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14th September 2017

Testing for holistic hamstring health in the clinic

Multi-factorial risk requires multi-factorial fix

It is widely recognised hamstring strain injury risk is multi-factorial in nature (Thorborg, 2014). It is then only a small and logical step to take to identify hamstring risk factor management also requires an equally multi-interventional and multi-disciplinary approach to safeguard clients from both initial and recurrent problems.

More than just strength, more than just length

The last few years has seen injury reduction strategies focussed upon eccentric strength development, with the Nordic hamstring exercise playing a central but opinion dividing role upon both the social media and academic literature stage. As this approach is seen to elicit desirable change in both strength and muscle architectural properties related to reducing risk (Timmins et al., 2016), clinicians and S&C practitioners must strongly consider this exercises’ inclusion within their return to play or hamstring health maintenance protocols (Oakely et al., 2017). Yet, numerous, long-standing risk factors such as hip musculature extensibility (Witrouw et al., 2003), fatigue (Small et al., 2010) and dynamic alignment of the lumbo-pelvic region (Chumanov et al.,2006) remain unchecked if eccentric strength remains our only tool of assessment and injury risk mitigation.

Synergies and alignment: not just ‘what’ but ‘how’

Within the past 12 months, three key papers, authored by a research group from Ghent University, have placed the inter-muscular recruitment relationships between the hip extensor synergists (hamstrings and gluteus maximus) and the dynamic alignment of trunk back in the spotlight with regards to injury risk.

A 2017 publication by the group, considering a prone hip extension test, revealed footballers were eight times more likely to experience a first-time hamstring injury if their hamstring musculature activated after their contra-lateral erector spinae but prior to their gluteus maximus. Yet, as the majority of hamstring injuries occur during sprinting (Opar et al., 2012), the recruitment patterns of the hamstrings and their synergists during this activity are of interest. Schuermans’ 2016 paper identified footballers who demonstrated a higher level of gluteus maximus recruitment during the front swing phase of sprinting were at a lower risk of hamstring injury, another finding highlighting the importance of these hip extensor synergists in the overall maintenance of hamstring health. In support of these neuromuscular measures, a 2017 publication by this same group, identified footballers who displayed what the team described as higher levels of anterior pelvic tilting and thoracic side bend during the airborne phase of sprinting, were at increased risk of a first-time hamstring injury.

Reading movement to safeguard synergists?

Taken as a whole, and supplying an alternative to just eccentric strength, kinematic and neuromuscular markers observed during both high velocity and static contractions, may successfully inform on injury risk. However, within both clinical practice and performance focussed environments, the ability to identify altered patterns of recruitment and risk associated kinematics is no trivial matter. Due to the technology and time typically required to both gather and process the data for any one athlete, such measures often remain solely within the pages of academic journals.

The realities of the clinic will typically require clinicians to rely upon skills of observation and interpretation alone, a task heightened in complexity once confronted with multi-joint activity, performed at speed. In light of this, the above literature focussing upon sprint kinematics certainly raises questions with regards to how movement is to be evaluated and whether emphasis should focus upon the weight-bearing or swing leg.

If attention is centred upon the open kinetic chain, swing leg, the deviation in sagittal plane pelvic alignment associated to increased hamstring risk may indeed be an ‘excessive’ amplitude of anterior pelvic compared to controls. Alternatively, for the stance leg, the same positioning may be assessed as a trunk forward lean or a closed kinetic chain hip flexion. As the debate still continues as to the exact moment of hamstring injury (late swing or early stance - Liu et al., 2017), both interpretations possess clinical relevance. Additionally, the rapidly loaded stance leg soon becomes the swing limb. This constant interaction between eccentric closed and open chain demand, may mean both movement patterns can be filed as ‘high risk’, requiring scrutiny of both weight bearing and non-bearing challenges within any risk identification protocol.

Systemised Assessment

From a Movement Performance Solutions perspective, the work of this research group highlights not only the need to assess the interactions of the hamstrings and their synergists but also to identify and clearly label risk associated movement patterns such as sidebend, anterior pelvic tilt and/or hip flexion. Through the use of site, direction and threshold, (site = hip, direction = flexion, threshold = high or low threshold of muscle recruitment), movement can be observed, questioned and evaluated within the clinic environment so as to inform on risk associated movement and recruitment patterns in the absence of costly kit.

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Chumanov, E. S., Thelen, D. G., Sherry, M. A., Heiderscheit, B. C., & Weir, J. (2006). Anterior Pelvic Tilt Increases Hamstring Stretch During Sprinting. Medicine & Science In Sports & Exercise, 38(5), S265-S266.

Liu Y., Sun Y., Zhu W., Yu J. (2017). The Late Swing And Early Stance Of Sprinting Are Most Hazardous For Hamstring Injuries. J Sport Health Sci, 6, Pp. 133-136

Oakley, A. J., Jennings, J., & Bishop, C. J. (2017). Holistic Hamstring Health: Not Just The Nordic Hamstring Exercise.

Opar, D. A., Williams, M. D., & Shield, A. J. (2012). Hamstring Strain Injuries. Sports Medicine, 42(3), 209-226.

Schuermans, J., Danneels, L., Van Tiggelen, D., Palmans, T., & Witvrouw, E. (2017). Proximal Neuromuscular Control Protects Against Hamstring Injury In Male Football Players: A Prospective Study With Emg Time-Series Analysis During Maximal Sprinting. Br J Sports Med, 51(4), 383-384.

Schuermans, J., Van Tiggelen, D., Palmans, T., Danneels, L., & Witvrouw, E. (2017). Deviating Running Kinematics And Hamstring Injury Susceptibility In Male Soccer Players: Cause Or Consequence?. Gait & Posture.

Schuermans, J., Van Tiggelen, D., Danneels, L., & Witvrouw, E. (2016). Susceptibility To Hamstring Injuries In Soccer: A Prospective Study Using Muscle Functional Magnetic Resonance Imaging. The American Journal Of Sports Medicine, 44(5), 1276-1285.


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