Hockey hamstrings - Talking about tears
Through my involvement with the Henley Hockey ladies and mens 1st teams, both as a player and a casual physio, I am no stranger to a hamstring injury. Hamstring injuries are one of the most prevalent non contact injuries in high speed sports. Although the exact mechanism of injury (MOI) and the rate and severity of injuries in field hockey is an area where more research is needed, the sport involves several movement patterns that may increase risk of injury to the hamstring:
* Sudden deceleration/acceleration, e.g. if the play gets turned over quickly (Sprint related injury)
* Hip flexion playing positions, e.g. a sudden forward bend into a tackle with a partially extended knee (stretch related injury)
* Sudden and quick change of direction
* Neuromuscular fatigue
* Older playing age of athletes
* Previous hamstring injury
* Imbalance in strength ratios of quadriceps:hamstring and/or reduced mobility of quadriceps/hip flexors (as prolonged periods are spent in a hip flexion position)
Lets recap the anatomy...
The hamstring muscle group includes 3 muscles: The semimembranosus, semitendinosus and the biceps femoris. All three muscle cross two joints (the knee and the hip) with the exception of the short head of the bicep femoris which only crosses the knee. The hamstrings work to flex the knee and extend the hip.
The biceps femoris attaches to the medial ischial tuberosity (long head) and femur and inserts to the posterior fibula head. The semimembranosus and semitendinosus both originate on the ischial tuberosity and insert on the posterior tibia. The semimembranosus sits deeper and is bulkier than the semitendinosus which has a longer thinner tendon distally (which is often the tendon of choice for an ACL reconstruction). The adductor magnus shares a common attachment on the ischial tuberosity and is sometimes grouped together with the hamstrings as when the hip is in deep flexion it initiates hip extension (and can commonly be injured in a deep squat/lunge position under high load).
The hamstring are innervated by the sciatic nerve which passes very closely by the tendons of the hamstring. Often with hamstring tears/tendinopathies athletes will experience neural irritation due to the proximity of the anatomy of the two structures.
So what happens to the hamstrings?
Tears and tendinopathies are the most common injuries I see when working with club level athletes. For the sake of this blog I will be discussing tears.
Tears can be graded using the British Athletics Muscle injury Classification system and recovery time varies depending on the following:
- Location of tear (myofascial - a, muscle belly - b, or musculotendinous junction)
- size of tear (0 - small tear to 4 - complete tear)
MRI may be used within a more elite sports population and this allows for accurate grading (0-4 and a-c). At amateur level this categorisation is made based on subjective and objective history taking. You cannot be exact on the location of injury without imaging but by applying clinical reasoning you should be able to get a good feel/impression.
What might I expect to see in a hamstring tear?
Subjectively there may be a feeling of a pull or a sudden sharp pain when pushing off to sprint, changing direction or lunging into a tackle. There may be pain during the activity or pain that develops after. The athlete may 'pull up' or fall if the tear is higher grade. A very simple sign is the athlete will grab their hamstring, no need to over complicate anything there! If you haven't seen it already I recommend watching the video of Derek Redmond in the 1992 Barcelona Olympic final where he tore his hamstring and his father came onto the track to help him finish the race, very inspirational.
Objectively, depending on the extent of the injury there may be pain on palpation, loss of range of hip flexion and/or knee extension in a straight leg raise (stretch of the hamstring), a loss of strength +/- pain on contraction (high hamstring stretch and load, prone knee bend etc.), there may be bruising present in the posterior thigh. There may be a palpable gap in the muscle.
Thank you to one of my athletes for letting me use these images of bruising post grade 2 tear (likely 2B given the presentation).
Needless to say a thorough assessment by a professional will be required in order to determine the extent of the injury and to rule out differential diagnosis.
Lets get down to it... how do we get it better?
At amateur level, unless the extent of the injury is high, there is unlikely to be need for surgical intervention or imaging. Recovery time will depend on location and size of the tear, with MTJ tears being notoriously lengthier and more sensitive to rehab. It can be anything from a few days (e.g. grade 0) to 6 months (e.g. 4C).
Pain management in the early phases is key (as per my previous blog, the use of ice and anti-inflammatories, although have been show to help reduce pain, may delay a natural healing response and the balance of risk of this should be considered). Avoiding prolonged or excessive compression (prolonged sitting, bending at the hips, over striding/stretching).
Early stage: Here we want to start gently strengthening and loading the muscle tissue to encourage healing but not over do it/make things worse, we are guided by the natural healing process all the way through recovery and aiming to optimise this.
- Heel dig bridge progressions
- Standing knee bends
- Prone hip extension
- Prone knee bend
- Seated knee bends
Mid stage: Here we want to gradually increase the loads on the tissue and start to mimic the movement patterns we need to go back to our goal activity. Tissue healing is more advanced at this stage so we can increase weight and start to incorporate more mobility with less risk or flaring things up.
-Progress bridging, at this stage you should be onto single leg bridging with your foot further away from body.
- Romanian deadlifts (start with no weight and slowly progress as able)
- Nordics curls
- If assessed as safe and suitable start to build up running endurance, start with slow runs and avoid over striding. Stick to flat routes. You can gradually build this up.
- You can focus more on mobility at this stage, avoid excessive stretch, tight/stiff muscles respond better to being put under tension AND load (eccentrics are good for this - Nordics/RDLs).
- Using A skip and B skip type drills is a nice way to break down technique and work on control - can break into down into movement segments, change speed etc.
Later stage: Now we can start to make it more sport specific/higher level. We want to think about restoring the energy storage and release properties of the tissue.
- Supine tantrums (lie on back with legs out straight, place a resistance band 20-30 cm off the floor and taught and kick legs onto band.
- Jumping and landing biomechanics: box jumps, triple hop, vertical jump, lateral jumps etc.
- Sprint work (reaction speed, top speed, hill running etc.)
- Change of direction drills
- Quick tackling/reaching drills
- We may also want to look at increasing lactate thresholds here for hockey as it involves short fast sprints but also moderated paced longer runs too.
Other aspects to consider throughout rehab:
- Improve lumbopelvic control to optimise hamstring function (e.g. if hip flexors are dominant then hamstrings may be in a lengthened position which may make then more prone to re-injury)
- Improve neuromuscular fatigue by including sprint training, lactate threshold training and aerobic/recovery runs/cardiovascular.
- Work on other posterior chain muscles such as glutes which also work to extend hip.
- Improve neuromuscular control with exercises such as double to single leg hops, aeroplanes, bosu ball work with stick and ball skill.
As always, this is a guide and each athlete is individual, therefore one program does not fit all.
PREVENTION IS BETTER THAN CURE
I would strongly encourage anyone involved in sports to be carrying out a mix of training including strength and conditioning specific to their sport. Not only might it improve your performance but its great for other things like bone health, reducing muscle atrophy with age, mental wellbeing. A few of my favourites for hockey are:
- RDL variations
- Bridge with eccentric heel slides
I will be doing a series of hamstring rehab on my social media over the next few weeks to demonstrate some ideas and exercises so stay tuned.
References and interesting articles
Askling, C. (2011). Types of hamstring injuries in sports. British Journal of Sports Medicine, 45(2), e2-e2. https://doi.org/10.1136/bjsm.2010.081570.15
Barboza, S. D., Joseph, C., Nauta, J., Van Mechelen, W., & Verhagen, E. (2018). Injuries in Field hockey players: A systematic review. Sports Medicine, 48(4), 849-866. https://doi.org/10.1007/s40279-017-0839-3
Chu, S. K., & Rho, M. E. (2016). Hamstring injuries in the athlete. Current Sports Medicine Reports, 15(3), 184-190. https://doi.org/10.1249/jsr.0000000000000264
Danielsson, A., Horvath, A., Senorski, C., Alentorn-Geli, E., Garrett, W. E., Cugat, R., Samuelsson, K., & Hamrin Senorski, E. (2020). The mechanism of hamstring injuries – a systematic review. BMC Musculoskeletal Disorders, 21(1). https://doi.org/10.1186/s12891-020-03658-8
Duhig, S. J., Shield, A. J., Opar, D., Gabbett, T. J., Ferguson, C., & Williams, M. (2018). Infographic. The effect of high-speed running on hamstring strain injury risk. British Journal of Sports Medicine, 53(16), 1034-1035. https://doi.org/10.1136/bjsports-2018-099358
Erickson, L. N., & Sherry, M. A. (2017). Rehabilitation and return to sport after hamstring strain injury. Journal of Sport and Health Science, 6(3), 262-270. https://doi.org/10.1016/j.jshs.2017.04.001
Hollander, K., Wellmann, K., Eulenburg, C. Z., Braumann, K., Junge, A., & Zech, A. (2018). Epidemiology of injuries in outdoor and indoor hockey players over one season: A prospective cohort study. British Journal of Sports Medicine, 52(17), 1091-1096. https://doi.org/10.1136/bjsports-2017-098948
Huygaerts, S., Cos, F., Cohen, D. D., Calleja-González, J., Guitart, M., Blazevich, A. J., & Alcaraz, P. E. (2020). Mechanisms of hamstring strain injury: Interactions between fatigue, muscle activation and function. Sports, 8(5), 65. https://doi.org/10.3390/sports8050065
Lancaster, M. (2019, March 18). 11 factors that differentiate sciatica from hamstring or other causes of posterior thigh pain. Sports Injury Bulletin. https://www.sportsinjurybulletin.com/11-factors-that-differentiate-sciatica-from-hamstring-or-other-causes-of-posterior-thigh-pain/
Mallac, C. (2018, December 21). Adductor Magnus: Tales of tightness. Sports Injury Bulletin. https://www.sportsinjurybulletin.com/adductor-magnus-tales-of-tightness/
Patel, A., Chakraverty, J., Pollock, N., Chakraverty, R., Suokas, A., & James, S. (2015). British athletics muscle injury classification: A reliability study for a new grading system. Clinical Radiology, 70(12), 1414-1420. https://doi.org/10.1016/j.crad.2015.08.009