Hamstring injuries: prevention and treatment— an update

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Hamstring injuries: prevention and treatment— an update

Based on:
Hamstring injuries: prevention and treatment -an update, Peter Brukner,Br J Sports Med 2015 49: 1241-1244  doi: 10.1136/bjsports-2014-094427

While the concept of eccentric muscle training has been an important component of the rehabilitation process for many years, it now appears that these exercises must be in the lengthened position.

This makes sense when you think that the majority of hamstring muscle injuries are located in the long head of biceps femoris, a muscle that straddles both the hip and knee joints.

The standard leg curl exercise, therefore, does not work the long head sufficiently. As a result, lengthening eccentric exercises such as the Nordic hamstring exercise (NHE), the Romanian dead lift and Askling’s ‘extender’, ‘diver’ and ‘glider’ exercises are now becoming the mainstay of post injury rehabilitatioSkærmbillede 2015-11-11 kl. 14.36.11nSkærmbillede 2015-11-12 kl. 23.02.23

Two papers have proposed parameters by which hamstring rehabilitation programmes can be created

Malliaropoulos et al suggested the following parameters—injury mechanism, hip or knee dominant, location, targeted muscle, length rather than strength, training parameters—should be considered when devising a rehabilitation protocol.

2. Guex and Millet suggested a conceptual framework for strengthening exercises for hamstring muscles specific to the terminal swing phase of sprinting based on six key parameters (contraction type, load, range of motion, angular velocity, unilateral/bilateral exercises, kinetic chain) for strain prevention.

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After analysing some of the frequently used hamstring strengthening exercises, they came to the conclusion that the ‘optimal exercise had not been designed yet’. Finally, they noted that strain prevention is not only a question of strength, but also depends on the timing of contraction, or a combination of both

For a number of years the only RCT comparing different hamstring rehabilitation programmes was Sherry and Best study, which reported significantly lower reinjury rates in athletes who completed a progressive agility and trunk stabilisation (PATS) programme, compared to those whose rehabilitation programmes focused on isolated hamstring strengthening and stretching.

A Comparison of 2 Rehabilitation Programs in the Treatment of Acute Hamstring Strains Marc A. Sherry, Thomas M. Best, Journal of Orthopaedic & Sports Physical Therapy 2004

Askling et al performed two identical studies, one in footballers and other in sprinters and jumpers, and demonstrated that a rehabilitation protocol consisting of mainly lengthening type of exercises (L-protocol) is more effective than a conventional protocol in promoting return to sport after acute hamstring injury.

The most conspicuous characteristics of the more successful L-protocol were the systematic attempts to put load on the hamstrings during maximal dynamic lengthening, using exercises entitled The Extender, The Diver and The Glider. On this basis, they recommended that hamstring injury rehabilitation protocols should be preferentially based on strength and flexibility exercises that primarily involve exercises with high loads at long muscle–tendon lengths.

Other exercises (Not EvidenceBased, but more Open Kinetic Chain exercise)


It was concluded that measuring postgame hamstring isometric maximal voluntary contraction asymmetry on a weekly basis may be helpful in identifying adverse reactions to load (ie, inhibition, presence of symptoms, or both) that could represent early warning signs for hamstring strain susceptibility

Prevention is better than cure and there is evidence that a programme of eccentric hamstring exercises, such as the (1) yo-yo curl og nordic hamstring exercise (2)

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