well as MRI and palpation measures. A χ² test was
MRI applied to investigate differences in proportions of injury type
All players underwent an MRI investigation within 5 days after
the acute injury. MRI investigations were performed on a 1.5
Tesla superconductive MRI unit (Magnetom Symphony,
Siemens, Erlangen, Germany). Briefly, longitudinal, sagittal and
frontal short tau inversion recovery (STIR) images as well as
transversal T1-weighted and STIR images (5 mm slice thickness
and 0.5 mm gap) were obtained from both legs.4 A muscle was
considered injured when it contained high signal intensity
(oedema) on the STIR images, as compared with that of the
uninjured side. If more than one muscle/tendon was injured,
the one with the greatest signal abnormality was considered the
‘primary’ injury and the second largest, the ‘secondary’ injury.
In this study, MRI parameters were quantified only for the
primary injury. The free proximal tendon (PT) was deemed
injured if two of the three following parameters were present:
the tendon was thickened, and/or had a collar of high signal Figure 1 L-1 ‘The Extender’. The player should hold and stabilise the
intensity around it and/or had high intratendinous signal inten- thigh of the injured leg with the hip flexed approximately 90° and then
sity, as compared with the uninjured side. The maximal longitu- perform slow knee extensions to a point just before pain is felt. Twice
dinal length of the muscle/tendon oedema was measured.4 In every day, three sets with 12 repetitions (online supplementary video 1).
Original article
RESULTS
Injury type and location
Fifty-four (72%) of all 75 MRI-verified hamstring injuries were
sprinting-type and 21 (28%) were stretching-type injuries. In 52
Figure 3 L-3 ‘The Glider’. The exercise is started from a position with
upright trunk, one hand holding on to a support and legs slightly split.
All the body weight should be on the heel of the injured (here left) leg
with approximately 10–20° flexion in the knee. The motion is started Figure 5 C-2 Cable-pendulum. A stationary cable-machine or
by gliding backward on the other leg (note low friction sock) and expander is used. With the uninjured leg as standing leg,
stopped before pain is reached. The movement back to the starting forward-backward hip motions are performed with the injured leg with
position should be performed by the help of both arms, not using the the knee in approximately 20–30° flexion. This exercise involves the
injured leg. Progression is achieved by increasing the gliding distance whole body and should be performed slowly in the beginning of the
and performing the exercise faster. Once every third day, three sets rehabilitation period. Once every other day, three sets with six
with four repetitions (online supplementary video 3). repetitions (online supplementary video 5).
Original article
was prolonged by 7.5 days (1SD±2.8, range 3–12) and 6.7 days
(1SD±2.7, range 3–14) in the L-protocol and C-protocol,
respectively.
Time to return
Time to return was significantly shorter in the L-protocol
compared with the C-protocol, mean 28 days (1SD±15, range
8–58 days) and 51 days (1SD±21, range 12–94 days), respect-
ively (figure 7). Time to return was also significantly shorter in
the L-protocol than in the C-protocol for injuries of both
Figure 6 C-3 Pelvic lift. This exercise is started in a supine position sprinting-type and stretching-type (figure 8), as well as for injur-
with the body weight on both heels and then the pelvis is lifted up ies not involving and involving the PT (figure 9). The sprinting-
and down slowly. Start with the knee in 90° of flexion. The load is type of injuries, per se, showed significantly shorter time to
increased by putting more of the body weight on the injured leg and return compared with stretching-type injuries (figure 8). Also,
by having a greater extension in the knee. Ultimately, only the slightly injuries not involving PT showed significantly shorter time to
bent injured leg is carrying the load. Every third day, three sets with return than those involving the PT (figure 9). Correlation ana-
eight repetitions (online supplementary video 6).
lysis showed that the shorter the distance to tuber was from the
most proximal pole of the injury measured by MRI or peak pal-
of the 75 players (69%), the primary injury was located in the pation pain, the longer the time was to return (table 2).
long head of biceps femoris (BFlh) and in 25 of those 52 (48%) A longer length of the oedema was also correlated with a signifi-
there was a secondary injury commonly (80%) located in the cantly longer time to return (table 2).
semitendinosus (ST). In 16 of the 75 players (21%), the primary
injury was located in semimembranosus (SM) and in 7 of those Reinjuries
16 (44%) there was a secondary injury. A clear majority (94%) There was one reinjury registered during the 12-month
of the primary injuries of sprinting-type was located in the follow-up period. This reinjury occurred in the C-protocol
BFlh, whereas SM was the most common (76%) location for 6 months after the initial injury. Both injuries were of sprinting-
the stretching-type injury. type and located in the BFlh. The reinjury took 12 days to
return compared with 16 days for the initial injury.
Table 1 Descriptive, MRI and palpation data, as means±1SD (median and range) or ratios (%) for players in the L-protocol and the C-protocol,
respectively
L-protocol (n=37) C-protocol (n=38) p Value
Original article
Original article
Table 3 Descriptive data, as means±1SD (median and range) or (%) for players in the MRI-negative group and the sprinting-type injury within
the L-protocol, respectively
MRI-negative (n=11) L-protocol (n=27) sprinting-type p Value
Lacking objective data we cannot pinpoint the factors causing should build on attaining eccentric loading at as long muscle
the remarkable difference in outcome between the two proto- lengths as possible.17–19
cols. The most conspicuous characteristics of the more success-
ful L-protocol were the systematic attempts to put load on the Factors predicting time to return irrespective of
hamstrings during maximal dynamic lengthening, the latter rehabilitation protocol
involving movements at both the hip and the knee. The contri- Earlier investigations of ours have identified two main types of
bution of eccentric actions might also have been greater in the acute hamstring injuries, one occurring at high-speed running,
L-programme, although we have no data to directly support typical for sprinters4 the other occurring during slow stretching
such a statement. Otherwise, the two protocols were made as to extreme muscle lengths, typical for dancers5 but also occur-
similar as possible in terms of early start after injury, thorough ring in other athletes.6 These types of injuries are best distin-
instruction and regular follow-up and progression in load/speed/ guished by identifying these typical injury situations, either
excursion based on the avoidance of the pain criterion. relying on players’ report or on other forms of documentation,
The selection of these properties of the L-protocol was based for example, videos from elite football matches as used here.
on the common assumption of specificity, that is, the rehabilita- Ekstrand et al7 showed that 70% of hamstring injuries in elite
tion training, within reasonable limits, should attempt to mirror football players occur during high-speed running and the rest
the particular situation that lead to the injury. Even though the with stretching, sliding, twisting, turning, passing, jumping and
exact mechanisms behind different types of hamstring injuries overuse. Their numbers are close to ours based on the number
are unknown, several pieces of indirect evidence point to the of players reported to us by the medical teams, 72% of the
aforementioned factors to be important14 16 and several authors injuries were high-speed running and 28% stretching-injuries,
have suggested that rehabilitating acute hamstring injuries occurring during, for example, high kicking, sliding tackle and
split motions. Establishing type of injury provides essential prog-
nostic information since stretching-type of injury has, on the
average, 84% longer times (59 vs 32 days) to return than
sprinting-type of injury in the present study. Other measure-
ments with similar prognostic value, that is, prolonging or short-
ening the time to return, are position of peak pain upon
palpation and position of the proximal pole of the oedema in
relation the ischial tuberosity as well as oedema length upon
MRI. Correlation analysis showed that the shorter the distance
to tuber and the longer length of the oedema the longer the
time to return. The latter two findings are in accordance with
earlier studies.4 20 21 Interestingly, these effects on time to
return were all independent of the two rehabilitation protocols
applied here. So, there seems to be room for developing exer-
cises that are more specific with respect to injury type and
location.
MRI-negative injuries
In our study, 11 players showed typical sprinting-injury, but had
no signs of acute hamstring injury upon MRI investigation. The
clinical examination, performed within 2 days, showed all
typical signs of acute hamstring injury, for example, distinct pal-
pation pain; pain provoked by isometric contraction of the ham-
Figure 10 Time to return, in days, for MRI-negative players (n=11, all strings and reduced straight leg raise performance, compared
performing L-protocol) or for players with sprinting-type injuries within with the uninjured leg. Possible explanations for this discrep-
the L-protocol (n=27). The boxes represent IQRs; in the boxes the ancy could be that the structural defect is below the detection
horizontal lines represent median values and black squares represent limit of the MRI or radiologist, the oedema is limited and
mean values; whiskers=mean±1 SD. *** Denotes significant difference cleared away within the 5 days before MRI, or spine-related
( p<0.001, Mann-Whitney U test). and/or neuromuscular disorders have provoked the acute
Original article
Original article
19 Malliaropoulos N, Mendiguchia J, Pehlivanidis H, et al. Hamstring exercises 22 Orchard JW, Farhart P, Leopold C. Lumbar spine region pathology and hamstring and
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These include:
Data Supplement "Supplementary Data"
http://bjsm.bmj.com/content/suppl/2013/03/27/bjsports-2013-092165.DC1.html
References This article cites 25 articles, 13 of which can be accessed free at:
http://bjsm.bmj.com/content/early/2013/03/26/bjsports-2013-092165.full.html#ref-list-1
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