Hamstring Injury Advice from Martin

Hi, I’m continuously getting questions about hamstring injuries in rugby and what to do about them, so I thought I’d put some info together with the latest thoughts and ideas from a clinical and biomechanical perspective……..

One of the most common injuries in sport is to the hamstrings. Typically though, although the pain often presents itself in the hamstrings, its often due to biomechanical load from another area that is not functioning correctly. Even if you tear the hamstring during sprinting, the underlying cause is often biomechanical, and unless that cause is addressed the problem will become recurrent or simply just not go away. You could even just have a hamstring that feels tight or won’t stretch out properly, either way the cause is often biomechanical.

Often these biomechanical causes are due to the pelvis or spine. A ‘rotated’ pelvis, (which is where one side of pelvis stiffens in an abnormal position) can go unnoticed for many years until the compensations start to cause problems. A rotated pelvis can increase the pressure on the hamstrings partially because it puts more tension through the muscle. In addition, these pelvic problems coupled with a stiff lumbar spine and stiff upper back can increase tension on the sciatic nerve. This in turn puts extra pressure on the hamstring.

Your pelvis can be abnormally rotated during day to day life by unaccustomed lifting or carrying, performing a repetitive movement abnormally or perhaps compensating for another biomechanical issue elsewhere in the body. In rugby, pelvic problems can be caused by a tackle, an awkward fall, scrummaging or landing awkwardly during a line out. In other words most things that occur during a rugby match! When the pelvis rotates, the piriformis muscle in the back of your hip goes into a protective spasm to minimise the pressure going through the joint. This spasm effectively prevents the joint from functioning correctly and so other areas have to compensate. If the problem is caught early enough, treatment will help. Simple therapy can mobilise the joint and improve its function. If however the problem is left for more than 6 weeks, the muscle will change its composition and become fibrotic and so be unable to function normally. In theses cases treatment will help in the short term, but whenever you start training again the hamstring problem recurs because the fibrotic muscle in the pelvis is still compromising the function of the joint and so putting more pressure through the hamstring.

This process can also affect the sciatic nerve. The problem is that when the piriformis muscle in your hip goes into spasm, it causes the sciatic nerve to become tight. It does this because the pelvis doesn’t move as well as normal, so the nerve becomes stiff and also because the nerve can run through the very piriformis muscle that’s in spasm. The body cannot allow damage to the sciatic nerve, its one of the main nerves in the body, so the muscles that would protect it go into a protective spasm. One of which is the hamstring group.

This protective spasm of the hamstrings can cause a number of problems that cause symptoms in the hamstring itself. It can make the hamstring feel tight and stiff. It can make the hamstring feel inflexible as it’s under constant tension. It can also cause a functional muscle imbalance. In other words, if the hamstrings are found to be ‘weak’ in comparison to the quadriceps (quads), one of the causes of this muscle imbalance could be the inability of the hamstring to fire correctly due to its state of tension, rather than it being fundamentally weak.

To manage this cause we first have to return the abnormal muscle tone in the piriformis muscle to normal. In other words you have to do ‘anti-spasm’ exercises for the muscle. Stretching or flexibility work just won’t cut it – it helps in the short term, but the tension returns in time. How often do you stretch to loosen a muscle, only to find the short term benefit disappears after a few hours or less? You need to return the muscle to normal function, not just stretch it. That is why stretching the hamstrings isn’t always the answer to your hamstring problems (in fact mobilising your sciatic nerve is far more effective in these cases). Once the spasm in your piriformis muscle is eradicated as much as possible, then the joint will rotate naturally back into its normal biomechanical position, so reducing the tension on the sciatic nerve and also the hamstring itself.

When the pelvis is back in place you should perform exercises to stabilise it. In other words exercises that educates your muscles to control your pelvis and trunk without them needing to go into spasm. Part of this process is achieved by so-called ‘core stability exercises’. See a local expert in sports injuries, they should be able to guide you through the biomechanics phase and the next stabilise phase.

The work we have just described is usually sufficient to eradicate the hamstring pain that is gradual in onset. In the case of a hamstring tear which was caused perhaps by a high velocity movement like sprinting, it will be necessary to compliment the work we have been describing with a progressive hamstring and pelvic rehabilitation programme as well. But please note that unless the biomechanical causes have been eradicated, then the treatment and rehabilitation process is unlikely to be successful in the long term. This is one reason why hamstring problems become recurrent – the biomechanical causes are not eradicated.

There are other causes of hamstring pain, these are not the only ones, but it is common enough for you to need to understand it, especially if your problem is not going away.

The main other biomechanical causes of hamstring problems are stiffness (or dysfunction) of the lumbar spine (lower back) and thoracic spine (upper back). Stiffness in either of these areas can increase the load on the pelvis and thereby affect the load on your hamstring. Think about when you walk or run, as your left arm and shoulder come forwards, at the same time, your right hip and leg are moving forwards. Meanwhile the opposite body parts are moving in the opposite direction – they are going backwards. Each side of the body works in unison to maintain balance and equilibrium while we move. So if one part of that chain of events does not function properly another has to compensate. So if we have a stiff upper back for example, and one shoulder can’t move as forwards as it needs to when you run, there is another part of the body that will take the strain – often it’s the pelvis.

If you suspect this background is affecting your hamstring injuries, try this exercise which is referred to as an anti-spasm exercise for the piriformis muscle in the pelvis.

4-sign exercise

Technique

1. Sit on a chair and cross one leg over the other as in the picture.
2. Place both hands on the inside of your knee.
3. Pull your knee up into your hands.
4. Pull up @ 20% of maximum effort, just enough to engage the muscles in your hip.
5. This is a static contraction, so make sure the leg does not move.

Instruction
1. Hold for 20 seconds.
2. Do 4 sets on each leg.
3. AM and PM
4. Before & after periods of activity or inactivity.
In the body, things are not always as they seem. Just because your pain or tension is in the hamstring doesn’t mean that’s where it is originating from. Always check the causes of your problems, they rarely exist where you think they do.